Head cases
Authors: Daniel A. Peterson
Journal: Journal of Clinical Investigation (2009)

Michael Paul Mason is a brain-injury case manager at the Brookhaven Hospital Neurologic Rehabilitation Institute in Tulsa, Oklahoma. In Head cases, he provides a very useful commentary on the outcome of brain injury that should be considered by patients and their families, health-care professionals and administrators, and those responsible for public policy on health-care delivery. 

Drawing on the author’s professional experience, Head cases is essentially a personal narrative organized into a series of patient vignettes. Each chapter focuses on the outcome of a patient’s brain injury, both in terms of the specific medical impairment and of the consequences this has for the patient’s ability to continue with life. Typically, postinjury life is impaired and differs substantially from the patient’s preinjury lifestyle. However, there are some poignant examples in which good may arise from the outcome, which helps to illustrate the complex and individual nature of brain injuries. 

There is a suitably broad representation of the range and severity of brain injuries and the long-term impact these have on patients and their loved ones. In an early chapter, Mason successfully introduces the basic neurobiology and neuropsychology underlying the vast range of outcomes that can result from a momentary and localized brain injury. The term brain insult is used to define the point of injury, and Mason explores the extended meaning of this term with regard to the consequences that the patient must live with following this pivotal event. Examples are given of injury resulting in severe seizures, memory loss, aggression, dissociative fugue state, and cognitive impairment. There is a particularly enlightening example of locked-in syndrome, a condition in which a patient is awake and aware but unable to move or communicate due to complete paralysis of nearly all voluntary muscles in the body. Pathology-derived injury is also addressed through examples of brain tumors and viral infection. A chapter describing brain injury and the consequences of posttraumatic stress disorder in Iraq War veterans is particularly moving and conveys the urgent need for rational reform of rehabilitation policy, as one considers the long-term care requirements of the injured, both military and civilian. 

What makes Head cases significant is not that the author has these experiences to relate but that he achieves a consistent and well-developed narrative that ties these individual stories into a comprehensive commentary on our ability to care for and accommodate these most vulnerable members of our society. The text is well written, reflecting an engaging style with strong and precise narrative construction distilling each vignette into a powerful, self-contained message that leaves the reader pausing to reflect. Classical references, philosophical musings, and discussion of the separation of mind and brain serve the author’s purpose of humanizing the brain-injury patient. As the author states in conclusion, “Their brains have undergone irrevocable change, but their humanity abides.” 

Head cases is not a call to action, but rather a call to understanding. Mason compels us to consider whether the current state of care for these patients is appropriate, without forcing a specific policy upon the reader. Brain injury may not always respond to rehabilitation, and long-term personalized care may be needed. Thus, this patient group, perhaps more than any other, illustrates that there is no single treatment plan or health-care policy that will meet the needs of all patients. Health-care professionals and administrators may find some of the matter-of-fact observations uncomfortable at times. But the real obstacle to progress identified in this book is the neglect of long-term care of brain-injury patients engendered by inadequate policies and insufficient resources. Unfortunately, the patchwork or absent provisions in many states are consistent with many aspects of health-care delivery in the US. One chapter tells the compelling story of a patient with a poor care outcome due to living on the wrong side of a state boundary. 

Empathy may be rekindled in reading, but policy change requires more dispassionate measurements to effect systematic change. There is a need to fund and conduct careful studies documenting the benefits and success rates of the longer and more intensive patient-tailored rehabilitative processes advocated in this book. Such data are needed to truly influence policy, and this book will have made an important contribution if it encourages such studies.

Head cases is compelling reading and will bring needed information and a sense of community and realism to brain-injury patients and their families. However, it also provides a valuable commentary on the health-care field and should be read by those in a position to influence public policy on rehabilitation programs. For the research community, Mason presents a humbling realization of how difficult the challenge of neurological restoration is while underscoring how important it is to pursue.