(0:09) James: I am talking to Julie Mitton and Mark Wilson, who are the theme leads for the Prevention and Education programme in the Health Tech Research Centre for Brain and Spinal Injury.

So Julie, perhaps I can come to you first. Prevention seems to me like the best way to reduce the long-term impacts of brain injury, am I right?

(0:28) Julie: Yes, everybody knows the expression, prevention is better than cure. And certainly, brain and spine injuries are actually, can be devastating events for people. So if there's anything that we can do to stop them from happening, we should be trying to do it.

(0:42) James: And Mark, I know that you work in emergency medicine, so you see people who have had these nasty injuries quite often. Are there times where you see people and you think, if only they just… this wouldn't have happened?

(0:54) Mark: Yes, very much so. So I'm a neurosurgeon and air ambulance doctor, so I regularly see people who, it's just beyond devastating when you see incidents happening. And trauma is usually an entirely preventable disease. So it is something that we, yeah, it's often associated with a great deal of regret. And I always feel our job is to minimise ongoing injury. There's no better than prevention, absolutely. But once it's happened, preventing the ongoing injury as well is a really important part of what we do.

(1:26) James: Yeah, that's interesting. So it's prevention a bit, I guess, in kind of education, stopping things happening. Wear a cycle helmet, put your seatbelt on. But also then that next stage of prevention of preventing things from getting worse, when we're kind of into hospital.

(1:40) Mark: No, so very briefly, everyone divides things up into primary injury, which is, you know, the impact, and then secondary brain injury is everything, or spinal injury, the thing that happens after that. And yeah, the role of public health and mitigating all the things you do, as you say, cycle helmets, road design is preventing the primary injury, but also there's then preventing the secondary injury from evolving as well.

(2:00) James: And Julie, what kinds of things can we do to stop those secondary injuries happening? Is it doing the way that we treat patients in hospital, or we assess them? What do we do to stop it?

(2:11) Julie: So one of the most important things we talk about if somebody's, if you've had an injury event. And (during that injury event) somebody has sustained an injury, the most important thing you can do is to try to make sure they get the right treatment as soon as possible after the event so you're minimising the consequences of that injury. So a really good example of that, it would be imagine you've had somebody come off a motorbike. And they're lying on the road. What you want is you make sure that actually, people don't start moving them around a lot. Because you want to look after their spine. So actually getting really good first response care as soon as you can afterwards, so that you're actually minimising the consequences of that injury event, is really helpful.

If we can stop the injury event happening in the first place, that's even better. So you know, making sure that motorcyclist is driving at the right speed by maybe having speed bumps in the road to slow people down or crash barriers to stop them coming off the road. Making sure that they're doing things like wearing a crash helmet so that you might not stop the injury event, but you actually might limit the head injury that happens when they do come off the bike. So there's lots of opportunities to intervene, both in sort of, the public environment and legislation, and then also in helping people adapt their behaviour so that they're less likely to sustain those injuries.

(3:34) James: Yeah, and I guess that's where the problem comes in, because it would be great if we weren't dealing with people. People are irrational, we do stupid things, don't they? And they know what they should do, but they don't do it.

Mark, are there other ways that we can kind of intervene? Are there innovations, technologies that we can use? We've talked a bit about road design. Are there things that we can do to prevent secondary injuries happening? Are there cool devices and bits of tech?

(3:58) Mark: Yeah, I mean, there's an absolute plethora. And yeah, you can talk about it in many different ways. There's tech out there that can help us triage better, so as in like make a better decision about what kind of resources are needing to be deployed. Detect injuries in a way from gyroscopic data in cars, things like that. There's a whole plethora of exciting innovations in this space. And I guess our job is to try and evaluate those as best we can, see which ones will have the biggest impact.

Although there is also an element of so-called marginal gains. Every little bit you can do to mitigate against both the primary injury and the secondary injury will have a knock-on effect. And the other thing to really emphasise here is that brain injury (like most other acute medicine) is a time-critical disease. So the longer something is left as a hypoxic injury, or a bleed that is progressing, the longer that is left, the more damage is done. So speed is an important component of most of the elements of triage and pre-treatment in what we're looking at.

