Accidents, Falls, and Head Trauma: What every family should know | Guide with Dr. Muthukumar M.Ch.

Table of content:

• Causes of head injury
• When one should take a call to rush to the hospital?
• Symptoms in children
• Parent’s responsibility
• How to prevent injuries in older people?
• Importance of helmet
• How to take care of ourselves without getting injured?
• Life of caretakers
• Post-head injury rehabilitation

Dr. Hema Sathish:You must have heard of head injuries very often. But you don’t have to be in a car to incur a head injury. You know there are many a times head injury can happen just while you are at home also.So, here to break this down we have Dr. Muthu Kumar who is a very well renowned neurosurgeon. We are privileged to have you over sir.

Dr. Muthukumar: Thank you.

Dr. Hema Sathish:You know he has got more than 92 journal papers published, that too all in the best authoritative international journals. It’s a real honour to have you over and thanks for accepting the invite sir.

Dr. Muthukumar: Thank you. It’s a great pleasure to be here.

Dr. Hema Sathish:Same here.So, well we were talking about head injuries. So, I would like you to tell me about what are the causes of head injury. You must have seen I don’t know how many thousands of cases. So, could you just tell us what could be the causes? Because for a common man to understand that in a head injury you don’t have to be only in a car crash or you have to have a terrible injury to have a head injury. At times what happens is they are at home or kids are playing somewhere and then they hurt their heads. So, when they should take action and when they can be okay about it.

Causes of head injury

Dr. Muthukumar:Well, as you rightly said, the head injuries can occur anywhere. But the most common cause of head injury continues to be the road traffic accident. So, especially in India and then more so in Tamil Nadu, the road traffic accident rate is phenomenally high.And in India accounts for a significant percentage. The highest road traffic accident fatality occurs in India. And among India, Tamil Nadu has the dubious distinction of having a relatively high road traffic accident rate despite having very good roads, infrastructure etc. So, road traffic accident is one of the common causes.

Second is there can accidents can occur at home also. Most common cause of accident at home is elderly people who are a little unsteady. When they go to the toilet etc. they can slip and fall. That is one another common cause. And young kids when they are playing, especially when they are toddlers, it is just not possible to control them. They can do all sort of crazy things and they can fall down and sustain head injury.

One thing which used to happen earlier and can happen even now is what is known as TV head injury, TV toppling head injury. Because nowadays we have wall mounted TV displays. Earlier we used to have table top TV displays. So, these kids when they go around, the TV can fall and the older TVs used to be very big. So, that also can cause that.

Dr. Hema Sathish:Yeah, I have seen one case.

Dr. Muthukumar:So, that also can happen.

The other thing is work related head injuries. Because what happens especially the people in construction work, people in painting, they can lose a foothold and fall from a height. So, that is another common. And one more common is assault. Assault is because especially in this part of the country, assault with sickle is fairly common.

So, these are the common types of causes of head injury.

Dr. Hema Sathish:So, now there are different types of head injury and usually when a child falls, everybody says that is fine, the child has just fallen, just rub the head. And you know until and unless they see bleeding, they do not go to a doctor. So, can you just tell us some points when the parent or the person who is next to the person who has been injured, the patient rather, when they should take a call that they have to rush to the hospital immediately?

 

When one should take a call to rush to the hospital immediately?

Dr. Muthukumar:Well, there are clear cut symptoms which should raise the alarm for the parent or the bystander. One is the child loses consciousness even for a brief while. Even for a brief while if the child loses consciousness. If the child is going to have vomiting or if the child is going to throw a fit or if there is going to be bleeding through the nose or the ear. These symptoms arethere; invariably the child has to be taken to emergency care for immediate attention. Other thing is if the child appears to be a little dazed and there’s a small bump in the head, you just rub it, apply some ointment, etc. Child looks okay, but then after some time starts vomiting. So if these types of symptoms come, you should never take them lightly. Take it lightly because what happens is especially in the age group between 1 and 4, these kids are not able to express themselves. Even if they have a headache, all they do is they’ll become irritable and they’ll start crying. So that is a symptom. If the mother knows best, especially mother knows, mother clearly knows. Child is conscious, but it’s not normal. When the mother says that, the emergency doctor or the neurosurgeon has to, the red light should start flickering. So that is a very important point.

Dr. Hema Sathish:How true. I remember sir saying this several times that the mother knows best and even my very old paediatric professor used to say that and that’s very, very true. If the mother feels there’s something wrong, then you got to dive in deep and find out what’s wrong with the child.

