Diagnosing TBI In The Emergency Room

Emergency Room Critical Step in Diagnosing TBI

by Gordon S. Johnson, Jr.

I have become increasingly frustrated by the prevalence of missed diagnosis of mild brain injuries. Seemingly several times a month, I come into contact with another client whose brain injury was not diagnosed in the emergency room. Despite significant symptoms of a brain injury in the emergency room, survivors are discharged with no more detailed diagnosis of brain injury than an analysis of the Glasgow Coma Scale.

The extent of neurological examinations in the emergency room are particularly poorly suited to diagnosing the non-coma brain injury, even though such injuries can become catastrophic in nature. If after the lapse of time, the possibility of permanent brain injury is identified, all imaging studies, such as an MRI or CAT Scan, will typically be negative.

Such might not have been the case if the studies were ordered early on. One of the most common types of undiagnosed brain injury is the diffuse axonal injury that is so common in the motor vehicle, whiplash type accidents. An MRI performed upon initial presentation to the emergency room, has a chance of identifying some evidence of this type of injury. Yet, MRI's are rarely performed when a patient presents himself/herself to the emergency room with non-coma brain injury trauma.

The patient is typically the primary source for what is perceived to be the most significant question: Did you lose consciousness. How reliable of a source is a person with a potential brain injury, to answer such a question? Certainly not without significant examination of the persons recollection of events. More significantly, loss of consciousness is not the litmus test for brain injury. Any change in mental state can be significant. Further, headache, lack of consistency in reported symptomatology, nausea and the need for oxygen could tip off the emergency team. Even a Polaroid photo of the accident scene and cars could point towards a head injury.

In discussing this problem with an emergency room doctor, I was asked the following question:

"Even if an MRI diagnosis traumatic brain injury, is there sufficient medical intervention possible, to justify the cost, or is this just being done to assist an attorney in proving the injury? "

His point was that unless the diagnosis of mild brain injury directs the physician towards a course of medical treatment that would help to cure the injury, it is difficult in today's cost conscious medical world, to justify a $1,000 test.

I was very disturbed by this rationale.

Does not the patient have the right to know the nature of his injuries, even if he cannot be treated? We do not limit our expenditures to diagnose other serious conditions based upon the likelihood of a cure. I believe there is specific medical treatment to help even the so called "mildly" brain injured. But medical treatment is his specialty, not mine. So I focused my response not on the medical interventions, but to economic cost of the missed diagnosis.

I started with the work place cost. Many people with traumatic brain injuries do not realize there is anything wrong, until they return to work. Many times, such return to work happens weeks or months after the accident. Especially in those cases where brain injury is associated with other trauma, such as neck or back injuries, the patients go through some period of convalescence related to the other trauma. Convalescing tends not to be very demanding upon one's intellectual functions.

However, as soon as they go back to work, their intellectual deficits cause problems. If neither the patient nor their employer has any idea that a brain injury has occurred, those deficits can result in serious mistakes at work. In a significant percentage of cases with the unsuspecting survivor and the uninformed employer, this change in work performance results in a job loss. If the mild brain injury had been diagnosed, even if not treated, the deficits could have been compensated for, perhaps eliminating the mistakes and saving the job.

I looked my doctor friend in the eye and asked him whether he and his patients would have a right to know if he suddenly had a drop in I.Q., an inability to concentrate, to remember things? While his intelligence might still be above normal, would he be able to function as his patients had a right to expect? Would the complicated differential diagnosis, which he now does from memory, still be possible? Even if his cognitive problems were temporary, wouldn't the consequences of not knowing be potentially catastrophic?

While the case of the doctor is easy, I submit that the vocational risks and costs are significant with anyone who has an undiagnosed brain injury.

I next stressed that the impact on the family from an undiagnosed brain injury, can also be demonstrated in economic terms. What is the cost of divorces that are so prevalent with the brain injured? Attorneys fees alone would justify the cost of an MRI. What of the serious disruption in families? Such is not just a personal loss, but a deeply economic one.

The value of early diagnosis is terribly significant even with the individuals who do not have permanent deficits. If someone said to the person with a non-coma injury in the emergency room: "For the next 60-90 days you should be careful in the way in which you do your job," work place mistakes and job loss could be greatly reduced. Likewise if they could say to your family members, that they should be tolerant of strange quirks in your personality, divorce might be greatly reduced. It is the unexplained change that is so hard for employers and families to tolerate.

I also compared the economic calculus of spending a $1,000.00 on a MRI, to the average of $250.00 spent on x-rays. Virtually everyone who presents to the emergency room with complaints of a sore neck, is given a full set of cervical x-rays. My doctor friend admitted, the chance of paralysis with a patient presenting with whiplash symptoms in the emergency room, is minuscule. In contrast, the chance of brain injury with someone presenting with the same whiplash symptoms, may be 10% to 15%.

It would be interesting to see a study done as to the relationship between the diagnostic cost for ruling out paralysis versus diagnostic costs for ruling out brain injury. With the incidents of brain injury being as much as a hundred times more prevalent, odds are that hundreds of times more dollars are spent on x-rays for normal cervical spines, than would be spent on MRI's for normal brains.

His argument again was that the medical establishment can do something to intervene when the x-rays come back positive for a potentially paralyzing condition. My point is that the intervention afforded by the knowledge of brain injury, is broader than just medical treatment.

We must find ways to better educate the medical community. That such a question is asked by a trauma physician shows that the medical establishment needs to know far more about brain injury. He and his peers must be made to understand that the diagnosis of brain injury, even the so-called mild brain injury, is as urgent as the diagnosis of cancer, broken necks and AIDS.

Understanding Subtle Brain Injury

The concussions that disable, are almost always more symptomatic at 24 hours, than at the 2-4 hour time frame when injured persons are evaluated in the emergency room. Brain injury symptoms escalate over the first 24 hours, because brain injury involves a cascade of events. It is critical that if you are still symptomatic the day after your injury, go back to the same Emergency Room, don’t wait for a doctors appointment. It is critical that the Emergency Room personnel see that the symptoms still persist or have gotten worse.

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