As I have been discussing for much of the last month on this blog, amnesia and confusion are not the same thing. An example more vivid than even a football quarterback was the concussion Conan O’Brien suffered on camera on his show last week. See for one of the multitude of stories on it at the Huffington Post: http://www.huffingtonpost.com/2009/09/29/conan-obrien-falls-hits-h_n_302471.html To really understand the lesson we can learn from this concussion, one must listen to the contrast between what Conan did shortly after his brain injury and what he remembers about it.
He clearly was dazed for a few seconds, but within 10-15 seconds he was on character, making a joke, running the show, directing his people what to do. As I watched, I clearly thought of the concussed quarterback, calling the plays, directing his teammates, avoiding rushing linemen and completing a pass. Yet despite all that activity, he remembers nothing of what he did after the event, nor even the moments leading up to the concussion.
Can anyone now doubt that you don’t have to lose consciousness to suffer a concussion?
Brain injury is a Process, Not an Event
“Brain injury is a process, not an event.” That one phrase has guided my advocacy with respect to concussion as much as any one thing. The author? Thomas Gennarelli, M.D. I am not sure when the first time he said it, but one such place he says it is the Chapter on Trauma in the famous neuropathology text, Greenfield’s Neuropathology: Graham, Gennarelli, Greenfield’s Neuropathology, ©1996 Oxford University Press, page 209.) He explains that quote further as follows:
“In various combinations and various severities, the resultant cellular dysfunction (of brain injury) defines the nature and extent of the primary injury, the outcome of which may not become apparent for several days or even weeks after injury.” (Graham, Gennarelli, Greenfield’s Neuropathology, 1996, page 197.)
The implications of that one statement are really quite staggering when compared to our normal triage for a brain injured individual. In my experience, a significant concussion will get these two primary evaluations. First, some EMT personnel will be on the scene, asking the person basic questions like what do they remember of the accident, where they hurt, were they unconscious. Then presuming they are transferred by ambulance to the hospital, the emergency room staff and the physician will ask similar questions, including almost invariably the three questions of orientation of the Glasgow Coma Scale: do you know who you are, where you are and what day it is? If they get those three questions right, they get a “perfect” Glasgow Coma Scale of 15 and are likely sent home.
When there are lingering questions about orientation, a report of uncertainty or a corroborated loss of consciousness, they may get a longer evaluation and a CT scan. Mild concussion survivors are sent home three to four hours post injury. More symptomatic survivors may take a little longer for the CT scan to be read and evaluated. Regardless, nearly all concussion survivors are released from the medical system by six hours after their accident. Big deal, brain injuries get better not worse, right?
Not if you believe Dr. Gennarelli’s published words. Greenfield’s says that it takes 24 to 72 hours for typical axonal swelling to occur. But to understand this issue fully it is important to understand more about neurons, the myelin sheath that protects them and the traumatic defect in the cell that occurs at the time of trauma, something called mechanoporation. “Mechanoporation is the creation of a traumatic defect in the cell membrane that occurs as the lipid bilayer is transiently separated from the stiffer protein inclusions such as receptors or channels.” Greenfield’s, page 204.
Sounds pretty damn technical for a blog? What “mechanoporation” means is that a defect is created in the insulation that protects the axon from the potentially toxic neurotransmitter chemicals that surround the axon. Each axon has small channels to allow just the appropriate amount of these neurochemicals into the axon, to allow it to transmit the electrical impulse down the axon. In the traumatic event, the axon gets stretched in such a way that the channels are opened too wide and too much neurochemical gets in to the axon. The result is toxic, but it can take up to 72 hours for the toxin do its damage.More about such neuropathology in our next blog.
Sport Concussion Guidelines Should be Applied to Real World Brain Injuries
Continuing with our football quarterback analogy about the difference between confusion and amnesia, lets also focus on another material area where the brain injured athlete gets better diagnostic methods directed towards them than the average member of the public: 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.
In our next blog, we will discuss why it can take up to 72 hours to be able to tell how serious a concussion or mild traumatic brain injury is.
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.
In our next blog, we will discuss why it can take up to 72 hours to be able to tell how serious a concussion or mild traumatic brain injury is.
Brain Injury – Amnesia and Confusion – A Probing Inquiry is Needed
This series of blogs started with the quarterback analogy, discussing all of the things an amnestic but not confused quarterback had to do on every play. 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.
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?
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.
Brain Injury – Amnesia and Confusion – An Important Distinction
My last blog concluded with the statement that amnesia and confusion are not the same thing. One does not have to be confused to be amnestic for an event. 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.
In our next blog, we will talk about ways to make the questions asked in the Emergency Room more specific for diagnosing amnesia, and thus 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.
In our next blog, we will talk about ways to make the questions asked in the Emergency Room more specific for diagnosing amnesia, and thus brain injury.
Brain Injury – Confusion and Amnesia – Not the Same Thing
I began both of my last two speeches holding a nerf football, asking the question of those in the audience, what it was an NFL quarterback did before he snapped the football. It took a couple of minutes each time, but among the answers were the following:
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.
More on this in our next few blogs.
- Listened for the play;
- Remembered the play;
- Communicated the play to his teammates;
- Assessed the defense;
- Made a rapid decision, based upon that assessment to use the called play or to audible to another play;
- Snapped the ball; and
- Executed the play, requiring instant judgment and reaction in the face of extreme stress of large bodies trying to dismember him.
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.
More on this in our next few blogs.
Back from Summer Recess
Blogging is one of those job responsibilities that never seem to quit and it is so easy to get behind on. Well, Congress is back soon, the kids are in school, and I better get back to this job as well.
It has been an important summer for my brain injury advocacy. I was elected this year to Chair the sub-committee of the national trial lawyers group on brain injury. The formal name of that group is the Traumatic Brain Injury Litigation Group (TBILG). The national association is the American Association of Justice (AAJ). I have served the TBILG and its goals of representing those with brain injuries since 1994 and I am honored to be chosen to lead it for the next year.
As part of my service to the TBILG, I moderated our program to over 100 attendees at our convention in San Francisco.
I have also recently given two speeches to brain injury groups on brain injury, one in Wisconsin on behalf of the Brain Injury Association of Wisconsin and one on Monday of this week in the Detroit area to the Michigan Association of Justice. The Wisconsin speech was entitled “A Lawyer’s Perspective on TBI.” The Michigan one: “Brain Injury is a Process, not an Event.” In the next couple of weeks, I will review some concepts from these two talks on this blog.
I have a busy fall ahead, but fall is one of my most productive times of the year and I will keep this blog up to date. Promise.
It has been an important summer for my brain injury advocacy. I was elected this year to Chair the sub-committee of the national trial lawyers group on brain injury. The formal name of that group is the Traumatic Brain Injury Litigation Group (TBILG). The national association is the American Association of Justice (AAJ). I have served the TBILG and its goals of representing those with brain injuries since 1994 and I am honored to be chosen to lead it for the next year.
As part of my service to the TBILG, I moderated our program to over 100 attendees at our convention in San Francisco.
I have also recently given two speeches to brain injury groups on brain injury, one in Wisconsin on behalf of the Brain Injury Association of Wisconsin and one on Monday of this week in the Detroit area to the Michigan Association of Justice. The Wisconsin speech was entitled “A Lawyer’s Perspective on TBI.” The Michigan one: “Brain Injury is a Process, not an Event.” In the next couple of weeks, I will review some concepts from these two talks on this blog.
I have a busy fall ahead, but fall is one of my most productive times of the year and I will keep this blog up to date. Promise.