Head Case

A year after sustaining a neurological injury in an accident, Dr. Laura Herzog was losing hope. Words eluded her; simple tasks were impossible. Then a colleague suggested she try hyperbaric therapy. Today she is leading a pioneering study of the effectiveness of this treatment for head injuries.

A car accident brutally cut short Dr. Laura Herzog's work as a physician. A year and a half ago, on her way from Katzrin to her home in Moshav Yonatan, the car she was driving flipped over and crashed into the mountainside. She was subsequently diagnosed with a mild head injury. The once brilliant and witty woman who had always possessed an excellent memory, an experienced pediatrician who, until seven years ago, was in charge of the pediatric track at Ben-Gurion University's medical school in Be'er Sheva, became a shadow of her former self. Her memory betrayed her, words kept getting lost, simple actions became impossible. "My brain, my most precious tool," she recalled this week, "became something that ranged from a fog to sticky chewing gum. I knew that things were in there, but I couldn't reach them or pull them out."

After a very difficult year, Dr. Herzog was close to giving up any hope of returning to normal functioning, let alone to her profession. But next month, at Assaf Harofeh Hospital, an unprecedented study will get under way: It will examine the effect of treatment in a hyperbaric chamber - in which patients breathe in oxygen that is at higher than atmospheric pressure - on chronic neurological injuries resulting from stroke or traumatic brain injury. Leading this study will be Laura Herzog.

Herzog, 50, is a living example of the success of this treatment. Six months ago, she ran into an old classmate who works in the pediatric neurology department at Assaf Harofeh. The friend told her about several brain-damaged children in the department, who'd experienced a significant improvement in their condition following treatment in a hyperbaric chamber. Herzog, who'd already sought the help of top experts in the United States, to no avail, decided to try the treatment herself.

After an intensive series of treatments inside the chamber, she felt a big improvement. Brain mapping done prior to the treatments highlighted the damaged spots in her brain where the blood flow was weak; after the treatments, the blood flow returned to normal. Herzog doesn't like it, though, when people call her a "medical miracle." She insists on keeping things in proportion: She is still feeling some heaviness, she sometimes forgets things and, above all, the cognitive effort she has to make is often wearying. Nevertheless, a month ago, with tremendous excitement, she resumed work as a pediatrician.

Our meeting takes place in her home in the Golan Heights moshav. As she makes her way from the parking lot to her house, friends greet her and sometimes ask for medical advice. She responds gladly. It's hard to believe, but just six months ago, when a neighbor would approach her, she says, she couldn't always remember how she knew the person or what his name was.

Herzog was born in Maryland and grew up in a secular Zionist home. Her father, William Pollin, a renowned psychiatrist, headed the National Institute on Drug Abuse. Her mother, Marilyn, was a social worker. Laura immigrated to Israel at age 22. After three years on kibbutzim - Hatzor and then Ein Dor - she returned to America and enrolled in medical school.

Herzog: "I decided to study in the U.S. because I was looking for a program with a community-based approach. I went to the States and took a few courses, and then heard that in Israel there was a medical school in Be'er Sheva with a holistic philosophy, and it sounded just right for me." She then returned to Israel, where she was accepted at Ben-Gurion University (BGU). Her ties with Soroka Medical Center, where the faculty of medicine is located, would last for nearly two decades: After graduation, she did her pediatrics residency at Soroka, and then served for years on the faculty - as a lecturer, a member of the admissions committee and, eventually, as director of the pediatric track, in addition to serving as a senior physician in the hospital's pediatrics department.

She met her husband, Dr. Eran Herzog, an anesthesiologist, during medical school. "In 2000, for completely ideological reasons, we decided to move to the Golan," she explains. "We'd always loved the Golan and we thought it was a place that's important to the Jewish people. So we made the move." By then, they had five children, ranging in age from four to 13. She began working as a pediatrician in various northern communities, and devoted one day a week to the pediatrics department at Rebecca Sieff Hospital in Safed. "Life seemed perfect," she says.

'Bump on the head'

One December evening, as she was returning home from Katzrin with a hitchhiker in her car, a large porcupine ran onto the road and got caught in the wheels. "The car suddenly veered left," she recounts. "And the steering system didn't respond. There wasn't much I could do. I saw that I was going to hit the mountainside. I was fairly calm. The thought went through my mind that nothing much would happen. At worst, the car would be totaled. The last thing I remember is a wall of rocks coming at me."

Her next memory is of the shouting of the passenger next to her. "At the time, I didn't realize that I'd passed out at all. I freed myself and my passenger from the seatbelts and I smelled smoke. That was the first time I got nervous. Somehow I stood up and then saw that I was standing on the door on the driver's side and that the passenger door was above me."

