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.