You know, in children, the skull is not very well developed. So there is a lot of room for injury. But in spite of all this, there are times when they develop internal bleeding and there are some other symptoms they develop. So why do you think this happens in children?

Symptoms in children

Dr. Muthukumar:In children, because if you take a child, when we were in medical school, we were taught child is not a little adult. That’s the reason why there’s a separate specialty known as paediatrics instead of internal medicine. And what we need to know is all kids are not same. The newborn is different. Infant, which is less than 12 years, is different. Toddler is different. Older child is different. Teenager is different. So anatomically and physiologically, these kids are different. So the way they present will be different and the way they express their symptoms will be different.Since you talked about the anatomy of the skull, it will be pertinent to say that in very young child, less than 2 years of age or until 18 months, especially the fontanel, the fontanel, there’s a dip in the skull will be open and the sutures will also be open. So as the child grows, the fontanel will get closed, the sutures. What happens is that if a very young child, less than 18 months or so, gets injured, there will be space, I mean, when the blood accumulates, to some extent, the expansion. So that can mask the sign of head injury.

Dr. Hema Sathish:Oh, that’s even worse then.

Dr. Muthukumar:That is, can mask the sign of head injury. This is compounded by the fact the child is not verbalizing, not vocalizing, not verbalizing, which means the child is, he or she is not, the boy or girl is not able to express. So that is why I said that the child is not very alert, irritable, crying. That’s the reason why I brought the mother knows best. So the grandma in the house knows that this child is not okay. So when you have that suspicion, that such a child should be immediately brought.Now, the toddler’s injury is a little different because there’s no way any parent can control what a toddler can do. So the toddlers can get into all sorts of troubles.

Dr. Hema Sathish:Unimaginably.

Dr. Muthukumar:Unimaginably. All of us have gone through that phase. So toddlers do have a, and this is where the, all sorts of, they can fall from height, they can sleep and fall. So all those injuries can occur. What happens in teenagers? Teenagers, nowadays teenagers do get involved in adventure sports. And for our teenagers, the bike is the adventure sport. So the most scary part is the bike is the adventure sport, especially because all these latest bikes, which are very powerful and given the chaotic nature of our traffic and the poor infrastructure, the chance of injury is very high. The chance of injury is very high. We do see a lot of teenagers who get a sustained head injury and come to us in a very bad shape. And it’s really worrisome because if the boy or girl gets such an injury and if it’s going to be very severe, sometimes the effect can be lifelong.

Dr. Hema Sathish:It’s true. Very true.

Dr. Muthukumar:The cognition, especially the education aspect, the scholastic performance can go down and then the behaviour can also change. Behaviour can also change. They may have memory disturbances, they can have behaviour disturbances, etc. which will not only affect their education, it will also affect their personal life. So the entire, whether it is a boy or girl, young or old, if one person of the family gets a head injury, it is not that, it is the entire family which suffers. I think this holds good for all diseases, but more so for a trauma, especially a head injury.

Dr. Hema Sathish:So it’s not a pride that your child is driving very early in life. So parents have to be aware that you shouldn’t let your child drive a two-wheeler or any kind of vehicle before the age of 18. It’s good for you, your family and for everybody around. So you must have seen a lot of cases, but I always believe that the parents also should take responsibility that the child is given a vehicle or a two-wheeler, especially a two-wheeler, only when they are fine to drive, you know, because they are very enthusiastic, they don’t realize what problems could come in. And I think the parents should also take some responsibility, right?What is your take on that?

Parent’s responsibility

Dr. Muthukumar:Absolutely agree with you, 100% agree with you, because I think parents do have a great responsibility. I think recently the motor vehicle act has also been amended. So if a person less than 18 years of age drives and causes an accident, the parent is liable.Oh, that’s really good actually. The parent is going to be liable. Please correct me if I am…

Dr. Hema Sathish:No, maybe the audience watching might not like it, but the fact remains that it should be like that because we have seen so many accidents, right, happen and where the person is very young, he doesn’t, he or she doesn’t realize what he is doing and he is very thrilled about having a, you know, two-wheeler which he can go in full speed, then goes and bangs on somebody else.I’ve seen accidents, several accidents and there was once a nine-year-old kid who was brought who had several injuries on her face, scars on her face and she had injury on her hand also and she was brought to me because, you know, for cosmetic corrections and stuff like that. So and I was feeling so bad for her because that poor kid was just walking to school. She was walking to her bus stop to go to school and there was this young boy who just drove a bike into her.

