Hidden Trauma

When Emma* found herself gasping for breath one evening in July, she shrugged it off. As a 38-year-old with no prior health issues, she assumed it would resolve on its own. But as the night went on, she continued to find it difficult to breathe, as though there were a heavy weight on her chest.

The Salisbury resident, who lives alone, phoned 911 around dawn and was taken to the ER by ambulance. There, she was wheeled on a gurney to a nursing station, where she waited for what felt like 45 minutes before finally, somewhat desperately, telling the staff she really needed to be seen now. She couldn’t breathe. In retrospect, she wishes she had called 911 immediately that evening, rather than waiting until dawn, as she realizes that was just more time her brain was not getting enough oxygen. She was put on a nasal cannula, which delivered oxygen through her nose.

Despite a negative COVID-19 test, Emma was told she likely had COVID—or another virus. Her white blood cell count was high, but all other tests came back normal. After two days, she was released.

“I came home to a whole new world,” she says. Her brain was not functioning as it used to, and seven months later, her symptoms persist. She struggles with short-term memory, in particular, and, like so many others suffering from brain injuries, she’s had difficulty finding the care that she needs.

“I don’t really know what the lessened oxygen has done to my brain, but I’m aware that lack of oxygen can cause memory problems,” she says. “I keep returning to: There must be damage to some areas of my brain that otherwise functioned before the lack of oxygen…Now I’ve come to terms with the fact that this kind of experience does lead to a brain injury.”

While people are becoming more aware of traumatic brain injuries, such as the kind you receive from a blow to the head, non-traumatic brain injuries—anoxic and hypoxic injuries caused by oxygen deprivation—have similar chronic effects, and can be just as detrimental and tricky to treat.

The pandemic, meanwhile, has become a perfect storm for these types of brain injuries. COVID itself can result in lack of oxygen and strokes. (That loss of taste and smell that continues for several weeks or months after a COVID infection? Experts say it can be due to brain damage.) The pandemic has also exacerbated domestic violence and drug abuse, both of which often lead to brain injury—through overdoses and, in the case of domestic violence, strangulation.

“One of the great challenges of an anoxic or hypoxic brain injury is that you really don’t know where the oxygen stopped going,” says Bryan Pugh, executive director of the Brain Injury Association of Maryland, which is based in Baltimore. “If I’m in a car crash and my airbag goes off, it’s really likely I’ve got a frontal brain injury. Then you have the ‘coup-contrecoup’ [injury], which sends your head back, and it’s very likely you have an occipital injury because the brain hits the back of your skull. If I get T-boned, the part of the brain that’s going to be impacted the most is the side, so you know what to look for.”

It’s much more difficult, however, to diagnose a brain injury due to loss of oxygen. “The reality is, with overdoses and strangulation and COVID, or any time you’re cutting oxygen off from the brain, you really don’t know what’s damaged,” explains Pugh. “It’s incredibly frustrating when you’re trying to tell a family member how long the recovery is gonna be, are they gonna recover, what are they gonna recover…You’re talking about the organ in the body that is both your personality and you. There’s a lot wrapped up in it.”

Patients out of acute danger are still left confused and frustrated. They say things like, “‘I used to be a mountain biker, and now I can’t balance to ride a bike,’” says Pugh. “Or ‘I used to be a reader, and now I forget everything I read.’ Or ‘I used to like to go to the movies, and now the flashing lights and the noise drive me insane.’ You just have to find your new normal.”

Which is not to say improvement and recovery is impossible. “The brain is an amazing organ and can rewire itself,” says Pugh. “We’ll see recovery from brain injuries 20 years out, 30 years out—all of a sudden they can do something they couldn’t do before.”

There’s a saying: If you know one person with a brain injury, you know one brain injury. Some commonalities are memory loss, slower processing time, sensitivity to light and sound, irrational anger outbursts, mental and physical fatigue, depression and anxiety, brain fog, impaired ability to make decisions or plans, poor impulse control, weakness, balance issues, smell and taste disorders, and headaches.

Dr. Anna Agranovich, a rehabilitation neuropsychologist at Johns Hopkins Medicine, performs a cognitive assessment to identify strengths and weaknesses of brain injury patients. Some tests, including MRIs and CT scans, can sometimes show injury. Treatment consists primarily of mitigating symptoms.

“We work together with our rehabilitation team in designing strategies to build on their strengths and get around their weaknesses,” Agranovich says. “We teach coping skills. There’s no one-size-fits-all. It’s very targeted and specific to each individual.”

They teach mindfulness to help with poor impulse control and emotional regulation, as well as compensatory memory strategies, like writing down important things to remember. “It’s a combination of different approaches based on a person’s presentation and their needs and level of functioning,” Agranovich says.

