I have become continuously frustrated by the amount of missed diagnosis of mild brain injury. Several times a month, we are contacted with another survivor whose brain injury was not diagnosed in the ER. Despite identifiable symptoms of a brain injury in the ER, injured persons are discharged with no more diagnostic effort devoted to them than an analysis of the Glasgow Coma Scale (GCS).
The nature of neurological examinations in the ER is poorly suited to diagnosing the mild brain injury (Subtle Brain Injury©), even though such TBI can become serious after discharge.
One problem with not looking for the TBI sooner, is that the window of time for an abnormal scan may be lost, although this problem has been reduced with the advantage of more modern imaging techniques. One of the most common types of missed brain injury is the diffuse axonal injury (DAI) that is so common in the motor vehicle, whiplash type accidents, which is far more likely to be diagnosed with an MRI rather than a CT scan.
The flaws in triage for TBI are many, but at its core is the reliance on the patient for what is perceived to be the most important question: Was there a loss of consciousness?
How can an intelligent doctor or nurse, rely on a person with a potential brain injury, to be a historian of things that happened when the person is expected to have memory loss, confusion about the event? At a minimum, a critical examination of the person’s recollection of events must be undertaken.
More significantly, loss of consciousness (LOC) is not the litmus test for traumatic brain injury. Any change in mental state can be diagnostically significant. In addition, headache, lack of consistency in reports of history, nausea and the need for oxygen could tip off the ER team. Even a digital or cell phone photo of the accident scene and vehicle damage could point towards a traumatic brain injury or head injury.
In discussing this problem with an ER doctor, I was asked:
“Even if an MRI diagnosis brain injury, is there sufficient medical intervention possible, to justify the costs of doing acute interventions? (In other words, are we just doing this to help the lawyers?)
His point was that unless the diagnosis of MTBI directs the physician towards a course of treatment that would help to cure the condition, it is difficult in a cost conscious medical model, to justify a $1,000 test.
I continue to be disturbed by this rationale.
Does not the TBI survivor have the right to know the nature of his or her injuries, even if such cannot be treated? We do not avoid expenditures to diagnose other serious conditions based solely upon the likelihood of a cure. While I believe there are medical treatments to help the “mildly” brain injured or concussed. Yet, in replying to the doctor, I focused my response not on the medical interventions, but to economic cost of the missing a TBI diagnosis.
I started with the vocational or work place cost. Many people with TBI do not realize there is anything abnormal until they return to work. Often times (particularly in the case of other serious injuries) such return to work happens weeks or months after the wreck. Especially in cases such as neck or back injuries, the injured person goes through a period of convalescence. Convalescing tends not to be very demanding upon one’s cognitive functions.
Yet when the injured person goes back to work, intellectual deficits may start to show up. If neither injured person nor his or her employer has any idea that a TBI has occurred, those deficits can result in serious mistakes. This change in work performance can result in getting fired. If the MTBI had been diagnosed, even if not treated, the cognitive challenges might have been accommodated, perhaps eliminating the mistakes and saving the job.
I asked my doctor friend whether his patients would have a right to know if he had a TBI, with a sudden had drop in I.Q., an inability to concentrate, to memory issues? While his IQ might still be above normal, would he be able to perform as his patients had a right to expect? Would the differential diagnosis, which he now does from memory, still be possible? What if he had a change in decision making or judgment as a result of a undiagnosed TBI? Even if his cognitive challenges were temporary, wouldn’t the consequences of not knowing, be potentially serious?
While explaining why a person should not try to practice medicine with an undiagnosed TBI is an easy illustration, the vocational risks and costs are significant with anyone who has an undiagnosed TBI.
In making my point to the ER doc, I next argued that the impact on the family from an undiagnosed TBI, can also manifest in economic ways. What is the cost of divorces that are so prevalent after TBI? The cost of divorce lawyers would justify the cost of an MRI. What of the serious disruption in family unit? While the personal loss is paramount, that personal loss results in severe economic loss as well.
The value of early TBI diagnosis is significant even with the individuals who have apparent full recoveries. If someone said to the concussed in the emergency room: “For the next 60-90 days you should accommodate for these expected deficits in the way in which you do your job,” mistakes and job loss might be greatly reduced. IF someone said to the family members of the TBI survivor, that they should be tolerant of new quirks in the injured person’s personality, family disruption might be reduced. It is the unexplained change in behavior that is so hard for employers and families to tolerate.
Things have changed in the 20 years since I had this debate with the poorly trained in TBI, ER doctor. Now sport concussion is well understood my many athletic trainers and coaches. Yet, the ER approach after a car wreck has changed far less than it should have. Those in the ER must come to understand that the diagnosis of TBI, even mild brain injury or concussion, is as important as the diagnosis of cancer, spinal cord injury and AIDS.