Continuing with this blog’s treatment of the “The Evolution of Our Understanding of Concussion, otherwise Called Mild Traumatic Brain Injury,” today I focus on the huge diagnostic disadvantage real world concussions have in the diagnostic process. While the sport concussion guidelines are a tremendous step forward, the single biggest problem in applying them to accidental concussion is accidental concussions are rarely witnessed by trained observers. Never is there a video tape of the forces that caused the concussion. Click here for Part IV of my Concussion Clinic Videos.
Certainly accidents have witnesses and often witnesses that are communicating with the concussed person within the first couple of minutes after the wreck or fall. But even 30 seconds after the incident may be too late.
Compare the situation where someone is in a car wreck to a boxing ring. If a fighter is knocked down by a blow to the head, the boxer presumptively has had a concussion. Yet in the vast majority of the cases, that boxer has returned to his feet within 10 seconds. If the fight isn’t stopped at that point, it means that the boxer has regained sufficient function to engage in his highly dangerous and demanding profession in less than 30 seconds. That model shows us that the window for observing the acute concussion evidence may be as short as 10 seconds.
If the same concussion occurred in an NFL or college football game, we would have a video tape of that concussion. While there isn’t a 10 second knockout rule in football, if a player is still down for 20 seconds, play has to be stopped. The concussion then gets analyzed from several different camera angles and archived for prosperity.
In a car wreck, unless there is a passenger in the car, no one is closely observing the injured person within that 30 second time frame. Certainly witnesses will congregate quickly, but not quickly enough. Almost never will there be someone trained in concussion diagnosis at the scene during the time window that the acute evidence is the clearest. If the concussion occurs in a fall, most times there are no witnesses.
Thus, the diagnosis of an accidental concussion requires either the reliance on a history from the injured person, who is likely to be unreliable historian of the event, or must be reconstructed. The only reliable measure to determine whether there was the concussion is to determine the existence and extent of post traumatic amnesia.