Brain Bucket | Straight Talk from the Stanford ER

Brain Bucket

The mild temperature and cloudless sky last Saturday lured people outside onto their bikes, horses, motorcycles and basketball courts. Unfortunately, even the most careful sports enthusiast can suffer an accident and several men and women wound up visiting our ED for a variety of bruises, lacerations, broken bones, and worse. By early afternoon, a motorcyclist with a lacerated spleen, truck driver with a hand fracture, and equestrian with multiple rib fractures (thrown and stepped on by her horse) had all rolled through the trauma room.

As I furiously clicked away orders for a patient with chest pain in our critical care room, the nearby trauma phone went off for the third time in under an hour.  The charge nurse pressed the receiver, "This is Stanford." A few phrases of the paramedic's report caught my attention: "Hi Stanford...trauma activation...elderly gentleman...unhelmeted...front tire rolled off...struck head on pavement...loss of consciousness...repetitive questioning...see you in 10." 

Someone nearby quipped, "Shall I put in the head CT order now?"

Minutes later, I stood amongst other members of the trauma team with a lead apron over my royal blue scrubs, purple gloves on my hands and red trauma shears in my back pocket. We chatted about the previous traumas of the day but quieted as the clerk pages overhead, "Trauma has arrived, Room 5".

Two paramedics calmly rolled the gurney into the trauma bay. The man strapped in C-spine precautions was chuckling about something said outside and trying to gesture with his hands tied to his sides.  I felt some relief; he was awake and talking.  The next thing that caught my attention was a two inch welt just near his left temple that was already turning a dark purple. I ran down the primary trauma survey..."airway intact, equal breath sounds bilaterally, 2+ pulses, moving all extremities (thankfully...).  Immediately, I performed a quick neurological assessment. "57Delta's" solo complaint was that his left head hurt; the rest of him appeared unscathed. He told me he was on a leisurely ride with his wife, when the front tire came off his bicycle causing him to pitch forward over the handlebars and land on his head. The rest of the events were foggy. His memory finally cleared somewhere on Route 280 while in the ambulance to our Trauma center. We rate a person’s overall level of consciousness with the Glascow Coma Scale. It is composed of three parts rated together on a scale of 3 to 15: motor response (1 to 6), verbal response (1 to 5), and eye opening (1 to 4). This patient had a GCS of 14 when the paramedics first picked him up because he was disoriented but currently had a perfect score of 15. I did not discover any focal neurological abnormalities, another reassuring sign. Nonetheless, our next course of action was to order that CT scan of his head.

CT three was ready and waiting. As 57Delta was alert and mentating very well we felt comfortable sending him across the hall for his scans. Some patients with severe head injuries must be intubated if they are obtunded and cannot protect their airway. He wasn't out of the woods yet though. The location of his hematoma was very close to where a major artery - the middle meningeal artery- ran underneath his skull. Fractures in that location can lacerate the artery causing a brisk bleed. Even though the injured person acts normal after the accident, blood accumulates undetected. These epidural hematomas will eventually run out of room to expand in the enclosed skull, causing pressure on the brain that can push it downward towards the spinal canal. As the base of the skull impinges on the brainstem – the area responsible for breathing – death can occur. We needed to get 57 Delta to the scanner to ensure he didn’t have a brewing neurosurgical emergency.

Minutes later, we scrolled through the images on the computer. Relief swept over me. No bleeding, no fractures. In the end, 57 Delta only needed two stitches and a tetanus shot and post-concussion instructions. His wife berated him several times for not wearing his helmet (a lecture I’m sure was carried on the whole drive back to his house) and promised to watch him closely over the course of the night for any mental changes. They were home in time for dinner. Before leaving the department, the man promised me he’d purchase a shiny new helmet to wear with his next bicycle.

57Delta was extremely fortunate. In my short time at Stanford I have cared for unhelmeted bicyclists who sustained major head injuries that likely would have been prevented if they were wearing a helmet. One teenager was taken urgently to the operating room to drain a bleed in his brain. Several others needed to be observed in the hospital overnight following severe concussions. These are just a few examples of the half a million bike riders injured every year in the United States. The CDC reports that head injuries account for approximately one-third of all bicycle related ED visits and two-thirds of all bicycle related deaths. Even those without any objective neurologic findings can suffer a postconcussive syndrome characterized by headache, dizziness, fatigue, irritability, impaired memory and concentration, insomnia, and lowered tolerance for noise and light. These symptoms may last anywhere from a few days to several months. It is estimated that one-half to three quarters of bike related head injury could have been prevented with a helmet!

For every 57 Delta that survives a bike related head injury, there are other patients whose lives are altered forever. It pains me to see bare headed cyclists out around Stanford’s campus and on the Portola Loop. The Stanford Campus bike shop and chain stores like Target and Walmart sell them for only $20 ( It is a small price to pay for protecting your head…and your life.

Jennifer Rossi, MD

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The Stanford Emergency Room is the center of emergency care at Stanford University.