(5:06) James: Yeah. And I guess part of that is knowing where to send people. Do you bypass the nearest hospital to go to a major trauma centre? Or is it more appropriate for them to get care in the nearest place because you might be there a bit quicker? And I guess those decisions are quite difficult to make sometimes.

(5:20) Mark: In a pre-hospital, I think they're very difficult. I think there's a whole host of decisions that we, you know, we don't know what's going on inside someone's head. That's the most important thing. In the in-hospital we do a CT scan, easy, not a problem then. But pre-hospitally, you know, is someone drunk? Are they just agitated because they have had a fight? Are they got hypoxic brain injury going on? And in the world we're living in now, a lot of elderly patients who may have underlying dementia or other things in that. Maybe that's the reason they're agitated. So trying to work out what is going on inside someone's head in the pre-hospital environment is very difficult.

(5:51) James: Yeah, interesting. So Julie, we sort of talked a bit about the prevention, and what about the education bit? It seems to me that that's education of first attenders, about the best way to treat and assess people, as well as education to prevent injuries happening in the first place. Who are the different groups that we want to target with these kind of education messages?

(6:10) Julie: So very often when we're working in injury prevention in the public health sphere, we try to look at the whole system, all of the different people that are involved in that event. So for example, if you were interested in preventing head injuries in sport, say. You'd want to think about, okay well, you might want to, there might be some individual behaviour change that you want, to make sure that the players are aware of what they can do to keep themselves safe from having that head injury. But also you've got to have the referee in the match. You might have to have the coach that trains the team. You might need to have, if there's some, I don't know, St John's Ambulance staff on the pitch side, you know, volunteering that weekend, you might need to know what they need to know. And then, you know, you've got your first responder team as well. So it's not just the education of a single individual. It's the education across the different people that are involved in that injury scenario that you want to be working with.

And one of the things we do have to remember with education is, education is one component of what we do. So just because we know we shouldn't do something doesn't mean to say we always follow the rules. You know, we all know maybe that we shouldn't drink too much alcohol, but that doesn't mean to stop. Every now and again, people might overindulge a bit. So just because you know something's bad for you doesn't mean to say you'll follow the rules. So having other things that work alongside education are really helpful.

(7:43) James: So are there particular projects that either of you are working on at the moment? I know that you both work in research in one way or another. Are there exciting things that you want to tell me about that you're already pushing to the fore?

(7:57) Mark: We have a big study at the moment called the spinal immobilization study, which is going to carry on for another year now. And that's basically randomizing people who have a traumatic injury to having the standard triple immobilization (which is collar blocks and tape) versus movement minimization. So slightly more comfortable, no collar, and they're allowed to sit up a little bit. Which for lots of reasons is a very controversial area of pre-hospital care, you know, whether we should be really triple immobilizing people or does that do more harm than good?

And that's because we've got another, we've recruited about 370 patients so far. We're going to get to 2,000 is our aim. So hopefully get some data from that that, can go on to educate in terms of what the right thing to do is. So that's a really simple example of this area of understanding the data better and then going on to make better recommendations.

And I should just also add, there's a lot of subtle stuff within this as well. So it doesn't have to be education (as in like, you know, flip charts and educating people) but actually you're doing, understanding the data better means we can put out better guidelines, better standards (for example, for helmet design) and other things that go on in the background. No one will ever see that that's actually a thing that's happening, but it does influence the management of TBI and spine and other things in that early phase.

(9:04) James: Yeah, I know there's a team in London have just done some cycle helmet research, haven't they, where they've classified which ones are the best and not necessarily the most expensive one that's kind of better for you.

(9:15) Mark: Often inversely proportional, to that.

(9:19) James: Yeah, looks nicer. And Julie, what about you? Have you got current projects that are kind of exciting you?

(9:21) Julie: Yes, so we've been doing a project trying to maximise the value of the existing data that we've got, for children that are turning up to the emergency department, following a relatively mild bang to the head, so these mild traumatic brain injuries. What's interesting about those children is, the vast majority of them do really well afterwards, they recover quickly, they get back to normal and they're fine.

