Connecticut is the latest state to be weighing a law that would protect student sports players from the after effects of concussions.
Democratic lawmakers in the Nutmeg State have proposed the legislation, according to The Hartford Courant. http://www.courant.com/sports/other/hc-concussions0126.artjan26,0,93453.story
The law’s slogan is “When in doubt, sit it out.”
So far two states, Washington and Oregon, have already passed laws protecting student athletes from the effects of concussion. California has similar legislation pending.
The proposed Connecticut law mandates that student athletes who are believed to have suffered a concussion wait a day until they return to play their sport. The law also requires that coaches be educated about concussions.
The Connecticut bill is being sponsored by State Sen. Majority Leader Martin Looney of New Haven and Sen. Thomas Gaffey of Meriden.
Attorney Gordon Johnson
Past Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
Ex-Washington Football Player Sues School District, Chiropractor Over Concussion-Related Brain Injuries
A former high school football player in Washington State is suing his old school district and a local chiropractic clinic for brain injuries he received in 2006.
Adrien Gault alleges in his lawsuit that the Sequim School District didn’t follow protocol by allowing him to come back and play football after sustaining multiple concussions, according to a story, http://www.komonews.com/news/local/82474567.html,
from the Peninsula Daily News that KOMO-TV ran on its Web site.
Sequim Chiropractic Clinic owner Robert Bean and his wife were also named in the suit, which seeks unspecified damages. The lawsuit was filed in Clallam County Superior Court.
According to the story, Bean wasn’t qualified to clear Gault to resume playing football, which he did despite the fact that the young player had received multiple concussions, and had to be taken from the field on a stretcher in one instance.
When he was a senior for the Wolves high school team Oct. 20, 2006, Gault went into a coma on the sidelines shortly after he had collided with a teammate during warm-ups. He had suffered a subdural hematoma.
The suit charges that the school district knew that Gault had suffered numerous concussions prior to the Oct. 20 incident, according to the story.
Gault claims that he has problems stemming from his brain damage, including a memory lapses and headaches.
Brain injury and chiropractors should never mix. No one suspected of a concussion should be seeing a chiropractor, not just because of something like this that could go wrong, but because of the risk of an artery dissection from neck manipulation.
Attorney Gordon Johnson
Past Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
The Near-Fatal Football Injury That Lead To California’s Proposed Laws on Concussions
We recently wrote that California is considering new legislation that would impose strict guidelines on when high school athletes can return to the field after sustaining head injuries. Only three other states have policies as strict as the one California is considering.
The San Francisco Chronicle today has a detailed story, http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2010/01/24/MN6V1BM6OR.DTL, on
the young man whose near-fatal football injury lead to the proposed legislation.
Blea was playing for San Jose Academy High when he was hit in the chest during a play at a Thanksgiving Day game last year. He got up from the field, got to the sidelines and then collapsed. He was put in a drug-induced coma for a week, spent almost a month in hospitals and lost 31 pounds, according to the Chronicle.
The story cites a number of statistics regarding high school injuries. For example, about 68,000 concussions were sustained during the 2008 high school football season, according to the National High School Sports-Related Injury Surveillance Study.
And the man who helped organize that study, Ohio State associate professor Dawn Comstock, said that in 2008 16 percent of high school football players who had concussions where they lost consciousness went back to play that same day.
Blea played as a running back and linebacker, positions that one study found are most likely to get concussions.
Two U.S. high school players died as a direct result of football injuries last year, the Chronicle story says.
Physicians say Blea’s outlook is good, but he can’t play football again.
When he was hit, Blea fell and his head hit the turf, with his brain “slamming against his skull,” according to the Chronicle.
The story then describes his surgeries and recovery.
Attorney Gordon Johnson
Past Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
The San Francisco Chronicle today has a detailed story, http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2010/01/24/MN6V1BM6OR.DTL, on
the young man whose near-fatal football injury lead to the proposed legislation.
Blea was playing for San Jose Academy High when he was hit in the chest during a play at a Thanksgiving Day game last year. He got up from the field, got to the sidelines and then collapsed. He was put in a drug-induced coma for a week, spent almost a month in hospitals and lost 31 pounds, according to the Chronicle.
The story cites a number of statistics regarding high school injuries. For example, about 68,000 concussions were sustained during the 2008 high school football season, according to the National High School Sports-Related Injury Surveillance Study.