An ambulance arrived quickly and the two women were rushed to the hospital. Only in the ambulance did Herzog notice that she was injured. "I had a lump the size of a half-grapefruit on my head. I said: 'Okay, I got a bump on the head,' and all I could think about was that I wanted to go to sleep. I didn't think that anything was seriously wrong. I was just desperate to go to sleep." She was released from the hospital after being diagnosed with a concussion and told to rest. At home, she couldn't stop vomiting. "For ten days, I was a total wreck," she says. "And I don't even remember most of it."

Her family could tell that something wasn't right. Herzog wasn't pronouncing words clearly, she kept forgetting things and most of the time she just slept. "The process of [experiencing] a head injury is a fascinating process," she now says. "You never realize how badly things are messed up until others tell you. At first, I didn't notice the mistakes, the difficulties. The only thing that bothered me was the noise. The noise drove me mad and this is very typical of head injuries. I went around with earplugs. Even now, when a few people are speaking with me simultaneously or when there are several stimuli around me, my brain shorts out.

"In the beginning, the most noticeable thing was the memory loss. In the first months after the injury, I lost 20 kilos. I simply forgot to eat. I'd go to the kitchen and then I'd see something and it would distract me from the hunger and I'd get busy with something else. You know how many times I went in the kitchen and then couldn't figure out how I got there?

"It's like an extreme case of attention deficit disorder. Every little thing would distract me from something else. The big problem was with the kids. When I'd say to them: 'I told you to do such-and-such,' they'd tell me: 'You didn't tell us.' I'd start to talk about something, switch to something else, and then go back and repeat what I'd said before. The kids would say: 'Mom, you already said that.' My whole life, I'd relied on my mind and especially on my fantastic memory - for people, faces, details; I could remember children who'd been my patients in the hospital 15 years earlier, which bed they were in, which room; I remembered the blood test results of every patient from two years before. And now I had no recollection at all of what I did 10 minutes ago?"

Herzog also had difficulty speaking; she found it hard to retrieve words from her memory. "I wanted to say something and what came out was gibberish. I got lost. Simple things, everyday things - I couldn't find them. In the next stage, and this is the fascinating part, because you see how the brain rehabilitates itself - instead of gibberish I would say the wrong words and then people would correct me. At a later stage, I groped for the words and then came out with those that were close to the ones I wanted, that were similar."

How did your family cope?

Herzog: "In the beginning, we all thought it was a temporary thing. That it would pass in a week or two. I wasn't functioning at home. One of the problems with head injuries is the indescribable exhaustion and weariness. I'd get up in the morning feeling great. I'd make lots of plans. I'd wake up my daughter, make her a sandwich, rinse the three plates in the sink - and that was it. I was wiped out. I had no more energy. It's like your head is a battery that can't hold a charge. The battery charges, but then it gets drained very quickly. The household wasn't functioning. I'd put in a load of laundry. After a few hours, I'd be all proud of myself for remembering to transfer the clothes to the dryer. And later I'd discover that I never turned on the machine."

Simple calculations became impossible, and she was unable to resume her great love: reading. "When I started to read again - and that took me a long time, too - I couldn't keep track of the characters in the book. I got lost. I reached a point where I'd take a piece of paper and write a list for myself of the characters. And I still had trouble."

CT scans found no damage to her brain, but this did not bring her relief. To the contrary: "It bothered me that everything looked normal," explains Herzog. "Because if everything is normal, then what's wrong? Maybe it's all in my mind? Maybe it's all psychological? One of the toughest problems with head injuries is that people think the problems are psychological. You see this person who looks just the same. He walks and talks, he looks okay. So what's the problem? Why aren't you okay? Everything looks fine. People don't believe you. The feeling was like, 'Come on, get over it already. You got hurt, yeah, but that's over now.'"

That's frightening. Could a person lose his sanity from something like this?

"It's possible. In the U.S. there are half a million people a year with mild head injuries, like me. It's been described there as the silent plague. These people are unable to go back to work; families fall apart. These people become society's lost souls. I personally felt my self-confidence slipping and slipping. Suddenly, everyone was telling me: 'Yes, you said that. No, you didn't say that.' I suddenly felt like no one believed me. I wouldn't leave the house without my husband. Otherwise, I'd get lost."

Bird cages and igloos

But Herzog didn't give up. She consulted with doctors, hunted for every scrap of information on the Internet and began working with an occupational therapist. "She did cognitive testing on me and it really angered me, because it's like putting a mirror right up to your face. I was asked to copy shapes and I had trouble with that. I was asked to describe what was happening in a sequence of pictures and the words eluded me. I called a bird cage an igloo. It was awful. The occupational therapist sent me for testing for attention and concentration deficit. As a doctor, I used to send children for this test. I thought: What could be so hard about it? You sit in front of a computer screen and when an X appears you have to click on the mouse. Simple? Not at all. My finger became a living creature with desires of its own. I was going crazy. I couldn't control it."

