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Doctor: Gabrielle Giffords 'holding her own' after shooting

By Rob Stein and Shankar Vedantam
Washington Post Staff Writers
Monday, January 10, 2011; 11:55 AM

Rep. Gabrielle Giffords's doctor said the congresswoman was "holding her own" at a hospital in Tucson early Monday morning, with CT scans showing that the swelling in her brain is not getting any worse.

President Obama and first lady Michelle Obama led the nation in a moment of silence at 11 a.m. Eastern time to pray for Giffords and the other victims of Saturday's shooting rampage. Six people were killed, and, in addition to Giffords, 13 others were injured.

Hundreds of lawmakers and Congressional staffers stood shoulder-to-shoulder outside the Capitol in a cold wind, as flags flew at half staff at federal buildings across the country. Obama and his wife appeared on the South Lawn of the White House with scores of staff members, and stood solemnly for a minute before returning indoors. At the Supreme Court, all nine justices bent their heads and closed their eyes, and the packed courtroom fell completely silent until Chief Justice John G. Roberts Jr. said, "Thank you."

Giffords, 40, was shot through the head Saturday, allegedly targeted by a deranged constituent. Doctors said Sunday that the passage of the bullet through only one side of her brain and her initial responsiveness give hope she could survive and even possibly recover.

"We are more and more encouraged," physician Michael Lemole, who is treating Giffords, said on ABC's "Good Morning America." He said doctors "want to start getting her out of bed in coming days" to avoid blood clots, and will be watching out for signs of new internal bleeding or infection.

The Arizona Democrat has entered a crucial 48-hour period when swelling from the trauma of the bullet blast could cause as much damage to her brain as the initial wound, possibly triggering a major deterioration of her condition, medical experts said. Giffords also likely faces a long period of rehabilitation to limit permanent disabilities.

While most people who are shot in the head or suffer other severe head trauma do not survive, there have been remarkable cases of victims who have come back- such as Jim Brady, President Ronald Reagan's press secretary, who survived a gunshot wound to the head during the 1981 assassination attempt. Brady lost the use of his left arm and leg, but largely recovered otherwise.

"It's hard to say anyone is ever really completely okay after being shot in the head, but [Giffords] has a good chance of being able to walk away from this," said Arthur Kobrine, a professor of neurosurgery at Georgetown University Hospital who treated Brady's injuries. "She has the chance to move around and laugh and walk and cry and talk and maybe even return to Congress."

Brady's injury was much more serious than Giffords's, yet he made a "miraculous" recovery, Kobrine said. Still, doctors said there is no way to predict Giffords's prognosis.

"Everyone is cautious about calling it, but I am optimistic," said Peter Rhee, trauma medical director at the University Medical Center in Tucson, whose team got Giffords into neurosurgery within 38 minutes after first seeing her.

"This is about as good as it gets," Rhee said. "When you get shot and the bullet goes through your brain, the chances of your living are very small."

The shot was fired at close range, allegedly by 22-year-old Jared Loughner. It entered the congresswoman's brain at the back and exited from the front, which suggests she was turned - or turning - away from him as the shot was fired.

The bullet traveled through a significant portion of Giffords's brain, Rhee said, but fortunately did not cross from the left hemisphere to the right hemisphere, or vice versa. When a bullet passes across a brain, it is much more likely to do more devastating damage, including to life-sustaining areas such as the brain stem.

"The people who tend to do best are the ones who have gunshots that do not cross through the midline," said Christopher Kalhorn, associate professor of neurology at Georgetown University Hospital. "When gunshots cross the midline, the prognosis is much poorer."

In Giffords's case, only the left side of the brain was damaged by the bullet. An intact left or right hemisphere means a victim can retain significant functioning even with the other side severely damaged.

Damage to the left hemisphere, however, can be more serious than damage to the right. The left side of the brain controls movement on the right side of the body and, for all right-handed people and most lefties, is also largely responsible for speech and the ability to understand speech. Doctors said this makes the congresswoman's responsiveness to basic commands remarkable.

"When I first heard about a gunshot wound at point-blank range I thought, 'There's no way she's going to survive,' " said Vivek Deshmukh, director of cerebrovascular neurosurgery at the Providence Brain Institute in Portland, Ore. "But if she came to the hospital and is following commands, that really bodes well for her. That means the bullet must have missed some crucial areas."

Before she was wheeled into surgery Saturday, Giffords was able to respond to commands such squeezing her hand and showing two fingers, which suggests that she can hear, understand and execute basic motor movements.

But doctors cautioned that there is a significant gap between being able to execute such commands and recovering the complex social, communication and executive skills that go into being a member of Congress. From a medical perspective, such responsiveness immediately after the shooting is an important clue as to the congresswoman's odds of survival - but not necessarily her prognosis.

Lemole, a surgeon at University Medical Center in Tucson, said that the amount of "devitalized" brain tissue that they removed was small. With Giffords under heavy sedation and breathing on a ventilator, doctors said they have been unable to determine whether she is capable of more complex communication. So far, there have been no reports that Giffords has been able to talk after being shot.

"That's a key question. The most critical part of the brain on the left side is the part of the brain that controls speech," said Eugene Flamm, chairman of neurosurgery at the Montefiore Medical Center in New York. He said the left side also contains areas crucial for judgment, reading and other high-cognitive functions.

Next to the immediate damage caused by the bullet's entry and exit, the largest source of trauma in a gunshot injury is internal bleeding and the buildup of pressure in the brain within the first 72 hours, doctors said.

Although doctors could do nothing to reverse the immediate damage, Lemole said, they did remove bone fragments lodged in her brain, some dead brain tissue and some healthy bone from the skull to give her brain room to "relax" and relieve pressure that might build up.

"The general rule of thumb is the faster you recover, the better your recovery will be," Lemole said. At the same time, he cautioned that that was only a rule of thumb, and that recovery among individual patients ran the entire "gamut." Recovering from a gunshot wound to the head, he added, was a process that could last months, years or even a lifetime.

Giffords is likely to be receiving antibiotics to reduce the risk of infection and anti-seizure medication to prevent seizures, several experts said. In some cases, a device is placed in a patient's brain to measure the levels of pressure. Doctors said Giffords could return to surgery to have a tube inserted to drain fluid if pressure does increase.

"Swelling can be equally destructive. If you have swelling inside the brain, the brain has nowhere to go. It causes other injuries to other parts of the brain. So the most important thing you can do is relieve the pressure in the brain," Deschmukh said.

With the full extent of the damage to the congresswoman's left hemisphere unknown, it is not clear whether Giffords will recover complete functioning.

"Whether she'll be able to recover from this is not clear to me, and I'm sure it's not even clear to the doctors who are caring for her at the moment," Flamm said.

There's also an element of sheer luck. In a much-cited case, a metal rod exploded into the brain of a railroad worker named Phineas Gage in 1848, destroying important parts of it. Gage recovered significantly, and lived another 12 years.

vedantams@washpost.com steinr@washpost.com

Researchers Lucy Shackelford and Allison Klein contributed to this report.

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