And the man who helped organize that study, Ohio State associate professor Dawn Comstock, said that in 2008 16 percent of high school football players who had concussions where they lost consciousness went back to play that same day.
Blea played as a running back and linebacker, positions that one study found are most likely to get concussions.
Two U.S. high school players died as a direct result of football injuries last year, the Chronicle story says.
Physicians say Blea’s outlook is good, but he can’t play football again.
When he was hit, Blea fell and his head hit the turf, with his brain “slamming against his skull,” according to the Chronicle.
The story then describes his surgeries and recovery.
Attorney Gordon Johnson
Past Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
California Weighs Strict Laws To Protect Student Athletes With Concussions
Momentum for the Lystedt Law which prevents a concussed scholastic athlete to return to the game in which he or she receives a concussion continues to grow. California, often on the vanguard of American culture and society, has joined the movement to impose tough laws to protect young sports players from concussions.
California is considering new legislation and a proposal from the state’s high school sports federation that would mandate that physicians have a say before an injured can return to play, according to a story Friday in the San Bernardino County Sun.
The story, http://www.sbsun.com/sports/ci_14244046, says that only three other states have policies as strict as the one California is considering.
The legislation was proposed after the near-death of San Jose High Academy Football player Matt Blea, according to the story.
California Assemblywoman Mary Hayashi has introduced two bills. The first would require coaches to become familiar with the symptoms of head injuries. The second would require a physician to give an OK before an injured player could get back on the field.
That second bill is similar to a proposal that the California Interscholastic Federation, which governs sports at about 1,500 schools, is considering.
Currently many California school districts mandate that injured student players must get a physician’s release before resuming play, according to the story. But not all schools have such a policy.
Zachery Lystedt was a high school football player in Washington who suffered a mild concussion early in a game but continued to play. Near the end of the game he suffered another concussion, which resulted in a severe brain injury. His injury became the impetus for a law in his home state of Washington prohibiting any return to play of a scholastic athlete after a concussion.
Attorney Gordon Johnson
Past Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
California is considering new legislation and a proposal from the state’s high school sports federation that would mandate that physicians have a say before an injured can return to play, according to a story Friday in the San Bernardino County Sun.
The story, http://www.sbsun.com/sports/ci_14244046, says that only three other states have policies as strict as the one California is considering.
The legislation was proposed after the near-death of San Jose High Academy Football player Matt Blea, according to the story.
California Assemblywoman Mary Hayashi has introduced two bills. The first would require coaches to become familiar with the symptoms of head injuries. The second would require a physician to give an OK before an injured player could get back on the field.
That second bill is similar to a proposal that the California Interscholastic Federation, which governs sports at about 1,500 schools, is considering.
Currently many California school districts mandate that injured student players must get a physician’s release before resuming play, according to the story. But not all schools have such a policy.
Zachery Lystedt was a high school football player in Washington who suffered a mild concussion early in a game but continued to play. Near the end of the game he suffered another concussion, which resulted in a severe brain injury. His injury became the impetus for a law in his home state of Washington prohibiting any return to play of a scholastic athlete after a concussion.
Attorney Gordon Johnson
Past Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
Evolution in the Understanding of Concussion – Length of Amnesia Correlates to Severity of Brain Damage
Continuing on with the discussion of my Concussion Clinic videos, today’s topic is The Length of Amnesia is the Best Predictor of Severity of Injury. Today’s video is here:http://www.youtube.com/profile?user=braininjuryattorney#p/u/8/WB9ErwpKnXk
Brain injury is one of those things that everyone feels the need to classify, typically into categories of mild, moderate and severe. A severe brain injury is one that involves extended coma. I don’t have any trouble with that definition for severe brain injury.
The controversy in classifying brain injuries revolves primarily around whether there was a brain injury at all and where the break point is between mild and moderate brain injury. The problem with all classification battles in the mild to moderate category is too much is based upon the identification of symptoms in the first hour, where it is not how symptomatic a person is at two hours, but how long the symptoms last that is significant. This is especially true with the most predictive symptom, amnesia.
With respect to severe brain injury, the Glasgow Coma Scale is a reasonably accurate indicator of severity. It also has the benefit of nearly universal adoption, making outcome studies based upon it reliable because of the large number of patients studied. But when the brain injury is below the severity level that loss of consciousness or a change in mental state is witnessed by a medical professional, the GCS has little validity. Most concussed individuals will get the highest score of 15, regardless of how significant the concussion is and how symptomatic they are at the time given the score. The GCS score at the mild end is only a test for confusion, not amnesia. To get a “perfect” GCS score, a patient needs only have his eyes open, be able to carry on a conversation demonstrating orientation (he knows who he is and where he is) and that he can follow simple commands. Compare that to how oriented a quarterback must be to continue to play in the game.
