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Traumatic Brain Injury – The Critical Role of Family on the Road to Diagnosis Treatment and Recovery

Brain damage is one of the leading causes of death in people under the age of 45. Many of those with mild to moderate injuries appear uninjured and have few outward physical manifestations of personal injury. In short, they “look” fine, despite the fact that they have suffered a serious personal injury that can mean the loss of a job, the destruction of personal relationships, and the anguish that comes with knowing all this. which was lost.

Mild to moderate survivors of traumatic brain injury are routinely reassured by doctors that they will recover from fatigue, slow thinking and reduced memory, just as they expect to recover from cuts, d bruises and broken bones. The all-too-common belief is that time heals all wounds. For every rule there is an exception and unfortunately time does not cure all traumatic brain injuries. Over time, doctors treat objective physical injuries, but the head injury does not receive the special attention it requires and TBI goes undiagnosed. Consequently, many traumatic brain patients with permanent impairments never receive a full evaluation by a neuropsychologist, including neuropsychological testing. Without examination by a neuropsychologist, this personal injury cannot be diagnosed, and these patients never receive proper care and treatment for their physical, cognitive, psychological, sexual, and social impairments. including rescue and ambulance ward, emergency room and hospital records if there has been an admission. A comprehensive package is essential because it contains all of the detailed assessments and objective measurements performed by emergency medical technicians, ER nurses, physicians, and neurologists that are necessary to understand the nature and extent of that personal injury. .

Since the brain regulates our state and level of consciousness, we can learn a lot about the extent of brain damage by assessing consciousness itself. If the level of consciousness is different from normal, the head injury is serious, regardless of what a physical exam or other evidence may indicate. The categories of altered consciousness are:

• Confusion – The mildest form of impaired consciousness, in which individuals have difficulty thinking coherently. For example, they may not be able to solve a simple math problem or remember what they ate for breakfast. Often they seem disoriented and may not talk much.
• Stupor – At this level, individuals are often close to a comatose state and do not respond to normal stimuli. They can only be aroused by intense or painful stimulation, such as having their toe squeezed or being stuck with a pin. They can open their eyes, but only if vigorously forced to respond.
• Delirium – This intense state of altered consciousness is often the result of exposure to a toxic substance. People with delirium are disoriented, frightened, irritable and hyper-reactive. They do not understand what they see or hear and are prone to visual hallucinations.
• Coma – The most severe form of impaired consciousness, in which a person is completely unconscious and does not respond to any kind of stimuli.

Doctors use a system called the Glasgow Coma Scale (GCS) to accurately assess and describe patients’ levels of consciousness. To understand the severity of a brain injury, the patient’s condition at first assessment is important. The more severe the initial presentation, the more severe the injury and the reduced likelihood of a full and complete recovery. The scale is based on three individual responses measuring eye, verbal and motor responses. Physicians consider the expression of a total GCS score of limited value; what is more important is the score in each of the three individual categories. Each level of response indicates the degree of brain damage.

The lowest score is a 3 and indicates the patient’s lack of response. An alert and oriented person would be rated at 15.

Any period of unconsciousness is a warning signal to exclude permanent brain damage, i.e. to assess the nature and extent of brain damage. Loss of consciousness should always be considered significant. However, a report of no loss of consciousness does not mean that brain damage has not occurred. Many head injuries result in a prolonged period of confusion with patchy memory. It is common to ask patients what they remember when they wake up. Most important, however, is the constant and continuous memory reboot. In many cases where there is no specifically identified period of loss of consciousness, the continuous memory will not restart until several hours or days later.

The most common type of brain damage is silent and elusive. Called post-concussion syndrome, this bodily injury is most often caused by what appears to be a minor head injury. People may sustain a head injury but never lose consciousness and appear to be doing very well. The difference between post-concussion syndrome and traumatic brain injury is that PCS is temporary. TBI is not. Days or weeks later, people experience problems with memory, reasoning, or judgment, or they may simply report that they don’t feel well and are not the same person they were before the accident. These injuries are not readily noted in the injured survivor’s medical records, but are well understood by family members, close friends and co-workers who know the survivor is “not the same person” as they are. was before this serious personal injury. changed their life.

