• head injury
• motor crashes

Sometimes we don't respond to the statistics on trauma among adolescents because they are so mind numbing. Stereotypical views of adolescents as reckless and irresponsible also may inhibit our prevention efforts. Too often we focus on mortality and ignore morbidity. The difference between the two is measured in fractions of a second at the time of the injury event and forever in the lifetime of the survivors. Let me illustrate what I mean by telling you about Rhonda.

I first saw Rhonda as a patient when she was 15 years old. She had come from the Okanagan Valley and was referred because of acting out behaviour. She came from a religious family. Her mother was a homemaker and father ran a small contracting business. The family was very respected, had a reasonable standard of education, and a comfortable lifestyle. Rhonda had been an above average student who did not smoke or drink, and was an accomplished pianist. At least that is the way things were before she was injured.

It was a hot, clear summer day when Rhonda hitched a ride home from a schoolmate. They had been at the beach with friends. Steve was 16 years old, had had his driver's license for three months, and was driving his “new” pick-up truck. He was very proud of it. They set out for town with four teens in the front cab and three, including Rhonda, sitting in the back. They had shared a few beers so every one was happy but not drunk. No one except Steve was wearing a safety belt. It was supposed to be a fun filled 20 minute ride but it proved to have a lifetime impact.

The last thing Rhonda remembered was the three of them sitting in the back singing to the booming rock music. The crash reconstruction showed that Steve lost control on a curved stretch of gravel road. The truck rolled before coming to a stop, upside down, in the ditch. The teens in the back were all thrown clear but one boy hit a tree and died while the truck crushed the other boy.

Rhonda was more fortunate. She was found, unconscious, but otherwise uninjured some 10 feet away. She was transported 150 miles to the nearest neurosurgical unit. The next thing she remembered was waking up in hospital with her neck in traction and a splint on her right arm. The next few days were pretty much a blur. She was gradually ambulated, and discharged a week later and soon returned to school. Life was returning to normal, and everyone was telling her how lucky she was.

She later told me that, even then, she didn't feel lucky. She felt guilty for being alive, sad about losing two of her friends, and mad at Steve for getting off scot-free. Meanwhile, the crash left her with a disfigured hand, no longer able to play the piano, and with parents who seemed to always be hovering over her. Besides, she still had the coroner's inquest to look forward to.

The next two months were a disaster. On October 1, her birthday, she decided to celebrate with her friends. She got roaring drunk and became so depressed that she ended up in hospital on suicide watch. It was later reported that she had begun acting inappropriately at school, laughing at nothing or talking loudly, starting fights, and coming to school drunk. The family called the school counsellor to see how she was doing and discovered that she was missing classes and getting failing grades. Before they knew it, she was suspended.

At home, she just sat around the house all day and partied most nights. Sometimes she wouldn't come home at all and was beginning to hang out with an older crowd. Her parents worried that she was doing drugs and would become pregnant. These concerns prompted the appointment with me.

I did a full interview and physical assessment and saw her parents as well. I found Rhonda to be a pleasant, attractive, modest young woman who was perplexed by the way her family had arranged for her to see me. She acknowledged that her lifestyle had changed but denied it was influenced by the crash or her injuries. She was the same old Rhonda, just having more fun. Why should they make such a big deal?

Rhonda's behaviour didn't strike me as particularly rebellious but I acknowledged that her drinking was out of character for her and for her family. Based on the personality changes, history of binge drinking in the weeks before the accident, her subsequent rages, failing school performance, blackouts, and bouts of depression, I thought she was an early alcoholic. Rhonda was certainly not convinced but I went ahead and recommended alcohol and drug counselling and a negotiated return to school. Things seemed headed in the right direction.

In fact, her school performance didn't improve, she began to go to all weekend drinking parties, and would return home in a terrible state. After much agonizing, her parents, fearing the impact of her behaviour on the other children, kicked her out of the house. They arranged for her to live with an uncle, and I agreed to see her weekly.

But coming to Vancouver was not the end of Rhonda's rocky road. In fact, it seemed to only increase her risk taking behaviour. She continued drinking, was sexually assaulted by an older man, moved in with a physically abusive boyfriend, and lost touch with her family. But she kept coming to see me and bit by bit the pieces of the puzzle began to come together.

While in Vancouver she became even more socially inappropriate. She was back at school but couldn't remember where her locker was at school, was found to be performing at a grade 8 level in math (she had been in an advanced math class in grade 10), and was becoming very impulsive. This was when I began to wonder about my diagnosis. Was the head injury a more significant factor than her supposed alcoholism?

We arranged for her to be assessed by a group who specialized in reviewing head injury cases for the Insurance Corporation of BC (ICBC). Their report was quite clear, confirming the importance of the head injury. The psychological test results resulted in recommending a different rehabilitation program. She started on one intended to retrain her in some basic cognitive functions. She was slow to accept this new diagnosis and the change of direction it would require but liked the therapist and realized that attending an ICBC prescribed rehabilitation program might increase her chances of obtaining financial compensation from the crash. I confessed to her parents that I was afraid that she would blow the money on booze and drugs.

Eventually Rhonda graduated from high school and got a job as a waitress. Her lifestyle improved a little. She would laugh and tell me “I am mellowing”. When she turned 19 the compensation money came and she blew it all on clothes and partying. Six months later she was broke and desperate. It was then that she met Pete. Within a year they were married, she was pregnant, and both were back living in her home town.

Rhonda called me recently. I hadn't heard from her in two years. It was her 21st birthday. She told me she just decided to phone me to say “hello” and let me know that she was happy in her marriage, was expecting her second child, had stopped drinking, had reconnected with her family, and was taking some community college courses. I told her about an article I read on subtle head injuries and we joked about how I had accused her of being an alcoholic. She remembered that I had predicted she was going to end up on skid row. How wrong I was! However, in those days we paid little attention to “minor head injuries”. Today, I hope we would know better and would not let a year go by without moving more quickly to provide appropriate cognitive therapy.

Any injury prevention specialist could review the crash and Rhonda's subsequent history and identify many opportunities for prevention. For example, zero tolerance of drinking-driving, graduated licencing, better police supervision, safety belt enforcement, emergency first aid training, more accessible ambulance services, and better brain injury assessment programs. The reality is that we still sometimes overlook these opportunities.

Rhonda's tragedy was not a statistical abstraction and the clinical challenges she presented ended up consuming an incredible amount of resources. She has, with characteristic adolescent resiliency, responded to the challenges. Rhonda seized the opportunity to build a new life for herself. She is fortunate the story ended as well as it did but the long term impact on herself and her family remains to be assessed.