Followup to Injuries in Jamaica Air Crash

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Posted on 25th December 2009 by Gordon Johnson in Brain Injury

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I was once a news reporter and I understand the process of gathering news, but it is amusing in retrospect what the first reports of a major event look like. Take for example this story in the New York Times about the American Airlines Flight 311 crash in Jamaica on December 23: http://www.nytimes.com/2009/12/23/world/americas/23briefs-Jamaicabrf.html?scp=1&sq;=american%20airlines%20flight&st;=cse

The story said:
An American Airlines flight from Miami overshot the runway in Kingston on Tuesday but came to a safe stop, an airline spokesman said. The spokesman, Charley Wilson, said that there were no reports of injuries or fatalities, and that all the passengers were off the plane.
How does American Airlines release a story like that? All one has to do is look at the wreckage of the aircraft to know that people had to be hurt. See the photo from the Jamaica Observer at http://www.jamaicaobserver.com/news/Observer-first-in-the-world-to-report-AA-crash Miracles notwithstanding, there is no way an airplane is torn apart like that without injuring virtually everyone who was near the fracture points. The Jamaica Observer reported further on the status of injuries:
One hundred passengers were reported injured when the plane crashed and broke in three after landing at the airport shortly after 10:00 Tuesday night.

Most of the injuries were classified as lacerations and blood trauma. A few fractures of long bones and ribs were also reported. On Thursday, a statement from the Ministry of Health said that 13 of the 14 passengers who were admitted to hospital have since been released.
It is great news that all but one of the passengers was released from the hospital for Christmas. But as I said in my last blog, being released from the hospital does not give any of that group of injured people a clean bill of health as far as brain injury is concerned. There is no question that there were concussions on that plane. There was simply too much force involved in tearing up that jet to not have injured some brains. To tear apart an airplane like that severe twisting forces must have been involved. Those forces could have been just as severe to any passenger on board, but especially to those sitting in the seats adjacent to where the plane broke up.

The important thing now is that anyone on board who is having any head injury symptoms go back to the doctor or emergency room and get the kind of follow-up evaluation that an NFL quarterback would get. Most important in that follow-up is a determination as to whether there has been any amnesia, or loss of memory for events, between the time of the accident and the time of the evaluation. Post-traumatic amnesia is the single most important predictor of a negative outcome from a concussion. Other obvious symptoms that should be taken seriously are balance or visions problems, confusion and headache.

Concussions can disable. The concussions that disable are the ones that are symptomatic 24 to 72 hours after the injury. Now is the time to identify those symptoms.

Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.

http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
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Brain injury is a Process, Not an Event

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Posted on 15th September 2009 by Gordon Johnson in Brain Injury

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“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.

Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.

http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
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Brain Injury – Amnesia and Confusion – A Probing Inquiry is Needed

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Posted on 11th September 2009 by Gordon Johnson in Brain Injury

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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.
  • 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.

Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.

http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
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Brain Injury – Amnesia and Confusion – An Important Distinction

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Posted on 10th September 2009 by Gordon Johnson in Brain Injury

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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.

Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.

http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
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Brain Injury – Confusion and Amnesia – Not the Same Thing

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Posted on 9th September 2009 by Gordon Johnson in Brain Injury

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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:

  • 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.
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.

More on this in our next few blogs.

Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.

http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
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Amnesia was a Missed Marker of Brain Injury in World War I Shell Shock

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Posted on 12th June 2008 by Gordon Johnson in Brain Injury

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In this series of blogs, we have been focusing on the synergistic interplay between the emotional problems related to combat stress and war-time brain injuries. The previous blog focused on Charles Myers’ 1915 case studies of three British soldiers injured in World War I, and what we believe to be his failure to properly factor in amnesia, loss of smell (and taste) and the neuropathological and biomechanical explanations for brain injury. See “A Contribution to the Study of Shell Shock” published in the British Medical Journal, The Lancet, on February 13, 1915. Today, we will focus on the specifics of amnesia, with the next blog relating to loss of smell and the next, the likely neuropathology of these three injuries.

