Posted on 11th September 2009 by Gordon Johnson in Brain Injury
amnesia, brain injury, brain injury attorney, brain injury lawsuits, Glasgow Coma Scale
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.
Posted on 10th September 2009 by Gordon Johnson in Brain Injury
amnesia, brain injury, brain injury attorney, brain injury lawyer, concussion, Glasgow Coma Scale
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.
