Brain injury is one of the leading causes of death in people under the age of 45. Many who suffer mild to moderate injuries do not appear to be injured and have few outward physical manifestations of personal injury. Ultimately, they “remain” well, despite the fact that they have suffered severe personal injury that can mean job loss, the destruction of personal relationships and the anguish that accompanies the knowledge of all that has been lost.

Doctors assure mild to moderate traumatic brain injury survivors that they will recover from their fatigue, slow thinking, and reduced memory, just as they expect to recover from cuts, bruises, and broken bones. The all too common belief is that time heals all wounds. To every rule there is an exception and unfortunately time does not heal all traumatic brain injuries. Over time, doctors address objective physical injuries, but head injury does not receive the special attention it requires, and traumatic brain injury goes undiagnosed. As a result, many patients with head injuries and permanent disabilities never receive a full evaluation by a neuropsychologist, including neuropsychological testing. Without testing by a neuropsychologist, this personal injury cannot be diagnosed and these patients never receive adequate care and treatment for their physical, cognitive, psychological, sexual, and social impairments. A complete kit is essential because it contains all the detailed evaluations and objective measurements by emergency medical technicians, emergency nurses, and physicians and neurologists that are necessary to understand the nature and extent of this personal injury.

Since the brain regulates our state and level of consciousness, we can learn a lot about the extent of brain injury by assessing one’s own consciousness. If the level of consciousness is not normal, the head injury is serious, regardless of what a physical examination or other evidence indicates. The categories of altered consciousness are:

• Confusion – The mildest form of altered 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. They will often seem disoriented and may not talk much.
• stupor – At this level, people are often close to a comatose state and unresponsive to normal stimuli. They can only be aroused by intense or painful stimulation, such as having their toes pinched or being pricked with a pin. They can open their eyes, but only if forcefully forced to respond.
• Delirium – This intense state of altered consciousness is often the result of exposure to a toxic substance. People with delusions are disoriented, fearful, irritable, and hyperreactive. They have no idea what they see or hear, and are prone to visual hallucinations.
• Eat – The most severe form of impaired consciousness, in which a person is completely unconscious and does not respond to any kind of stimulus.

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 condition of the patient at the first evaluation is important. The more severe the initial presentation, the more severe the injury, and the likelihood of full and complete recovery is reduced. The scale is based on three individual responses that measure ocular, verbal, and motor responses. Clinicians consider the expression of a total GCS score of limited interest; the most important thing is the score in each of the three individual categories. Each response level indicates the degree of brain injury.

The lowest score is a 3 and indicates that the patient does not respond. A person who is alert and oriented would have a score of 15.

Any period of unconsciousness is a red flag to rule out permanent brain injury, that is, to assess the nature and extent of the brain injury. Loss of consciousness should always be considered significant. However, a report of no unconsciousness does not mean that brain injury has not occurred. Many head injuries result in a prolonged period of confusion with irregular memory. It is common for patients to be asked what they remember upon awakening. However, it is more important when constant and continuous memory is reset. In many cases where there is no specifically identified period of unconsciousness, continuous memory will not reset for many hours or days afterwards.

The most common of brain injuries is silent and slippery. Called post-concussion syndrome, this personal injury is often caused by what appears to be harmless damage to the head. People can sustain a head injury, but they never lose consciousness and seem fine. The difference between a post-concussion syndrome and a traumatic brain injury is that PCS is temporary. TBI is not. Days or weeks later, people will experience problems with memory, reasoning, or judgment, or may simply report feeling “off” and not being the same person they were before the accident. These injuries are not easily reported in the injured survivor’s medical records, but are well understood by family members, close friends, and co-workers and know that the survivor is “not the same person” they were before this injury serious staff. they changed their lives.

In today’s world of short medical visits, doctors do not have the time and, in many cases, the training to ask the patient about detailed changes in their ability to cope with a head injury. Since many people get better over time, reassurance is the common form of medical care provided by a family doctor or general practitioner. The result is that “peace of mind” denies the patient treatment because it fails to ensure an honest diagnosis.

Family members are the first to recognize impairments and changes caused by head injury, long before the patient is prepared to admit chronic impairments, but unfortunately this important information is not fully communicated to the doctors. Also, by definition, asking a person with memory problems details of their cognitive losses is problematic. It’s the equivalent of asking a patient “how long were you knocked out?” Once you lose consciousness, you don’t know it, and rarely does anyone instantly regain full consciousness. Going in and out of acute awareness is common. For the same reasons, asking a person with memory problems what they don’t remember is not helpful. And there is no clear line between depression, fatigue, irritability, and memory lapses caused by brain injury or other causes, although these symptoms are characteristic of a brain-injured patient. That’s why it’s so important that a spouse, parent, or sibling with first-hand knowledge attend follow-up medical exams.

 

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

In many cases, as the attorney for the head injury survivor, I have worked with family members to prepare a detailed letter to a treating physician that identifies changes in learning, communication, and other skills experienced by the patient and how As a result I have obtained a referral to a neuropsychologist for evaluation and testing. Getting the proper medical care and treatment, especially for TBI survivors, requires the intervention and support of family members and often a qualified attorney who knows and understands the signs and symptoms of brain injury.

A word of caution. Don’t be discouraged if a doctor refuses to order neuropsychological testing because a CT scan or MRI shows no lesions—that is, the images read as if they were within normal limits.

 

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

Note that an MRI using a T-3 alone is not sufficient unless software that provides diffuse tensor and fiber tracing images is used. This combination of hardware and software allows specially trained professionals to identify axonal nicks and other finite lesions not otherwise seen on MRIs performed on T-1 or T-1.5 machines. More importantly, MRIs are not the first step in diagnosing traumatic brain injury. The recognized method of diagnosing the remnants of traumatic brain injury is through testing by a neuropsychologist trained to assess for TBI.

 

When should a recovery be expected and to what extent? The general rule is that the shorter the recovery time, the more complete the recovery. Although each person is different, patients tend to recover sensory, motor, and language skills faster and more easily than writing and math skills, memory, attention, general intelligence, and social/emotional balance. In addition to the longer recovery time, the loss of these skills and abilities is often more devastating.

Motor and speech recovery usually occurs within three to six months of injury. Attention and memory are usually the most difficult to recover.

The rate of recovery is usually greatest during the first three months. The recovery then tends to slow down over the course of the first year balance. This is one of the reasons why it is valuable to obtain a neuropsychological evaluation soon after the head injury and use this baseline to compare with subsequent tests to measure changes and understand the degree of improvement.

In general, after six months some improvement may occur, but it is usually not significant. After that point, there is no healing in the conventional sense. Damaged brain cells and nerve pathways do not regenerate. People can and do learn to compensate for their injuries through the use of other skills and that is where rehab specialists come in handy.