Amnesia in Myers’ patients. Myers seemed completely ignorant about the nature of amnesia and its correlative symptom of confabulation. Each of his patients had hallmark examples of post-traumatic amnesia. Soldier #1’s recollection of the ambulance ride is a classic: “He thinks he must have slept on the ambulance, as he remembers nothing.” How telling that Myers initialized those words in the original, as if it was evidence for what he said needed no comment, the similarity to “hysteria?”

Soldier #2’s narrative begins with the statement: “Can remember nothing until he found himself in a dressing station at a barn lying on straw.” According to Myers’ narrative, the soldier’s description of how he got hurt is clearly contradicted by uninjured eye-witnesses.

Soldier #3’s bizarre theory that he must have been knocked into a lake is a pure example of confabulation. The soldier admitted it was something he deduced, not something he actually remembered. Myers states: “He does not know how he got there or how he left the cellar, but he remembers being in another hospital before he was admitted here.” What other explanation is there for such statement other than amnesia?

While 1915 is nearly 100 years ago, it still seems odd that a combat physician would not realize the significance of amnesia with respect to a diagnosis of injury to the brain. As I have often commented – there is a collective wisdom passed down through the ages with respect to the symptoms of brain injury. The most understood of those symptoms is amnesia. See my essay: The Boy who Could Not Remember, taken from an Alaskan Indian myth.

Yet, Myers ignored that wisdom and the evidence in his own detailed case notes. The result: the wrong diagnosis. Could it be that with the other innovations of modern warfare having their genesis in World War I, the horror of supplanting thousands of years of human experience with the arrogance of a “modern” diagnosis, also arose?

What has been the impact of Myers getting it wrong on Western medical thought? That is hard to measure. But his sarcastic reference to the obvious hysteria diagnosis was published in the leading medical journal of its time, The Lancet. Over the next 75 years, the culprit of a false diagnosis of “hysteria” seeps into almost all neurological diagnosis. Only by focusing on the clear cut neuropathological clues found in Myers’ detailed case studies, can this stain on neurological diagnosis be removed.

Tomorrow: This series will continue with a focus on the significance of loss of smell and taste to a modern diagnosis of brain injury.

Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.

http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney

The Need for Periodic Followups after a Concussion

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Posted on 4th April 2008 by Gordon Johnson in Brain Injury

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As I discussed yesterday, if the person is seen the day after the concussion, there is a fertile opportunity to actually test the injured person’s memory formation, to see if they are in an amnestic period. Yet, no where in the Facts for Physicians Toolkit, does it call for a return visit the next day.

In the sports situation, the athlete doesn’t get back into the game if he or she is symptomatic at 15 minutes. So what does that mean? They don’t determine that the person is able to go back into the game at two minutes, they wait fifteen minutes. If there are no symptoms at 15 minutes, they send them back in. If they are symptomatic at 15 minutes, they don’t get back into the game until their symptoms have cleared for a significant period of time.

If it is classified as a significant concussion, they don’t get back into the game until their symptoms have cleared for seven full days. Now here is what is significantly different about the way that average people who get head injuries, brain injuries in motor vehicle accidents or falls are treated different than an athlete.

With an athlete, let’s take an NFL quarterback, there are millions of dollars at stake as to whether or not and when, that person can play again. That means that every day that such person continues to be symptomatic it is a problem. Which of course means that every day some expert in the field of brain injury or at least in the field of sport concussion, is evaluating them to see if they are still symptomatic.

If we could take that model of daily evaluations to see if symptoms have cleared and apply that to injuries that happen in motor vehicle wrecks , I believe we would be able to sort out the accidents and brain injuries that are significant from those that are not.

What I would like to see is a change in two significant things in respect to people who have concussions in motor vehicle accidents and other accidents are treated. First, there has to be an analysis done of memory not confusion in the ER, as discussed previously on this blog. Second, we need to demand a 24 hour follow-up, preferably at the same facility.

Sorting out confusion from amnesia at the ER on the day of the event is only going to tell us what is going on in the first three or four hours. “Brain injury is a process, not an event. “ (T Gennarelli) It can take 72 hours for the full effect of brain injury to start impacting on the mind. So more important than asking better questions about amnesia on the day of the accident is to ask them something the next day.