Dr. Muthukumar:I can recount a similar experience that happened to one of my closest friends, very close friends, just happened last year about eight, nine months ago and he had gone with his wife to drop his daughter to some other place and they were waiting for a cab. They were waiting on the pavement, not on the road, they were waiting on the pavement. This teenage boy drove this car in such a rash way, he hit two autos and hit this gentleman and his wife and his wife, both of them became unconscious and I am in this hospital’s OPD at 11 o’clock or 11.30 I get a call from his number and somebody else is talking. So whose phone is this? This particular person has sustained a head injury, we are taking him to the nearby hospital.

Oh my God, must have been such a shattering experience that now he has undergone three surgeries. He has undergone three surgeries. He has improved but not normal, right? So it’s a very close personal friend of mine, like a right hand to me and these things are numerous experiences that I have plenty of experience in that.

So the thing is first parents should not only think about the future of their kids but they should also, we also have a responsibility to the other members of our society. One thing I would say is never, however much your kid insists, there are certain times when we have to put our foot down and say no, that’s far no further, right?

And second thing I have observed that something is kids never often don’t listen to what we tell. Yeah, they see what we do and then they follow it. So in this context it will be pertinent to observe next time, for the next one week, 10 days when you are driving on the road, just look at the number of two wheelers. You see a family with one kid in front, dad, another kid and mother and you can see the parent occasionally, not always, occasionally parents jumping the signal, right? Parent coming in the wrong direction. Now what happens is that this five-year-old kid or eight-year-old kid who sees that, he or she thinks that if my dad or mother is going to do it, maybe it’s the right thing to do.

Dr. Hema Sathish:Yeah, probably.

Dr. Muthukumar:And he or she will do it, either they will get injured or they will injure someone else. Either way, someone is going to suffer. All because we are not prepared to spend two minutes at the signal. Or we are not prepared to take a U-turn somewhere else. We just want to take a shortcut.And we can’t rely on the government. We don’t have enough. No government, no country in the entire world has enough police personnel to enforce all the rules. We have to have some civic sense, some responsibility has to be there. So I think parents, as you rightly pointed out, parents do have a significant role. First thing is set an example by driving properly, sticking to the traffic regulations, and insist upon the kid that do this, don’t do that.

Dr. Hema Sathish:That’s very, very true because we are the ones who set examples for our children. We are the ones who can teach them, tell them how to go about things. And we have to be responsible.And I’m glad that there’s a law which has come in because I have seen many cases. I just spoke about a little child, but I’ve seen many, many cases where somebody has driven very harshly and gone and hit somebody else who was so innocent. They would have been just standing somewhere. Or there was one instance when they were sitting in the veranda in their house and somebody has just driven in scrupulously inside and just hit the gentleman over there and the man died. And it was so sad to hear. The case was in fact brought in dead. The patient was brought in dead to the hospital.

Dr. Muthukumar:It’s a very heart-wrenching experience.Even though I’ve been treating head injuries for more than three and a half decades now, when we see a breadwinner of a family or a young teenage boy getting admitted with a very severe head injury, which is probably sometimes life-threatening, and then you see the family members crying outside the ICU, even though we have seen hundreds of such cases, every time it’s painful to see that because even though we may not as doctors, we may not show our emotions outside, but we feel the impact of that. Because as I said, it is not the patient alone. The entire family, the course of that family, everything will change. From that point onwards, that life will not be the same again. That life will not be the same again.

Dr. Hema Sathish:And again, the person who is incurring the injury also, their life is also going to change so drastically. You never know if they’ll be back to normal again. Absolutely. So the seriousness of the situation has to be understood by everybody around.

Dr. Muthukumar:So years ago, I think in our national society, it is the National Society of India, we have a trauma awareness before most of the conferences, the annual conference, whichever city we conduct it, the day before the conference, on the evening, we have a trauma awareness program, head injury awareness program, spine injury awareness program, etc. So we call the school students, college students, the traffic police.

Dr. Hema Sathish:That’s very good.

