Subtle Brain Injury

Continuing on with the discussion of my Concussion Clinic videos, today’s topic is the Need for Periodic Follow-ups. Today’s video is here: http://www.youtube.com/profile?user=braininjuryattorney#p/u/11/dEWHgwRywtY

When the sport and concussion guidelines are applied properly there is a 15 minute post-injury evaluation to determine whether this concussion or “ding” was serious enough to require further follow-ups. An injured player is not supposed to return for at least 15 minutes. At 15 minutes, if they continue to be symptomatic, they are not to return to play in that game and not until the expiration of 7 days from the date they cease to be symptomatic.

While the 15 minute rule is not quite good enough, it is important that an athlete is at least required to wait that long before he or she returns. As brain injury is a process not an event that can take 72 hours to manifest itself, the 15 minute rule isn’t perfect. Yet I realize that 15 minutes is a compromise, that generally protects the player. While there are exceptions, the concussion that is completely asymptomatic at 15 minutes is probably not going to be serious. But keep in mind, that Natasha Richardson could likely have passed a superficial orientation test at 15 minutes and she died before they could get her to a hospital. Also with non-professional sports, there is a strong movement to not allow any return to play.

The truly important part of guidelines is the “no play for seven days” if the concussion continues to be symptomatic at 15 minutes. Thus if there is symptomotology of brain injury at 15 minutes, the professional team’s medical staff will do follow-up testing each day to determine whether the athlete continues to be symptomatic. (What happens in amateur sports may be entirely different but is a topic for a different blog.)

If we could take that model of periodic follow-ups and apply that to the brain injuries that happen in accidents, we would then likely identify almost all concussions that are likely to be disabling. Add two more levels of inquiry to that process and we could have an excellent concussion diagnosis system.

Distinguish between Confusion and Amnesia. I have discussed this issue in depth earlier in this series, but absence of confusion does not mean absence of amnesia. Amnesia is the real litmus test for concussion. Remember that amnesia is not a black curtain of memory, but the inability to remember the amount of information we would normally remember. What does “normal memory” mean? Take this an example.

At a real world hospital, if you aren’t bleeding when you get to the Emergency Room, you start your time there with a 20 minute conversation with the billing department. Then you sit in the ER waiting room for a while, normally too long. A normal person’s memory might not include the name of the person who was taking their insurance information. But a normal person would remember the process. They would remember filling out a form, even if they didn’t remember what the form said. A normal person would remember fishing the insurance card out of their wallet. Likewise, a normal person would very clearly remember how long they waited in the ER. A normal person would remember the most seriously hurt person who was waiting with them. People tend to remember blood, etc. If the doctor or other ER person would ask these kind of questions, evidence of amnesia would likely be clear.

Next Day Follow-up. Even more important than asking better questions on the day of the accident, is to have a medical professional ask them something about their memory the next day. Amnesia at 24 hours is far easier to spot. How much they remember of the pervious 24 hours events will show how severe this particular concussion is. With all of the momentum for better diagnosis for NFL and amateur football players, we must also clearly recognize that the care they are getting is infinitely better than the million plus other people a year who suffer a concussion, most who are at much higher risk of a bad outcome. See http://www.tbilaw.com/blog/2010/01/nfl-football-concussions-versus-real.html