I have two classes of concussion cases. Those where the people went to the ER on day two, and those where they didn’t. In almost every case where the loved ones of the injured person were concerned enough about injured person’s behaviors that they took them back to the hospital, I was able to prove a brain injury occurred. It wasn’t that the second day’s ER staff was so much more competent. It was that by day two, it had become so much more obvious that a concussion had occurred.

When you go to see the doctor 24 hours after your concussion and it is a significant concussion, even busy doctors in the emergency room will spot amnesia and even if they aren’t confused about what happened in the accident, they are confused about what they have been doing.

If we believe it is important to treat those with lasting effects of concussion, we must identify those who are the highest at risk. If we are really going to improve how we sort that out, the key is to make sure they go back to the doctor, preferably the same emergency room. If we change this protocol, we also need to change forms, like the ACE form from the CDC, to tell the doctors what to ask, like: “What did you do since you left here?”

If the patient can only remember a few things, they are probably having amnesia. If they can remember all of it, then they probably don’t. If they don’t remember anything, then it is a significant head injury.

We must change the way we look at the long term potential for a head injury, brain injury, in the 24 hours after the accident. We must start giving the accident victims the same type of care and concern we give athletes who are injured in sports.

Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.

http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
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CDC Acute Concussion Evaluation – Improved Process

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Posted on 3rd April 2008 by Gordon Johnson in Brain Injury

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Included in the CDC Facts for Physicians Toolkit, http://www.cdc.gov/ncipc/tbi/physicians_tool_kit.htm but not as conspicuous as I believe it should be is the Acute Concussion Evaluation (“ACE”) Form. Click here to go directly to such form: http://www.cdc.gov/ncipc/tbi/ACE.pdf

This form is a major step forward and I wish that it was used comprehensively at every Emergency Room and clinic. However, I do have two major concerns with this form, things that could easily be corrected and which would make a tremendous difference in diagnosing and treating the concussions. My first concern is the Amnesia portion. The second, which we will discuss tomorrow, is the serial followup issue.

Amnesia Questions. Here is what the ACE Form asks re on Amnesia and related acute symptoms:

• 3. Amnesia Before (Retrograde) Are there any events just BEFORE the injury that you/ person has no memory of (even brief)? __ Yes __No Duration
• 4. Amnesia After (Anterograde) Are there any events just AFTER the injury that you/ person has no memory of (even brief)? __ Yes __No Duration
• 5. Loss of Consciousness: Did you/ person lose consciousness? __ Yes __No Duration
• 6. EARLY SIGNS: __Appears dazed or stunned __Is confused about events __Answers questions slowly __Repeats Questions __Forgetful (recent info)

Compared to what is routinely asked, this form is a major step forward. Perhaps the best question on the form is “Repeats Questions.”

Here is what the form’s instructions portion says with respect to its Amnesia questions:

3/4. Amnesia: Amnesia is defined as the failure to form new memories. Determine whether amnesia has occurred and attempt to determine length of time of memory dysfunction – before (retrograde) and after (anterograde) injury. Even seconds to minutes of memory loss can be predictive of outcome. Recent research has indicated that amnesia may be up to 4-10 times more predictive of symptoms and cognitive deficits following concussion than is LOC (less than 1 minute).1

The literature completely supports the statement about the significance of Amnesia. My problem with this form is it too narrowly defines the time focus for Amnesia. Amnesia can begin in the period of time after “just AFTER the injury”. Why not just add a few simple sample questions to the form? And make those questions open ended, not something that can be answered with a yes or no. Ask questions where the examiner actually has to listen to a detailed explanation of what the patient remembers. How about these additions:

What can you tell me about the observers at the scene before the ambulance got there?
What can you tell me about the ambulance ride?
Did you have to wait in the emergency room? Who else was waiting?
What questions did they ask you about your insurance, your billing?

All of these questions make sense on the day of the accident. Adreniline improves memory. But that effect is short lived. These questions test memory whether memories were encoded, for the period of time when the adrenaline has worn off. These questions test that critical time frame from 5 minutes post accident to two hours post accident. Questions like these may tell us far more whether the person is converting short term memory into long term memory (saving it to the hard drive of their brain) than questions about the accident itself.