Dr. Muthukumar:And the city officials, etc. And then conduct a head injury awareness program. So that we have been doing that. And then we also have a neuro trauma society of India, which also has come out with contacts, all this interaction with the public to impress upon them.So what is required is prevention. The age-old saying, prevention is better than cure, holds very good everywhere, especially in head injury. So now when you say prevention, yes, of course, we have to prevent by not getting injured. Now in older individuals, as you said, avoiding a fall. So could you give some thoughts about what you feel, how we could prevent injuries in older people or how the family members can take care of their loved ones who are older and who are not very stable?

How to prevent injuries in older people?

Dr. Muthukumar:It’s a very important thing because world over, including India, the average life expectancy is increasing. Somewhere in India, somewhere in the late 70s, and the next decade or so, we will be touching close to 90. So that’s the projected estimate. So we are going to have elderly people. And elderly people have their own set of problems. One is that their reflexes will not be as brisk as they were when they were young. When they are wearing. And the second thing is, some of them may become a little unsteady due to age-related neurological issues. thing which commonly happens is that many of my patients, elderly patients, when they come to me for some other complaint, because elderly people generally have insomnia, they have difficulty falling asleep. As we grow older, it’s a natural process, we have difficulty falling asleep. And then they ask me for a sedative or hypnotic. I tell them that I don’t have any problem prescribing a sedative, but you are elderly, you are definitely going to get up once or twice, if you are a diabetic much more often, in the middle of the night. An elderly person is likely to be a little more unsteady. And if you are going to be drowsy from the sedative which I am going to prescribe, the chance of you falling is very high. So you think about it before you ask for this medication. I think they should be made aware of that. Made aware of that.When I spend time with them and tell them this particular aspect, several patients say, no, no, I’ll try to manage. Or occasionally some of them, on those days when I am just not able to get to sleep, or I have somebody to take care of me. So the best thing is prevention. So make them aware that when we grow older, the chance of fall is not only if we can fracture a hip, you can also injure your head. And many of the older individuals, because they have cardiac issues, they may be on medications like aspirin, clopidogrel, etc., which increase the chance of bleeding inside. So what happens is all these multiple problems will add together. So one small event, just a small slip and fall, one thing will lead to another. It’s like a pack of cards falling. Like a domino effect. So that’s very important.So one of the things, so there are, I think there are, if a person, elderly person feels unsteady, does not have anyone to look after, or they don’t want to disturb them, they can use a walker or some such thing. And the toilet they can have, because toilet when they get up from the toilet, sometimes they may feel a little giddy. So when they get up, they can have some sort of a handrail on the side. So that will help, especially while taking bath, they can slip and fall because of the soap on the floor. So it’s better to sit, have a stool.So these are all small, simple measures, which if they reduce, it’s not possible to completely eliminate the chance of head injury. We can make an effort to reduce the chance of injury.

Dr. Hema Sathish:So they’re very, very small things, but they can take you a long way. So your loved ones should be taken care of, even with small, small things.So one best preventive method is wearing a helmet. If you wear a helmet, how much can you save your brain or your head from getting badly injured or you from getting very debilitated?

Importance of helmet

Dr. Muthukumar:I think helmet should be, or helmets are mandatory in our country. In many states, it’s mandatory only for the driver, only for the person who drives the two-wheeler. And there are some states I’ve seen, I think in Northeast or somewhere, where the pillion also, I don’t know whether it’s because of law or they are doing it on their own. The pillion also.

Dr. Hema Sathish:Yeah, some cities they have, the pillion rider has to wear.

Dr. Muthukumar:In fact, if you look at it, the chance of a pillion rider sustaining head injury is more than the, because the pillion is likely to be thrown off in the case of a collision. So ideally everyone should have a, everyone, both the person who drives the two-wheeler and the pillion, both should be wearing the helmet. And there is absolutely no doubt, absolutely no doubt that helmets certainly prevent head injuries.Suppose, that doesn’t mean that, suppose you get run over, the head gets run over by a truck. Those are so severe injuries that even helmets cannot prevent. But vast majority of head injuries can be prevented. Okay. Even if the helmet breaks, at least what you lose is only the cost of the helmet. Your life is saved. Right? So that way helmets do have a role.And I have started seeing some cycling enthusiasts, even in our city, they have started wearing helmets, the bicycle helmets. So that some awareness is coming. And I have to say that after the recent change in the road traffic regulations, which came into force a few years ago, the complaints with the helmet has certainly increased.

Dr. Hema Sathish:That people also understand.

