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19 March 2015

Graham didn’t know what had hit him – he was fine when he left the pub

In this week's Health Matters, a man finds he has been hurt on the way home - and Phil Whitaker suggests sometimes the best thing to do is move on.

By Phil Whitaker

A week before I saw him, Graham had suffered a head injury. He’d sustained a sizeable laceration at the back of his scalp, and the impact must have been of sufficient force to knock him out cold. He could remember leaving his brother’s 40th birthday celebrations at about one in the morning. His next memory was of being in A&E and having his wound stitched. He was told that a passer-by had found him wondering aimlessly, covered in blood, and had summoned an ambulance, but he had no recollection at all of these events.

A period of amnesia is invariable with a significant brain injury and, indeed, it serves as a gauge of severity. In the worst cases whole weeks or months of life can be lost irretrievably. Graham had a gap of a couple of hours, meaning his outlook was good: a full recovery could be expected. Nevertheless, the post-concussion symptoms he was experiencing – headaches, dizzy spells, irritability and poor concentration – were likely to persist for up to six weeks.

The brain is cushioned inside the protective case of the skull by a bath of cerebrospinal fluid (CSF). CSF absorbs the shocks of day-to-day activities but is unable fully to mitigate the effects of powerful impact with another object. Post-concussion syndrome can be thought of as the gradual resolution of the bruising and swelling of the brain that arises in such circumstances.

One immediate problem was knowing what had caused the injury. Graham had been more than merry when he left the party to walk home, so the likeliest thing was that a slip or stumble caused him to fall backwards and crack his head on the pavement. Other explanations were possible, though: he could have had a seizure, for instance, or suffered a disturbance of heart rhythm, causing him to faint and fall. Him being a previously healthy father-of-three in his late thirties, these were unlikely but not impossible. The lack of an eyewitness, together with Graham’s amnesia, meant we were never going to know. The only thing was to wait and see: if there had been an underlying problem it would very likely recur.

He returned the following week with a new air of bewilderment about him. He said he wanted to discuss “the assault”. In the days since I’d seen him, the police had been in contact to say that his bag – missing since the incident – had been found abandoned in a front garden. His wallet had been stripped of cash and credit cards. Most disturbingly, evidence of his blood had been found at shoulder height on a nearby wall. The police inferred that he’d been shoved hard into the brickwork, sustaining the knockout blow. His assailant(s) had then taken everything of value in his bag, leaving him unconscious in the street.

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People come to terms with traumatic events in different ways, but memory is a crucial common factor. We replay things again and again in our minds over a prolonged period, gradually processing what has happened and moving on from it. For some, the emotions aroused are intolerable: memories are repressed instead and the trauma remains unprocessed, its effects resurfacing in nightmares, flashbacks and the myriad other psychological symptoms that comprise post-traumatic stress disorder.

For Graham, the challenge was different – he had no memory either to process or to repress. He would probably never know who had attacked him, what had actually gone on between them, whether he could have done anything to avoid it happening. Indeed, while the police’s account sounded plausible, he might always be dogged by uncertainty as to whether it was the truth.

Gently, I encouraged Graham to get back to work and return to normal life. The greatest threat to him now was to become “stuck” in his presumed victimhood. The greatest protection against that lay in reimmersing himself in family, friendships and the other roles that had given him his sense of self before the night of the lost hours

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