Bus Accident and Brain Injury - Even the "Minor Injury" Patients Need to be Checked for Amnesia

I began two my last two speeches on brain injury holding a nerf football, asking this question: What idoes an NFL quarterback have to do before he snaps a football. It took a couple of minutes each time, but among the answers were the following:

• Listen for the play;
• Remember the play;
• Communicate the play to his teammates;
• Assess the defense;
• Made a rapid decision, based upon that assessment to use the called play or to audible to another play;
• Snap the ball; and
• Execute the play, requiring instant judgment and reaction in the face of extreme stress of large bodies trying to dismember him.
  

To complete the play from start to finish requires an immense ability to process, remember and use information. Clearly, someone cannot be confused and do all of those things, and particularly, do them in a series of plays, a game.

Yet, there is really no question that a quarterback can do all of those things, win the game, yet be amnestic for all or a portion of the game. The anecdotal evidence of such occurrences are numerous and undisputed.

How could this be true? Amnesia and confusion are not the same. How is it we learned that the NFL quarterback was amnestic where so many people are treated and released from the Emergency Room with no hint in the medical record of concussion? NFL quarterbacks have press conferences, normal people get asked what day it is. So parents, when your child is released from the hospital after a bus accident, give them the equivalent of a press conference, as discussed below.

There is also another material area where the brain injured athlete gets better diagnostic methods directed towards them than the injured kids on a school bus: serial follow-up exams. A little over a decade ago, the Brain Injury Association of the U.S.A. in working with the American Academy of Neurology developed the first set of the “sport and concussion guidelines.” That first set did several really important things, the most notable was that it clarified that a loss of consciousness was not necessary acute event for a diagnosis of a concussion. The Sport and Concussion guidelines were not the first time that was clarified, but it was the first time it came from the Neurological national association.

From a long term standpoint, the most important thing those guidelines did was to create return to play guidelines. If an athlete who was not knocked out ceased to be symptomatic within 15 minutes of the concussion, then that athlete could return to the game. If they continued to be symptomatic after 15 minutes, then they could not return to a game for seven days after they ceased to be symptomatic. As this rule created a waiting period from the time they ceased to have brain injury symptoms, it required the training staff and or team doctors, to continue to do followup exams, every day after the injury. If you franchise quarterback can’t go back in the game for seven days after apparent recovery, you will make sure they get checked out every day.

Sadly, no non-athlete gets that kind of serial followup. Since no one sees any serious risk of harm for returning to work too soon, no one really makes any effort to determine whether the symptoms are occurring on day two, day three. That is so tragic, because there is really no doubt that if we did evaluate mild traumatic brain injury survivors at 24 hours, 48 hours and 72 hours, that we would probably be able to distinguish between almost all of those who were at risk for long term disability.

Why is this distinction important? Because amnesia, the presence and length of it is the single most important predictor of outcome post brain injury.

Virtually all of our current triage methods for brain injury diagnosis test only for confusion. “Do you know what you are doing right now” is the essence of the EMT evaluation, the ER diagnosis. A Glasgow Coma Scale evaluation with a concussed person, is only asking if someone knows where they are, who they are and what day it is. Can anyone imagine the amnestic NFL quarterback not being able to answer those questions? So the NFL quarterback gets a 15 Glasgow Coma Scale, what some marginal expert witnesses call a “perfect score”, even though after the game he will not remember the game.

Certainly not all concussions result in permanent disability. In the vast majority of those concussions the injured person gets better - in fact gets better very quickly, maybe even within minutes. But when you are talking about the vast majority of something that happens millions of times a year, the minority of that group, still adds up to a lot of disabled people.

It is the concussions where people continue to be symptomatic hours and days later that are to be taken seriously. But how are we to know the difference if we don’t design our care, our triage, our diagnosis for concussion or brain injury, around questions and tests that distinguish whether people have amnesia. Not one question on the Glasgow Coma Scale asks the injured person about events between the time of the injury and the present. This must change or we will continue to underdiagnose hundreds of thousands of people every year.

If we were to design a protocol to determine whether a quarterback was amnestic of the events of a game, any sports writer could do it. Ask the man about the plays, the winning scores, the interceptions. Especially the interceptions. If a quarterback doesn’t remember the interceptions, he is clearly suffering from amnesia.

Is it really that much harder to determine amnesia in the real world? Yes and no. We don’t have the blueprint of what the person was doing for the hour surrounding the injury like we do with an NFL quarterback. But if the person was in an automobile accident and was taken to the Emergency Room, we do have at least an idea of what might have happened to them in the last hours.

• Question One: Tell me about the ambulance ride.
• Question Two: Did you have to check in with billing before you got to me? If so, tell me about the process.
• Question Three: I see you are wearing a neck brace. Who put it on? When did you begin to hurt?

See, it really isn’t that hard. We know an awful lot about what the person likely has been doing in the past hour. See if they remember the details.

When asking the questions, don’t ask simple yes or no questions. If yes or no questions are asked, use them as a simple transition to more open ended questions. If you direct the persons response with a yes or no question, you will learn very little about how they are thinking. Make them talk, recall and explain. By the time the person is seen by a doctor in the ER, it is often two hours post accident. That may be late enough to determine the beginning of issues with amnesia.

If the doctor would imagine himself a sports writer asking a quarterback about the game, our identification of amnesia in the Emergency Room could grow exponentially. It is time to move beyond the level of inquiry of the Glasgow Coma Scale.

Parents, when your kids get home from the hospital after a bus crash, you be the reporter, you ask the tough questions, you be satisfied with the answers. Not just the day of the accident, but every day for a week. If you aren't satisfied with the answers, take your child back to the hospital.

Contact the Brain Injury Law Group: 1-800-992-9447

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