Dr. Muthukumar:People also understand. And since the police are also a little strict with their enforcement, the complaints with wearing helmet has also certainly increased. But it is still not sufficient. Everyone who rides a two-wheeler should wear a helmet. Preferably the pillion rider. I personally feel even the pillion rider should also wear a helmet.One of the things I found is I have seen patients who have sustained head injury, very educated patients, occupying high position who drive two-wheelers. One person has come to me at least once, many, but at least I remember one who came to me three times. Okay, all the three times he did not wear a helmet. The first time he was in the ICU for one month. And he was almost, he was one foot in the grave. And this man recovered so well, went back and came back one year later with another head injury. This time it was a mild head injury. And I asked him why you have specifically told you why you should wear a helmet. No, sir, I was just going to the next street. I thought it was a short drive. Short drive and someone came in the wrong direction, hit him as we were talking. So, and this is something because accidents are not pre-planned. They are called accidents because they happen unexpectedly. So even if it is going to be a short drive, it has to be.And worst thing? Those people who wear helmets, they should always strap their helmets. Because especially in the morning time, when you see, when the people are rushing to their office, to their work, they are in a hurry. So what happens? They just put the helmet. They will not strap it. Oh, that’s not. When you fall down, the helmet will be the first thing that will be flying away. So it is not going to protect you. So there are many times when I stand at the signal and somebody is standing in the two-wheeler with this helmet not buckled. I almost have a tendency to roll down my window and tell him, please buckle. But then sometimes people might not like to get the advice.And I have seen, in our own hospital, I have seen several patients where the helmet went on women, the patients. So wearing helmet is mandatory. Pillion should also wear a helmet. And please make sure, please make sure that you strap your helmet. And the helmet is not being worn for the police. So please don’t place the helmet on the petrol tank. Please don’t place it on your area mirror. It is not worn for the police. It is worn for you and for your future generations. So it is very important that you should wear the helmet, both the rider as well as the pillion.

Dr. Hema Sathish:Excellent, sir. Because I hope at least some people learn from this. And there’s one more thing for prevention, which I always believe from my heart is, you know, if you see somebody like, we see many a times, you know, this parents take two children and they ride on a two-wheeler in India. It’s very common because we don’t have much rules and regulations. And they are the ones who are in a hurry. They do not follow any rules, no regulations. They just cut through traffic and just zip, zap, zoom. So when you see them, you know, I keep telling my children and I do it all the time. I say empathize with them. Let them go if they are in a hurry, you know. Because if somebody in a car or something makes a mistake or we go ahead or we just, you know, we say, oh, what the hell, he’s going ahead. And if we hit him even lightly or even bump him off, the number of people who are going to be hurt are much more.

Dr. Muthukumar:Yes, I completely agree with you. I also do the same thing. In fact, one occasion somewhere in our city it happened. Couple of, you know, the youngsters and the teenagers with their high-speed bikes, they used to drive very fast in a zigzag way. So on one particular occasion I saw these people coming in from a distance in my rear view mirror, I slowed the car.

Dr. Hema Sathish:Yeah, that’s the best thing to do.

Dr. Muthukumar:I slowed the car because I at least let them go. So let them not get hit. And for some reason I had moved to the left side of the lane. I didn’t notice there was a traffic policeman standing there. He didn’t do anything. He didn’t, I mean, because they just zipped past us. There’s no way the traffic policeman could have stopped it. Now what happened, this policeman came and I rolled down the list and said, why did you stop? See, I told him I’m a neurosurgeon. For so many years I have seen young boys like this getting admitted to the ICU. And I have seen their parents crying outside the ICU. So when I see a young boy or a girl driving like crazy, first thing is let them go home safely. Let them go home safely. So I slow down the car, let them pass. This is the minimum we can do. Because we cannot advise, stop and advise everyone. It’s not possible.

Dr. Hema Sathish:But at least somewhere, you know, we should also be part of somebody else’s prevention of head injury and accidents.

Dr. Muthukumar:That’s absolutely true.

Dr. Hema Sathish:So when you see a patient with a head injury, there is a lot of things which will happen to them after the head injury. This is one part prevention, how not the head injury should happen. But unfortunately, if such a thing has happened, what do you see and what happens to them after that? So if we could talk about that, maybe it could create more awareness amongst people to understand that, you know, they should take care of themselves and not injure their heads.

 

How to take care of ourselves without getting injured?