There are some children who appear to have a relatively mild bang to the head, but actually, they really struggle afterwards. They have problems with their sleep, they have problems with their concentration, they don't settle back into school, they start getting, you know, behind with their schoolwork, they might start getting known as the naughty child in the classroom. All sorts of things can escalate out. And those behavioural changes that happen are likely to be linked to the concussive episode that they've had. But actually it wasn't realised that, although there were no signs, they were absolutely fine in the emergency department, there was no care that went wrong, for some reason those children don't have the good outcomes.

So what we've been trying to do recently is look at emergency department data, and then look at children who then come back into care with symptoms afterwards to see, can we work out which children are more likely to have problems than not? And what we hope we might be able to do with that, that could lead on to other studies, where we can then sort of maybe try to test some prediction tools. That emergency department doctors could use to try to think, “okay, this is somebody we might want to bring back and actually check how they're going in a week's time or in a month's time”, rather than letting them go back without any follow-up. So that's an area where I think it's a good example of how, actually using data, can really help us think about improving these head injury outcomes in the longer term.

(11:13) James: Yeah, really interesting. I've met some people who had their injury when they were really quite young and they were fine until they hit puberty. And everything kind of went out the window, and then you don't even remember that there was a head injury 10 years ago and get lost. So finding somewhere, I guess, of trying to predict the outcome in advance is going to be really valuable, isn't it, for that kind of cohort?

(11:35) Julie: And we increasingly know that multiple concussions are really bad for you. Yeah, you know, I don't think that was historically really understood. But actually now we know, that those people who do less well in their careers, in school, people who are more likely to get involved in trouble with the law and things like that, often they've had a history of more than one concussion. So there's a real need for us to sort of identify these people at risk early, and try to do what we can to prevent those poor outcomes.

(12:09) James: Yeah, interesting. We started this conversation, I guess, talking about how we prevent the injury, but actually what we're about doing is preventing those people getting lost in the criminal justice system or preventing really poor quality of life for people further on down the line.

I guess that brings us to one of the aims of the HRC really, which is to kind of support development of these new innovations. So in five years time, what do you think we're going to see? Are we going to see some great things changing behaviour or changing those impact of those primary injuries? What do you recon Mark? What you think? What's going to happen? What's in the magic box?

(12:45) Mark: No, I think there's a lot of things that are happening moving in parallel. And that's the way it should be. So, we're already seeing this even over the last 10 years or 20 years with guidelines for concussion, and you know, innovation. And I've been in this space for a reasonable amount of time now, and the things that we've kind of been predicting over the last few years are now coming to the fore. So the ability to get better preoperative diagnosis from whether it be from biomarkers, or potentially imaging, those things are becoming reality at the moment. So and then, and then with the educational piece, the greater understanding of this, the more awareness, especially in schools, and those ones, I think are all happening in parallel. And what we need to do is just keep supporting that, and finding new innovative ways of taking that in for the next 10-20 years as well.

(13:34) James: Yeah, and I guess it's finding that evidence base. So which ones of those things are actually making a difference and having that kind of impact? Julie, what do you reckon? What's in your magic box? What's going to be different in five years time?

(13:45) Julie: Well, what I'd really like to be different in five years time, is that we have a much better understanding of some of these population groups that are at risk and the circumstances that they experience. So if we can better understand who gets injured, how, when, where, why and how they get injured, that data can then indicate those areas where we want to target specific interventions, and where we need to develop the tech. Because the tech is built on having good quality data. So one of the things we need to get better at is capturing really good information about the circumstances of head injury and spine injury events. It's one of the things that actually, we don't often collect very well in hospital. Once you come into hospital, everybody's interested in collecting data about how you are now, but not necessarily about what happened when you got injured. So recording that is really helpful for us to then develop the tech that will help with the prevention messages and with the preventive care.

(14:52) James: Yeah, and I think something that we've been very weak on in the past is that we're quite good at understanding white Western men, aren't we? We know quite a lot about them and what happens to them and how they behave. Not quite so good at developing things for other kinds of communities.

Well, it's been a fascinating conversation. Thank you ever so much for finding the time to have a chat. The HealthTech Research Centre is really interested in hearing from people who are interested in being involved in research. You can bring your lived experience to us and tell us how you engage with the kinds of issues that I've been talking about with Mark and Julie. But on that note, we'll wrap up. Thanks ever so much for giving me your time. Good to speak to you.

(15:27) Mark: Thank you.
(15:30) Julie: Thank you.