Nepalese students take part in a candlelight vigil in Kathmandu on Oct. 15, 2012, to express their support for Pakistani schoolgirl Malala Yousafzai
The world remains riveted by the story of Malala Yousafzai, the 14-year-old Pakistani girl shot by Taliban gunman because she championed the rights of girls to receive an education. Flown to Birmingham, England, for more medical care, Yousafzai remains in critical but stable condition. TIME talked to Dr. Kritis Dasgupta, the medical director of the Brain Injury Program at the MedStar National Rehabilitation Hospital in Washington, D.C., for a sense of what the girl is going through.
TIME: Can you describe what kind of surgery Malala received from doctors in Pakistan?
Kritis Dasgupta: They had to do a craniectomy, which is removing part of the skull so they can get in [to remove the bullet] and also to relieve swelling. You open up the skin, and then you find a way to open up the skull. A lot of times, that’s a question of making holes and then cutting from one hole to another so you can take out a flap of the skull. And that’s to relieve pressure from swelling, because the skull is a closed space, and if you have too much swelling, you can have a danger to the brain of compression, which is extremely serious and can lead to even death if the patient stops breathing. They call it a decompressive craniectomy. They’re not going in primarily to fix the brain but to handle the immediate danger and take out things that could prevent the brain from healing. After that, you monitor.
Would they have had to shave her head to do the surgery?
Yes. They would have had to shave at least half of her head — the area around where they went in — so they can sterilize it. Often patients will have half a head of hair.
What are the benchmarks for recovery?
The initial benchmark is survival. [Another] is to have all the postsurgical issues resolved. If there’s swelling, they will wait for that to go down, which could be a matter of days to some weeks. Once you’re out of that acute phase, you have a sense of what are the residual neurologic deficits, and that’s when you really start the process of rehabilitation and recovery.
What sort of tubes would she need right now?
Right now she’s most likely unable to eat on her own, so they may have already put in a feeding tube — a tube that goes from the outside of the abdomen into the stomach. In the short term, they’ll sometimes put in a nasogastric tube [down through nose], but if it looks like it will be needed for any length of time, they put a feeding tube in the stomach. Most likely during the surgery she was on a ventilator to help her breathe. In addition to that, she’s probably on some IVs to give her fluids and to prepare to administer IV medication in case she has any kind of complication.
When would they stop sedating her?
That depends on what the medical issues are. If the patient is agitated or if the patient is in a state where, when she is allowed to wake up, she unconsciously is pulling out her tubes and putting herself at a risk of danger, then that’s one reason to do it. Generally I would say they try to, as soon as they can, reverse that coma as soon as the patient is stable and can come out of it.
What can still go wrong in the recovery process at this stage?
Infection from the surgery itself. Increased swelling. Hydrocephalus — fluid on the brain. Cardiac complication. Loss of oxygen to the brain, leading to brain injury.
When will they be able to tell what the long-term damage is?
Months to years. It’s six months to a year before you get a sense of what the long-term damage is. Her recovery and prognosis depend on what the initial neurological deficits are. Young people do much better, prognostically, for recovery. In the early stages there may be a lot of fairly dramatic improvements. The question becomes, What will be the long-term deficits, compared to her baseline? That’s often a much more difficult question that takes time. She may be able to walk and talk, but will she be able to function? I’m sure she’s a very bright girl. Will she be at the same level?
Is it possible that she’ll be able to return to how she was before the injury?
I would say, given the severity of the injury, there is a strong possibility there may be some deficits. That doesn’t necessarily mean she can’t function and have a fulfilling life, but [there is a chance of] higher-level cognitive deficits.
What sort of deficits?
Just surmising, so: She was shot in the left side of her brain. That can affect language abilities.
What about physical deficits?
An injury to the left side of the brain means that she could have some right-sided weakness. So that can certainly affect your ability to walk and do all of your daily needs like dressing, eat, write.
What will be her treatment moving forward?
I would anticipate she’s most likely going to be going through intensive rehabilitation, very likely in the inpatient setting. She’ll stay in a rehabilitation hospital for some time to work with a rehabilitation team, which consists of physical therapy, occupational therapy and speech therapy, would all be working with her to work on any deficits she might have.