Dr. Muthukumar:I think it’s an extremely important topic and needs to be emphasized because a lot of advancements have taken place in head injury management, which has significantly decreased mortality of head injury. The past 30 years or so, the mortality of head injury has significantly decreased because of advances in management and treatment. But still, the complete effects of head injury cannot be reversed in certain severe cases.

What I’m referring to is if the patient is going to have a severe head injury. Now, some of these patients, not all, some of these patients, some even with moderate head injury, can have memory disturbances, can have behaviour disturbances. Over a period of time in the first few months or so, these memory disturbances tend to improve. The behaviour disturbances tend to get settled down most often with medications, right? But there are some people for whom the damage has been so severe; they will not be able to go back to their original personality, both in their personal as well as in their professional life. So that is something that we need to keep in mind.

Because, for example, if a person is going to be a… I had one IT professional. He was a team leader in this particular good IT company. They took him back. They downgraded him fully knowing that he cannot perform because they wanted to give him a job. But he was not even able to perform at that level. Eventually, he was sent home. Eventually, he was sent home. Now, this 30-year-old man who has two kids, right? Now, just imagine that family.

So there are behaviour disturbances, which sometimes the spouse does not tell or the parents or the others do not tell. Some people may come out and tell us that these are the behaviour disturbances they have. So whenever a patient first in discharge from the hospital comes back to me for review, the first thing I ask them, apart from the physical aspects of their health, I ask them, how is their memory? I ask the spouse or the parent or the other caretaker, how is their behaviour? So these are important things that really matter.In fact, a study was done in our institution, not by some senior colleagues, and they found nearly 84% of patients with severe head injury.

Dr. Hema Sathish:That’s a large number.

Dr. Muthukumar:84% they had some sort of a varying from mild to severe cognitive impairment. And some of them get, there are some marital discords which ends up in the couple getting separated. So these are a lot, these are, that’s the reason why I said when we started off that it doesn’t affect that particular individual. It affects the entire family and even the next generation.Because if the parents are going to get separated, child is going to be raised in a single parent home, which is probably not a great thing.

Dr. Hema Sathish:It is traumatizing for the child.

Dr. Muthukumar:It is traumatizing for the child. And if the patient’s parents are alive, in their elderly age, in their old age, this guy or girl cannot take care of their old parents. So look at the implication of that. Look at the implication of that. And this is something which we see often. And to some extent, this can be remedied by medication, but some of them cannot be completely remedied. So once again, coming back, harping back on the same theme, prevention is better than cure.

Dr. Hema Sathish:We have seen that, especially in Indian scenarios, what happens is if a person is unwell, then all the focus is on that person. And what about the caretakers? What about the people around them? So they are all expected to sympathize, empathize and do everything. But it takes a toll on everybody. And that has to be kept in mind.

Life of caretakers

Dr. Muthukumar:Hattiya, Hiddhi, Bulsai. I think there are now in all major journals which deal with certain incurable diseases or diseases which have a prolonged duration. They study the caretaker burden, burden of the caretaker, caretaker burden. Because on the family members, it takes a big toll on the family members financially, socially, emotionally. It takes a toll on the family members. So especially if there is going to be a primary caretaker, that particular caretaker’s life will never be the same. So the caretaker burden is a big issue.

Dr. Hema Sathish:It’s very true and it’s very overlooked because people just think, oh, the person is so unwell, he or she is unwell. Why can’t you take care? I mean, one has to understand how much can that person push, how much they compromise so much on their life, especially if it’s a male and the woman has to take care. Oh my God, you have to handhold them so much to go through this. It’s probably much more painful than the person who is actually suffering with the disease.

Dr. Muthukumar:Absolutely.

Dr. Hema Sathish:They have done so much of counselling for them and it really hurts. And nobody in the world understands. Because for the outside world, for them to see, they would probably saying, oh, you’re so lucky that he’s still alive. And then you are there. You should be taking care of him because you are the wife. You should be doing this. And that’s very, very.

Dr. Muthukumar:It’s a very difficult job to take care of a very sick person for a prolonged period of time, irrespective of whether it’s head injury or some other issue. It’s a very, very difficult issue. And it takes a toll on the person who takes care. So the society and the friends and family should also have some empathy for the person who is taking care.So that’s something which, because what happens is when I shift my patient with severe head injury from the ICU to the ward, I tell them that circadian rhythm, the sleep-wake cycle will change. What happens is this patient will be sleeping during most of the time, not all, most of the time they’ll be sleeping during the day and they wake up somewhere around 1 a.m. That’s the time when the caretaker will be, even if they want to sit and look after them, they have no choice, but they will be falling asleep. And there have been occasions where after going home, the patient, because the caretaker has just fallen asleep for five minutes, got down from the bed, fell down, sustained another injury. So it’s not an easy thing to do.