In contrast, basing outcome on the length of amnesia not only correlates well with the GCS score in the severely brain injured population, it is sensitive enough to provide meaningful diagnostic guidance in the less severely injured. According to Lezak, Neuropsychological Assessment, citing Bigler 1990, the length of amnesia predicts as follows:
But the key to applying this score is first understanding what amnesia is and then assuring that the diagnostician, asks and records the right questions. Amnesia is not like the Hollywood head injury myth, where the main character does not remember who he is until he magically flashes on something, or gets that second blow to the head. According to Lezak as amnesia “does not end when the patient begins to register experience again, but only when registrations is continuous.” Lezak, 4th Edition, page 160.
The problem is that distinguishing between some imprinting of memory and “continuous” imprinting of memory does not lend itself to established tests which primarily focus on confusion. One standardized test for amnesia, the GOAT, (“Galveston Orientation and Amnesia Test”) has only one good question out of 10. The best question on the GOAT is “can you describe in detail the first event you remember after the accident.” But because this is the “subjective” question, it is the one researchers pay the least attention to. But even this best question, doesn’t account for the fact that amnesia may begin after the period for which this question is being asked. It is not what the person remembers about the first 10 minutes post-accident, it is what they continuously remember the next hours and days that is significant.
Attorney Gordon Johnson
Past Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
Brain injury is one of those things that everyone feels the need to classify, typically into categories of mild, moderate and severe. A severe brain injury is one that involves extended coma. I don’t have any trouble with that definition for severe brain injury.
The controversy in classifying brain injuries revolves primarily around whether there was a brain injury at all and where the break point is between mild and moderate brain injury. The problem with all classification battles in the mild to moderate category is too much is based upon the identification of symptoms in the first hour, where it is not how symptomatic a person is at two hours, but how long the symptoms last that is significant. This is especially true with the most predictive symptom, amnesia.
With respect to severe brain injury, the Glasgow Coma Scale is a reasonably accurate indicator of severity. It also has the benefit of nearly universal adoption, making outcome studies based upon it reliable because of the large number of patients studied. But when the brain injury is below the severity level that loss of consciousness or a change in mental state is witnessed by a medical professional, the GCS has little validity. Most concussed individuals will get the highest score of 15, regardless of how significant the concussion is and how symptomatic they are at the time given the score. The GCS score at the mild end is only a test for confusion, not amnesia. To get a “perfect” GCS score, a patient needs only have his eyes open, be able to carry on a conversation demonstrating orientation (he knows who he is and where he is) and that he can follow simple commands. Compare that to how oriented a quarterback must be to continue to play in the game.
In contrast, basing outcome on the length of amnesia not only correlates well with the GCS score in the severely brain injured population, it is sensitive enough to provide meaningful diagnostic guidance in the less severely injured. According to Lezak, Neuropsychological Assessment, citing Bigler 1990, the length of amnesia predicts as follows:
- Less that five minutes, very mild.
- 5 minutes to 60 minutes, mild.
- 1 to 24 hours, moderate.
- 1- 7 days, severe.
- 1-4 weeks, very severe.
- More than 4 weeks, extremely severe.
But the key to applying this score is first understanding what amnesia is and then assuring that the diagnostician, asks and records the right questions. Amnesia is not like the Hollywood head injury myth, where the main character does not remember who he is until he magically flashes on something, or gets that second blow to the head. According to Lezak as amnesia “does not end when the patient begins to register experience again, but only when registrations is continuous.” Lezak, 4th Edition, page 160.
The problem is that distinguishing between some imprinting of memory and “continuous” imprinting of memory does not lend itself to established tests which primarily focus on confusion. One standardized test for amnesia, the GOAT, (“Galveston Orientation and Amnesia Test”) has only one good question out of 10. The best question on the GOAT is “can you describe in detail the first event you remember after the accident.” But because this is the “subjective” question, it is the one researchers pay the least attention to. But even this best question, doesn’t account for the fact that amnesia may begin after the period for which this question is being asked. It is not what the person remembers about the first 10 minutes post-accident, it is what they continuously remember the next hours and days that is significant.