In today’s world of short medical visits, physicians do not have the time, and in many cases the training, to interview the patient about detailed changes in their ability to cope with a head injury. Because many people improve over time, reassurance is the common form of medical care provided by a family doctor or general practitioner. The result is that “reassurance” denies the patient treatment because it does not guarantee an honest diagnosis.

Family members are the first to recognize the deficits and changes caused by traumatic brain injury, long before the patient is ready to admit chronic deficits, but unfortunately this important information is not fully communicated to physicians. Moreover, by definition, asking a person with a memory impairment for details about their cognitive losses is problematic. It’s the equivalent of asking a patient “how long have you been knocked out?” Once you lose consciousness, you don’t know, and it’s rare for someone to instantly regain full consciousness. Going in and out of acute awareness is common. For the same reasons, asking a person with memory impairment what they don’t remember is of no use. And there is no clear line between depression, fatigue, irritability, and memory lapses caused by brain injury or other causes, although these symptoms are hallmarks of a brain-injured patient. . This is why it is so important for a spouse, parent or sibling with first-hand knowledge to attend follow-up medical examinations.

 

After 3 to 6 months, if deficits persist or if improvement is slower than expected, report more significant deficits in writing to the primary care provider and seek a referral to a neuropsychologist.

In many cases, as a head injury survivor’s attorney, I have worked with family members to prepare a detailed letter to a treating physician that identifies changes in learning skills and communications, among others, suffered by the patient and as a result, I obtained a referral to a neuropsychologist for evaluation and testing. Obtaining appropriate medical care and treatment, especially for TBI survivors, requires the intervention and support of family members, and often a trained attorney who knows and understands the signs and symptoms of an injury. cerebral.

A word of warning. Don’t be deterred by a doctor refusing to order neuropsychological tests because a CT scan or MRI does not show an injury, i.e. the images are read as being within normal limits.

 

First, CT scans cannot be used to diagnose TBI except in the most severe cases of fractures and hematomas. Second, the same is true for most MRIs. Unless the MRI was performed on a T-3 MRI machine, which uses sophisticated software to provide diffuse tensor imaging and fiber tracing that is studied and interpreted by a neuroradiologist trained in this protocol, the MRI report is not definitive.

Note that an MRI using a T-3 by itself is not sufficient unless software providing diffuse tensor imaging and fiber tracing is used. This combination of hardware and software allows specially trained professionals to identify axonal shears and other end injuries, otherwise invisible on MRI scans performed on the T-1 or T-1.5 machines. More importantly, MRIs are not the first step in diagnosing traumatic brain injury. The accepted method for diagnosing the remnants of a traumatic brain injury is through testing by a trained neuropsychologist to assess TBI.

 

When should we expect a recovery and to what extent? The general rules are that the shorter the recovery time, the more complete the recovery will be. Although every person is different, patients tend to recover sensory, motor, and language skills faster and easier than writing and math skills, memory, attention, general intelligence, and social balance. /emotional. In addition to the longer recovery time, the loss of these skills and abilities is usually more devastating.

Motor and vocal recovery usually occurs within three to six months of injury. Attention and memory tend to be the hardest to recover.

The rate of recovery is usually greatest during the first three months. The recovery then tends to slow down during the balance of the first year. This is one of the reasons why it is useful to obtain a neuropsychological evaluation soon after the head injury and to use this baseline for comparison with later tests to measure changes and understand the extent of the improvement.

Usually after six months some improvement may occur, but it is usually not significant. After this point, there is no more healing in the conventional sense. Damaged brain cells and nerve pathways do not regenerate. People can and do learn to compensate for their injuries using other skills and this is where rehabilitation specialists come in very handy.

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