Months passed. Herzog did not return to work. Between sessions of hydrotherapy and occupational therapy, she lay in bed. "Like a rag," as she describes it. The doctors she consulted kept saying that the body could recover from such an injury within six months to a year. And that whatever didn't heal within that time, would apparently never heal. The anniversary of the accident was approaching, and it was clear to her that she could not return to work.

"It was terribly frustrating," she says. "I'd go to conferences once in a while, maintain contact, and at a certain point, after I'd been home nearly a year, they started talking about having me come back in an administrative position. The idea just killed me. Being a doctor and taking care of people was something that had been imprinted in me my whole life, and all of a sudden I was supposed to switch to the bureaucratic side? It was so far away from who I was. And it hurt."

About a year after her injury, Herzog traveled to the U.S., to her father, in search of solutions. She consulted top neurologists, "and they said that everything I was going through were classic reactions to head injuries. That it would take a year, or a year and a half, until I was back to myself. Or not." She found a therapist who specialized in treating head-injury patients who wished to regain high functioning. This therapist had treated physicians, lawyers and other professionals from all over the world. "It meant leaving home for half a year," she says. "It was clear that this was the time to do this, but I agonized over it."

Shortly after she returned home from that trip, she got a phone call from Dr. Orna Epstein, a friend from medical school who was traveling in the Golan. The two met and Epstein, who works in the pediatric neurology department at Assaf Harofeh Hospital, told her friend about several children with serious head injuries, whose condition had improved dramatically after treatment in a hyperbaric chamber. Herzog was skeptical. "I told her that I'd looked the field up on the Internet and hadn't seen anything encouraging," she recalls.

The Institute of Hyperbaric Medicine at Assaf Harofeh is run by Dr. Shai Efrati, a specialist in internal and hyperbaric medicine and the hospital's director of R&D. One of the prefab buildings near the hospital entrance houses the largest hyperbaric chamber in the Middle East. Its enormous control panel, full of knobs and digital indicators looks like something out of science fiction. The chamber itself resembles a passenger cabin, with a dozen seats with oxygen masks hanging down. There's also a smaller chamber with six places, which is often used for children who can watch movies to help pass the time during the treatment. Many patients are sitting in the waiting room, a majority suffering from diabetes.

"The hyperbaric chamber makes it possible to increase the air pressure and adjust the concentration of gases as we see fit," explains Dr. Efrati. "We mainly treat wounds where there's ischemia - a restricted oxygen supply to the limb. The classic example is people with diabetes. When the disease damages the small blood vessels, a wound forms, and when there's a disturbance in the oxygen supply, the wound won't heal, since the healing process requires oxygen. In the hyperbaric chamber we increase the concentration of oxygen. The amount of oxygen is so great that it heals the wound. In this way, we're able to save over 80 percent of legs that would otherwise be amputated."

Cancer patients suffering the effects of radiation are also sent to the hyperbaric chamber, where the treatment helps damaged tissues to recover. Efrati says that five years ago, they discovered by chance that hyperbaric treatment is also helpful for patients with neurological injuries. A diabetic who was sent for treatment of a wound had also been paralyzed on her left side for years following a stroke. "She came for treatment of a leg wound," he recalls, "and after 20 treatments, she got up out of her wheelchair and started walking. We said: 'Wait a minute: What's happening here?' It appears that all the hyperbaric treatment centers in the world have reported similar incidents of the treatment seemingly helping with all different kinds of neurological impairment."

One day, Efrati received a phone call from Laura Herzog, with whom he'd once studied at BGU's medical school. "I owe everything I know about pediatrics to her," he says with a smile. In his modest office, he discussed with Herzog and her husband reports about the effects of hyperbaric treatment on neurological injuries, and told them about his personal experience as director of the institute. He explained that there was not yet any serious, clear-cut research on the subject, but that the results so far could not be ignored.

'Little things'

Herzog decided to give it a try. Treatment for diabetics and patients with radiation damage is included in the government-funded health basket, but this is not the case for people with neurological damage. Herzog paid for the treatments herself; the price of a single session in the hyperbaric chamber is NIS 680.

Before the treatment, Herzog underwent brain mapping for the first time. "The mapping found several areas with poor or defective blood flow," she explains. "At this point I knew that, according to all the experts, a year after the injury the chances of the damaged areas healing were pretty much nil."