Now if the patient is seen a day or two after the event, the questions should be focused on the time frame from 2 hours post accident, to the time of the evaluation. What have the done that day, what do they remember about the day before? A person who has significant memory gaps for the period of time from 6 hours post accident to 72 hours post accident, is someone at risk of significant long term problems. Sadly, this is a period where few people are actually seen by medical professionals and poor documentation of amnesia during that period occurs.

Tomorrow: The Solution: The Call for a Return Visit.

Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.

http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney

Evolution of the Definition of Concussion

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Posted on 1st April 2008 by Gordon Johnson in Brain Injury

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My last blog focuses the acute symptom of amnesia, the symptom that is now believed to be the most significant predictor of outcome after concussion. However, that is the modern way of looking at concussion, and unfortunately, not even all treatises or commentators on brain injury, are even willing to look at amnesia in absence of a documented loss of consciousness at the time of concussion.

I have a fairly extensive library of brain injury treatises in my library, something many of you who have seen my websites or brain injury videos will recognize. If we were going to look at those books, you might be surprised as to how different the definition of concussion is in those books from what is the current thinking about concussion.

For example, one of the treatises that is on more neurologists shelf than almost any other, Adams and Victor, Principles of Neurology- that books says that you can not have a mild brain injury, you can not have a concussion, without a loss of consciousness.

That frankly is wrong.

But this book has been restating that basic principle since it was originally published in 1977. The copy on my shelf was printed in 1997, and the most recent version says the same thing. That is not the current thinking about concussion, not the thinking of the CDC, not the thinking of the American Academy of Neurology. But because it is content on one of the leading treatises in neurologist’s own libraries, it is the thinking of a far greater percentage of neurologists than should in fact be the case.

The definition of concussion really started to change about 1992, even though the research behind that change dates back at least as far as 1971. What happened in 1992 is that there was the American Congress of Rehabilitation Medicine’s (“ACRM”) published its definition of “mild traumatic brain injury.” In that definition, the ACRM abandoned the absolute requirement that you had to have a loss of consciousness to be diagnosed with a brain injury. The ACRM definition substituted this requirement with four different, alternative, what I describe on my website as acute events. Those events were Loss of Consciousness, a Change in Mental State, Amnesia, and Focal Neurological deficits. Source: Mild Traumatic Brain Injury Committee of the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine, published at J Head Trauma Rehabil 1993:8(3):86-87 For the full context of the ACRM definition, click here.

The only one of those that really adds a significant amount to the diagnostic picture is amnesia. But because amnesia is one of those things that doesn’t have a true objective measure and something that is not particularly sensitive to be identified in the emergency room, amnesia has not helped us define mild brain injury/ in the cases where people are long term disabled as much as it should. See the previous blog on Amnesia, and the blogs that will follow later this week.

The 1992 ACRM definition of concussion was ultimately followed by the American Academy of Neurology’s work with concussion in sports. Those two movements had a major impact on changing the definition of concussion. That has ultimately lead to the extremely important “Heads Up Brain Injury in Your Practice “ which is published and distributed by the CDC. For those materials, click here.

Tomorrow: Concussion in Sport and How Relevant that is to Other Concussions

Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.

http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
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Amnesia and Brain Injury

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Posted on 25th March 2008 by Gordon Johnson in Brain Injury

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There is no more important issue for the diagnosis and determination of prognosis after a brain injury than the length and severity of amnesia. Amnesia is defined as the loss of memory for events, both before and after the accident. Loss of memory for events before the accident is called retrograde amnesia, i.e. similar to the use of the term retroactive, i.e. something that relates back to a time prior to the event. Loss of memory for events after the accident is called anterograde amnesia. This also includes problems with new learning. See http://tbilaw.com/AboutMildBrain16.html In non-coma brain injury cases, there is rarely any significant retrograde amnesia, and the term Post Traumatic Amnesia, (“PTA”) is often used generally to describe the loss of memory following an event.