Dr. Hema Sathish:It’s very tough.

Dr. Muthukumar:Very tough on the caretaker.

Dr. Hema Sathish:I’ve seen very close people who have, and you know, sometimes what they come and say, we can understand. But if somebody outside hears it, they’ll say, oh my God, that’s ruthless, they would say. But then it’s fair enough. But, you know, we have to tell them that, of course, and build their strength also. But, you know, empathizing with them and understanding that they also go through trauma helps them a lot more. So maybe you should keep that in mind also and help somebody who is the caretaker of a person who is actually injured or who is very unwell.

So sir, could you please elaborate a little on the post-injury, post-head injury rather, rehabilitation?

Post-head injury rehabilitation

Dr. Muthukumar:Post-head injury rehabilitation is a very important area. Unfortunately, this is a rather neglected area in our country. Because the past 30 years, clinical services, both in public and private sector, have improved very much. And the corresponding, there has been decreased in the mortal rate following head injury also. But then when it comes to post-head injury rehabilitation, the services are woefully inadequate. And this rehabilitation is extremely important, especially during the first few months or first year or so. That is the period when rehabilitation should be done properly. That is where the maximum effect can be achieved. And this rehabilitation should include:

• Cognitive rehabilitation.
• Occupational rehabilitation.
• Physical rehabilitation

If the patient has got a physical And it is preferably done in one center which has considerable experience, which have all the three under the same roof. So the patient spends one hour for cognitive rehabilitation, takes a break, goes for occupational rehabilitation or physical therapy or vice versa, somewhere like that. So the patient gets some time in between. Everything is under one roof. And the patient should preferably, if possible, or if it is needed, should stay in the same place. There should be facility for the patient and the family member to stay. So that way the ambience should also be such that they can stay, they should have all the comforts and they should have this cognitive, occupational, physical rehabilitation. This is extremely important.In this context, I’d like to say that when we talk of mortality in injury, most will talk of in-hospital mortality only. The mortality that occurs. So recently I had a chance to review an article from a very, very big tertiary care center in this country. It was published in a very good international journal. So the one thing I found and I wrote in the comment is that when I reviewed the literature in Western countries also, not only in developing countries, Western countries also, the post-head injury, post-discharge mortality, post-discharge mortality has not come down.

Dr. Hema Sathish:Oh. That is alarming, right?

Dr. Muthukumar:Post-discharge. So the study which I’m referring to had a multi-rate of inpatient mortality rate of 8%. The average post-discharge mortality even in Western countries is somewhere between 15 to 20%.

Dr. Hema Sathish:Oh my God.

Dr. Muthukumar:Can you believe that? Because there are several reasons for that. One is that in countries like ours, there is lack of adequate rehabilitation facility. And second reason is that with increasing use of alcohol and drug abuse, some of the patients who sustained head injury or patients who abuse alcohol and drugs, so they tend to repeat the same. They tend to be repeat offenders. Okay. So probably the word offender is not the right term, but they tend to go back and use drugs or alcohol and tend to sustain head injury.

Dr. Hema Sathish:Oh. That’s bad.

Dr. Muthukumar:So these things happen not only in developing countries like ours, but also in Western countries. There’s something which is really alarming because as medical professionals, especially as neuroscientists, we tend to focus mainly on inpatient mortality. What happens after the patient goes home? The post-discharge mortality, that is substantial. That does not come down. That mortality is due to various other factors, some of which I mentioned. So that is very important.

Dr. Hema Sathish:I think that’s where tertiary prevention takes its role. So there are so many things available for tertiary prevention. And I think, you know, as Sir said, so inside the hospital, mortality is less. But then once they go back home, there are so many other things which creep in.So it was wonderful, Sir, talking to you.

Dr. Muthukumar:Thank you.

Dr. Hema Sathish:Starting from the causes of head injury, how to prevent and then rehabilitation. I think we covered most of the spectrum. Of course, I know you have, your knowledge is so vast that one day might not be enough to cover this topic. But thanks a lot. It was wonderful having you here. Thank you, Sir.

Dr. Muthukumar:Thanks for the opportunity. Thanks for having me.