Determining Loss of Consciousness?
In most cases of brain injury without coma, the ER records will say “no loss of consciousness.” But what is involved in determining loss of consciousness? The ER people are never at the scene of the wreck. Also, there is usually at least a half hour gap between the time of the wreck and the injured person’s arrival at the ER. Only those at the scene can answer this question.
Even the EMT’s are not there until most of the evidence of loss of consciousness or change and mental state will have cleared. These symptoms last less than a minute in most cases. Confusion only a few minutes longer.
If the only individual who is asked in determining loss of consciousness is the injured person, then the report in the ER notes about their determining loss of consciousness, is of little probative value. The patient is a poor historian of events that occurred when they may have been disoriented, confused, unconscious or suffering from post traumatic amnesia.
TBI Diagnosis Requires a Reexamination of the Records
While it is improper to rely solely on the medical records, they are still key to any diagnosis of brain injury. It is important to look for corroborative clues, especially in the ambulance records.
Do the ambulance or other records include a reference to disorientation, nausea? Is what the injured person said to the EMT’s about symptoms and the events of the wreck, consistent with what the injured person told the ER attendants? Is the patient asking the same questions over and over?
If you closely examine these records, with a search for more than LOC, you may find important diagnostic signs that were missed in the discharge diagnosis.
NEXT: Investigator’s Role In Reconstructing the Diagnosis.