One of the leading text’s in the Field of Brain Injury, Lezak’s Neuropsychological Assessment, now in its 4th Edition, clearly states the prevailing opinion, that it is the length of Post Traumatic Amnesia that is the biggest predictor of outcome after a brain injury. The 4th Edition contains this chart with respect to amnesia:

TABLE 7.1 Estimates of Severity of Injury Based on Posttraumatic Amnesia (PTA) Duration
PTA Duration Severity
________________________________________________________________________

<5 minutes Very Mild
5-60 minutes Mild
1-24 hours Moderate
1-7 days Severe
1-4 weeks Very Severe
More than 4 weeks Extremely Severe

Now the problems with prognosticating brain injury from determinations of PTA is that this measure is rarely properly assessed by treating doctors after a head injury. Lezak explains this dilemma as follows:

“However, difficulties in defining and therefore determining the duration of PTA have made its usefulness as a measure of severity questionable in some cases (Jennett, 1972; Macartney-Filgate, 1990). For example, while it is generally agreed that PTA does not end when the patient begins to register experience again but only when registration is continuous, deciding when continuous registration returns may be difficult with confused or aphasic patients (Gronwall and Wrightson, 1980). Moreover, many patients with relatively mild head are discharged home while still in PTA, leaving it up to the examiner to attempt at some later date to estimate PTA duration from reports by the patient or family members, who often have less reliable memories. These considerations have led such knowledgeable clinicians as Jennett (1979) and N. Brooks (1989) to assert that fine-tuned accuracy of estimation is not necessary as judgments of PTA in the larger time frames of hours, days, or weeks will usually suffice for clinical purposes (e.g., Table 7.1). Length of PTA as more accurate than coma duration in predicting cognitive status two years after injury(D.N. Brooks, Aughton, et al., 1999). Yet failures to discriminate between moderately and severely impaired patients suggest that it may not classify patients with sufficient sensitivity for research (N. Brooks, McKinlay, et al., 1987).”

What does this all mean? It means that someone who is comatose for a week but has a rapid return of memory and a reasonably quick end to PTA may be expected to have a better outcome than someone who is never knocked out but continues to have PTA for more than a month. YES. I DID SAY THAT. Someone without a loss of consciousness can have a worse outcome than someone who is in a coma, if they have a longer period of PTA.

But alas, I am a lawyer, and how do I prove that someone has PTA that persists for weeks after a seemingly routine concussion? If the medical professionals would do their job of follow-up, my job would be so much easier.

I met with a client recently who was amnestic for as much as three months post accident. Among the highlights of what she doesn’t remember is an airline trip to visit a doctor, meeting her lawyer, the last four months of a pregnancy. While not remembering a lawyer might be a good thing, forgetting one of her first airline trips and a significant portion of her pregnancy, are undeniably abnormal. But are these memory gaps clearly documented in her medical records? One month post accident, she is seen by her family doctor, because her significant other is concerned about her memory problems and seizure episodes she is having. The doctor documents the seizure episodes but asks no probing questions about memory or even notes her boyfriend’s concerns about memory.

Why can’t doctors learn how critical documenting amnesia is? Is it so hard to ask questions of a person with Post Concussion Syndrome questions that will test whether that person is imprinting current memories to that person’s long term memory? The brain has a memory mechanism quite analogous to a computer’s RAM conversion to hard drive memory process. If you are creating a document on a computer and lose power or your computer crashes before you save the document, all will be lost and what was held in your computer’s RAM, will not be saved to your computer’s hard drive. Amnesia is the failure of the brain to convert short term memories into long term memory, in essence saving the memory to a different part of the brain.

In order to test for amnesia, it is necessary to ask questions of a person that determine what they remember about a few hours ago, what they remember of yesterday. Why is this so hard? It isn’t hard – it is just that it has never been made to seem important enough. Yet all of 50 steps of the classic neurological exam will tell us far less than simply asking someone what an injured person ate for dinner the night before the follow-up exam.

For more on my thoughts about identifying amnesia, see my YouTube videos at:http://youtube.com/profile?user=braininjuryattorney

Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.

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