“THE BRAIN IS AN AMAZING ORGAN AND CAN REWIRE ITSELF…”

DOVE, a program at Northwest Hospital in Randallstown, provides services to victims of domestic violence, many of whom suffer brain injuries. A 2017-2019 study by Brain Injury Alliance Nebraska found that 58 percent of women screened for a possible brain injury in domestic violence shelters tested positive. Estimates of individuals with brain injury in the public range anywhere from five to 24 percent. And in some cases, the person doesn’t even know it.

“We think of head injury as being one really bad injury to the head, but it could be that they’ve been strangled repeatedly and maybe thrown to the ground and hit their head a bunch of times,” says DOVE founder Audrey Bergin. “Maybe no one time caused loss of consciousness or any obvious injury, but the cumulative effect can impact the brain.”

Bergin has spent decades helping domestic violence victims, and says even diagnosing brain trauma is an uphill battle.

“One time I was in the hospital with someone who had been strangled really badly, and no one was offering to do any sort of radio-logical exam,” she says. “I thought, I’ve broken bones before and it’s not obvious on the outside that something’s wrong, but when they X-ray it, they see there’s a problem…In the emergency room, they’re just treating the emergency. With head trauma, there can be long-term, lingering effects.”

Because so many people come to DOVE with brain injuries, the staff is sensitive to their needs. They use lamps rather than fluorescent lights in the facility because fluorescents often bother people with brain injuries and can cause headaches. They supply everyone with a notepad and pen to help with short-term memory issues. They give clients information in small pieces, because they often have a litany of things to do and it’s hard for them to plan and be organized.

“It can be so complicated with these clients, when you see that they’re missing appointments and not able to prioritize, and realizing that it could be from emotional trauma or mental health issues or a brain injury,” Bergin says. “It could be very easy to label someone and say, ‘Oh, they’re not cooperating,’ or ‘They don’t want help.’ We try to understand what’s going on and not make assumptions.”

DOVE is staffed with counselors, case managers, an attorney, even a therapy dog, and a part-time nurse at LifeBridge follows up with client care. Since the pandemic began, Bergin has seen a huge increase in requests for therapy services, as well as an uptick in lethal domestic violence by an estimated 35 percent increase, and a 700 percent increase in the number of clients DOVE is sheltering.

“These women might say, ‘No, he never punched me in the face, but he choked me unconscious all the time’—which can lead to cognitive and executive functioning issues and the inability to initiate,” says Pugh. “Why do these women stay with these men? Maybe they have a brain injury and they’re not capable of thinking through how to [leave]. This was only made worse with COVID, because now you had to hunker down in place with your abuser, and there’s a greater likelihood that they lost their job or started using drugs or you started using drugs.”

After leveling off for three years, likely due to the overdose treatment Narcan, opioid overdose deaths increased by 23 percent in 2020. And those who survive drug overdoses are far from out of the woods.

“Now with fentanyl being sprayed on marijuana and mixed with Xanax and other drugs, people think they’re getting one thing and they’re not prepared to handle the high intensity,” Pugh says. “First responders are amazing at bringing these people back with Narcan, but it’s taking six, seven, eight hits [to revive them], and that takes five minutes each time, so some of these folks are coming back and they’ve basically been at the bottom of a pool for 30 minutes.

“We’re training people on using Narcan, but we’re bringing people back without really letting them know that, okay, you have a substance abuse disorder now, but you’ve woken up with a brain injury, and we have to treat that accordingly.”

Leslee Cramer, a longtime educator with Frederick County Public Schools, was in an abusive relationship when she was 18. Only years later, when working with a therapist, did she realize it had caused a brain injury.

“I was nearly strangled to death,” she remembers. “It took me four years in therapy to admit that was a brain injury. I never had a proper diagnosis, but I’m just as disabled as the person down the street who had a stroke and can’t speak.”

She has also suffered concussions since then, and notes that brain injuries have a cumulative effect. Now 57, she continues to have problems with energy, memory, processing information, headaches and neck pain, hormonal issues, and her seasonal depressive disorder was exacerbated “by a million,” as she put it—to the point where she moved to Florida about two years ago for the sunshine and warmer weather, knowing if she stayed in Maryland, she couldn’t function.

“I’m an educated person, and the first thing you think is you can research your way out of a brain injury,” she says. She’s tried various doctors, neurologists, psychiatrists, supplements, and biofeedback. Nothing has helped but coping strategies, adjusting her lifestyle as best she can. “A lot of us are struggling, and we’re falling through the cracks,” she says. “Thank God for art and music and sunshine.”

*Not her real name.