One of the great advantages of working on challenging and complicated brain damage cases is that I get exposed to some of the leading neuro-scientists in the world. This year’s common denominator amongst those minds is that I know many professionals whose research is benefitting from the huge infusion of research funds for brain injury, Iraq Style. That large sums of federal dollar is now looking into brain injury is great news. And another silver lining to the tragic cloud of a whole new generation of brain damaged veterans, is the emerging media attention to the brain injuries.
But this massive research move does come with a cost, and I am not talking about huge sums of US taxpayers dollars, which of course are being thrown at this problem, because of the political ground swell to do more for our veterans. The long range cost to this may be too much research, done too quickly, by people who don’t fully comprehend the nature and scope of the civilian post concussion syndrome problem. Already, we are seeing studies that are further muddling the line of demarcation between organic brain injury and PTSD. In a combat casualty, that line would be expected to be blurred. The whole concept of PTSD is something that arose out of combat, principally the Viet Nam war.
But when you separate Post Concussion Syndrome (or Subtle Brain Injury, as I call it) from the combat situation, there are very few cases where the PTSD is even a factor. Sure you could construct a fiction that anyone who has been thru a car wreck, has a certain risk factor for anxiety from such accident – it it was in fact life threatening and there was advance warning. Take for example the person who has the half second warning as they brake before a serious head on collision. That person may have gotten the fright of his or her life from the event. But most car wrecks aren’t like that. Most are rear end collisions where there is little or no “scare” involved until the wreck is over. Anxiety causing events and PTSD (shocking events) are different.
Personally, I don’t think that PTSD should ever have really applied outside of the combat situation, except in situations with prolonged emotionally distress (such as a rape or kidnapping). But our medical community likes to pigeon hole diagnosis into neatly defined categories, and if you don’t subscribe to the theory that concussion can cause permanent damage, then you have to look around for some sort of other convenient pigeon hole. The DSM-IV, the bible of psychiatrists, is the principal tablet from above for modern medicine when the organic diagnosis is not straightforward. PTSD has very strict diagnostic criteria, which only really make sense in the prolonged shock/stress situation. So even though this is not something you would likely see in a motor vehicle wreck and certainly not in other accidents, the diagnosis appears not only in practice, but in peer reviewed literature.
However, the biggest problem in basing our next generation of diagnosis of Iraq war head injuries is that soldiers are much like young jocks: they do not accurately represent the type of person who is typically disabled by a concussion nor the type of forces a civilian is likely to endure. Soldiers are predominantly younger individuals, in good physical condition (we certainly hope so) and who are primarily male. Those disabled from concussion are predominantly over 40, female and incapable of withstanding any where near the same type of physical trauma. This has been much of the problem with basing our current generation of research on concussion and sport studies. While the good news is that this research has predominantly moved the line as to when a concussion can occur – as young jocks are far less likely to be disabled than average – they understate the potential for disability in the civilian population.
OK, now that I have vented, let me be a hypocrite and tell you what my pet project would be for all of this research money: I want them to develop a detailed, standardized questionnaire that can be administered by ER personnel to test for AMNESIA. I would like to see a protocol where every ER room would have a questionnaire that they give anyone suspected of a concussion, with questions on it, that would tell you whether such person had complete memory from the period of time 5 minutes post accident, until the period of time of the examination. And by the way, at the bottom of that questionnaire, tell the medical professional to insist that the person come back in 24 hours and be asked the same questions again. See specific to this issue, my video at http://youtube.com/watch?v=dEWHgwRywtY For a general treatment of the role of amnesia in concussion diagnosis, see the full playlist of videos on this topic at http://www.youtube.com/view_play_list?p=F4E4FC0DCD4FA2E9
The repeated followups is the standard of care to release our million dollar quarterbacks to play in the next game, it hopefully will be the evolving standard of care to allow our soldiers to return to a combat situation. It must be the standard of care before ruling out a concussion in someone far more likely to be disabled by the trauma to the brain.