Nonetheless, Herzog decided to go ahead. She went to stay with her friend Dr. Epstein, and began a series of intensive treatments. Relatives and friends pitched in to look after her children who remained at home.

"At first, I started feeling more energetic," she relates. "I felt I could stay awake longer without crashing after every little thing. And later on, I felt an increasing clarity. Things started to fit together for me. Anyone who wears glasses knows the feeling when sometimes the lenses are really dirty and you don't even notice until you clean them. Then suddenly, things are so much clearer, you can breathe, you can see. That was the feeling.

"One day, I came with my husband to the hospital. He said, 'Come, let's go this way to the hyperbaric chamber.' And I said, 'Let's go another way,' and we decided that each of us would go his own way and we'd see who got there first. I walked there on my own. Afterward, my husband said to me: 'Did you notice? Ever since the injury, you've always walked together with me. Today you walked on your own!' These sound like little things, but they're very significant. Things I hadn't done before."

Herzog started to remember things, to find her way around, to discover the right words. "In the beginning, my husband would bring me from my friend Ilana's home to Assaf Harofeh. You need to realize, I'd been living for three months in this small community, and I couldn't find my way from the main square to my friend's house. Every day I would get lost all over again unless someone helped me find the house. Every trip involved mental preparation and maps and explanations. And then, suddenly, I was able to drive alone. Suddenly, I remembered where I was."

After a second brain mapping was done, there was no doubt: "The three areas with poor blood flow had disappeared," she says. "It had returned. The area with the defect was greatly improved." After 60 treatments, she went home. "I came home a different person," she says.

"When the treatments were done, Laura and her husband were sitting here," says Efrati, "and then she says to me: 'Shai, you're a horrible person!' I said, 'Excuse me?' And then she said, 'You have something like this right in your hands and you're not seeing to it that everyone knows about it?'" Herzog proposed that a proper research study be conducted. "My story is nice," she said this week. "But for now it has no medical 'weight.' In medicine, you have to speak the language of research."

Efrati picked up the gauntlet.

Why haven't there been any studies of this type until now?

Efrati: "The big centers for hyperbaric medicine are in the U.S. and they're all private. The doctors who work there wake up in the morning, have a leisurely cup of coffee, get into their Ferraris and drive to the private institute, where they have an endless line of patients waiting for them. What do they need research studies for?"

How does hyperbaric medicine help to repair neurological damage?

"There are lots of theories, meaning that we don't really know. But it appears that with all brain injuries, there are areas that are damaged and die completely, and then there are cells that are damaged in such a way that the metabolic process is minimal. The cell isn't dead, but it's not functioning either. Apparently, the introduction of a high concentration of oxygen restores these cells to life and we see this very clearly in the brain mapping. With Laura, we saw entire 'black' areas that were damaged coming back to life. It was just amazing."

Efrati says that, at any given time, Assaf Harofeh is treating about 10 patients with head injuries, but it's not certain that all need treatment in the hyperbaric chamber. "We don't have any statistics. There are no protocols. We don't know how to quantify the treatment, to tell a person how much it could help him, and that's because there's no research on the subject," he explains. "The moment there's research - this is the language that doctors will speak. It will obligate every neurologist to send his patient here, if necessary."

Efrati put the ball back in Herzog's court: He said he would approve the study - if she would lead it. Herzog agreed.

This past Sunday, she traveled from her home in the Golan Heights to Assaf Harofeh for a meeting with her research team about the study. The plan is to examine 120 people with mild to moderate head injuries. After initial brain mapping and cognitive testing, they will be divided into two groups. One will receive 40 sessions in a hyperbaric chamber, and afterward both groups will undergo another mapping.

This is not Herzog's only, or even primary, occupation these days. Four times a week she works at a well-baby clinic, where she warmly welcomes the new mothers and babies who come for check-ups. After every four appointments, she takes a 20-minute break - makes herself a cup of coffee, shuts the door and closes her eyes for a little while. "I recharge the battery," she says with a wink. "I'm still slow, I don't always remember, I get tired, but still I've made an amazing leap forward."

What role does faith play in your story?

Herzog: "I didn't grow up in a religious home, but from a young age I had a basic faith in God. I think that everything happens in the world for a reason. Six months ago, my father died very suddenly in the U.S. Because of my accident, my father came to Israel and stayed here for a month and a half, and I also traveled to him twice. He got to know my kids and the family got to know him. I actually saw him more in the last year of his life than I had for many years, and this was a blessing. It made it easier for me to come to terms with his death. "Another thing: If this study is successful, and we're able to prove that the treatment helps, we'll be able to help a lot of people. Then, thank God, I'll be able to say that I did my part."