It is not our style in Diagnosis to write tributes simply because our mission is to discuss diseases from human angle perspective. But when you come across an uncommon act of benevolence and love in this our endeavour, it becomes almost irresistible not to tell the story especially if one has the privilege of a medium. It so happened that on October 21, along the Lagos-Badagry expressway there was a ghastly traffic accident involving a small commercial bus, an Okada with a young lady as the passenger and a truck. The Okada rider died a few minutes after arriving at a sister health facility. The bus driver abandoned is vehicle and took flight. He was pursued by the colleagues of the bike rider. He managed to escape but his bus was smashed and set ablaze by an angry mob.
The female passenger on the bike was rushed to us in coma with laceration on the right leg. As at the time she came she was barely breathing and her radial pulse was weak and thread. It was pretty late in the day to contemplate a referral to a tertiary health facility, and the urgent need then was to restore the blood pressure as near normal as possible and to ensure that enough Oxygen gets to the brain. Making a diagnosis then was not our priority. A clinical impression of Traumatic brain injury was just good enough. Resuscitation and stabilisation of the patient were paramount in our minds then. Of cause the lacerations were sutured without any form of anesthesia administered.
In the interim the facility needed hypertonic glucose and saline solution dexamethasone or any available glucocorticoid and other drugs to make the patient comfortable. These in a profit driven private health facility will require some stipends- The patient had no relations around and even the touts that brought her to the hospital were demanding financial settlement for their effort. This resulted in serious argument and quarrel with other well-wishers in the hospital. To them the story of the good Samaritan in the bible was balderdash
At this point came an ‘angel’ by the name CHINYERE IBE a twenty-seven years old graduate of mass communication of Madonna University, 2014 set. Chinyere is from Imo state and was on her way to work somewhere in Lekki. She lives at House 7 Rasheed Yusuf street, Onireke opposite Ojo Barracks along Lagos Badagry axis. She works with Access Bank with office at Plot 7 block 2 Oniru Private estate Lekki. When she read the situation on ground, she did the unthinkable. She did not have extra cash on her but was bent on offering financial assistant to the victim. She requested for an account number to which money was transferred for the patient’s care. When the touts saw this kind gesture from the young lady, they were humbled and left.
Traumatic brain injury is commonly of two variants; cerebral concussion and cerebral contusion. Concussion is normally referred to mild head injury that temporarily affects brain function. This clinically may manifest as loss of consciousness, headache, nausea, vomiting, memory loss, difficulty with thinking, concentration, sleep disturbances and mood changes. Even when not unconscious, maintenance of a stable gait could be a challenge. These symptoms could commence immediately following the trauma or be delayed for a day or two. Structurally or anatomically speaking concussion is a diffuse and non-focal event inadvertently affecting a wider area of the brain when compared to the area of impact.
On the other hand, cerebral contusion results from a bruise of the brain tissue. This is commonly associated with small bleeding known as microhaemorrhages in the brain just like one can have in a bruise in any other part of the human body. It must be differentiated from cerebral laceration in which the membrane covering the brain, the Pia-Arachnoid is torn. Contusions usually result from severe head injuries. If the clinical features are related to the side of impact it is referred to as coup but if the bruise is on the opposite side of the impact it is known as contre coup. Classically it is the cerebral cortex area that is commonly affected in contusion mishaps. In terms of mechanism of complication during contusion it is pertinent to remind ourselves that the floor of the skull bone are various grooves and sharp edges on which the brain tissue can be rocked during accidents.
The hallmark of cerebral contusion is the relatively high expression of hemorrhage in the brain during the lesion. This is followed by a cascade of biochemical changes involving the extrusion of potassium ions from the neurons, an enhanced glucose uptake, decrease presence of glutamate and other neurotransmitters and a build of carbon dioxide. Eventually there is poor circulation of blood as a result of global fall in blood pressure following the impact. Dreaded in this course of events is the swelling or rather oedema of the brain. This would eventually lead to increase in intracranial pressure that may lead to the forcing down of midbrain structures through the hole where the central nervous system continues as the spinal cord known as foramen magnum or the big opening in the base of the skull.
This condition commonly referred to as herniation or coning is a life-threatening condition that can rapidly progress to fatality if adequate measures are not taken promptly. Thus in principle when a head injury presents either from a sports encounter, road traffic accident or domestic violence, the care giver should be proactive in managing hypotension, hypercarbia (increased carbon dioxide in the brain) and hyponatremia which is low sodium in the system. In a resource constraint environment such as ours, it is expedient to always remember the A, B, C, D, E, and F of the man agent of patient with either contusion or concussion who is in coma.
The letters stand for; A airway, B breathing, C cardiovascular integrity, D diuresis and F fluid balance. In about 50 per cent of cases in this environment, if there is no massive haemorrhage and cerebral laceration the patients eventually do come around it. But this has no bearing in long term sequalae of traumatic brain injury. Clinically speaking there not much of difference between the symptoms of concussion and contusion except that there may be local features both physical and neurological in relation to the area of assault in contusion.
With respect to our index case, the patient fully recovered consciousness by the third day on admission and was discharged on the fourth day. On their way home the relations expressed a lot of displeasure with the health facility because the patient was not give plenty of drugs to take home except paracetamol and multivitamins. They just couldn’t understand why the hospital was so stingy!