Attorney Gordon Johnson
Past Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
Evolution in the Understanding of Concussion – Non-Athletes are At Much Higher Risk of Disability
Continuing on with the discussion of my Concussion Clinic videos, today’s topic is Non-Athletes are at Far Greater Risk of Disability. Today’s video is here: http://www.youtube.com/profile?user=braininjuryattorney#p/u/5/Z3QvSHrWykI
Sport is an ideal laboratory to study concussion. First, almost all sport concussions get witnessed and in today’s world, most get videotaped. Second, a very significant percentage of them happen on university campuses where scientists and medical researchers are looking around for things to study. Three, they are predictable, happen in a confined space and to a subset of people who we can control. The predictability and control means we can actually study and test their cognitive abilities before they have the concussion. And then because we know they will have repeated concussions, we can study that as well.
The problem with sports as the laboratory is that we are studying those people who tell us the least about what might happen to average people who suffer accidental concussions. In the sport laboratory we are studying those people who are most likely to get better, to have an “apparent full recovery”. Thus, the sport and concussion literature has done an excellent job of dealing with the primary issue which they care about, determining when it is safe to expose our football players to another concussion. But the truly important issue, of what disability is likely to come from a concussion and how can we best diagnose and treat that disability, the sport laboratory tells us very little.
In fact, the dark side of neuropsychology is trying to use sports concussion research as evidence that concussion does not cause permanent damage. Anyone who has worked with Post Concussion Syndrome survivors knows that concussion or mild traumatic brain injury, can disable. The young male athlete’s apparent full recovery does not tell us very much about how someone older, someone not in extraordinary shape, someone who was not expecting to get hit, will recover.
Here is the reality of the real world of concussions: If you are significant at 24 hours, and you are female and you are over 40, you need to go see the doctor every couple of days until you get better. You need to see a doctor who is going to test your memory. You need a doctor who is not just to test your memory for things you know about your life, but what you have been doing in the 24 hours before that examination. And you need a doctor who is not going to just ask you those questions, but also ask the people you live with.
Obviously, disability happens to those who are not 40, not female, but the more vulnerable your brain is because of age, because of prior concussions, because of emotional challengers you have had in your life, the more likely you will have a bad result. If you are at risk for a bad result, you must be followed and diagnosed in that first week. If you don’t get that type of evaluation we will have no way of predicting whether this concussion will give you a few bad days, a few bad weeks or keep you disabled the rest of your life.
Attorney Gordon Johnson
Past Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
Sport is an ideal laboratory to study concussion. First, almost all sport concussions get witnessed and in today’s world, most get videotaped. Second, a very significant percentage of them happen on university campuses where scientists and medical researchers are looking around for things to study. Three, they are predictable, happen in a confined space and to a subset of people who we can control. The predictability and control means we can actually study and test their cognitive abilities before they have the concussion. And then because we know they will have repeated concussions, we can study that as well.
The problem with sports as the laboratory is that we are studying those people who tell us the least about what might happen to average people who suffer accidental concussions. In the sport laboratory we are studying those people who are most likely to get better, to have an “apparent full recovery”. Thus, the sport and concussion literature has done an excellent job of dealing with the primary issue which they care about, determining when it is safe to expose our football players to another concussion. But the truly important issue, of what disability is likely to come from a concussion and how can we best diagnose and treat that disability, the sport laboratory tells us very little.
In fact, the dark side of neuropsychology is trying to use sports concussion research as evidence that concussion does not cause permanent damage. Anyone who has worked with Post Concussion Syndrome survivors knows that concussion or mild traumatic brain injury, can disable. The young male athlete’s apparent full recovery does not tell us very much about how someone older, someone not in extraordinary shape, someone who was not expecting to get hit, will recover.
Here is the reality of the real world of concussions: If you are significant at 24 hours, and you are female and you are over 40, you need to go see the doctor every couple of days until you get better. You need to see a doctor who is going to test your memory. You need a doctor who is not just to test your memory for things you know about your life, but what you have been doing in the 24 hours before that examination. And you need a doctor who is not going to just ask you those questions, but also ask the people you live with.
Obviously, disability happens to those who are not 40, not female, but the more vulnerable your brain is because of age, because of prior concussions, because of emotional challengers you have had in your life, the more likely you will have a bad result. If you are at risk for a bad result, you must be followed and diagnosed in that first week. If you don’t get that type of evaluation we will have no way of predicting whether this concussion will give you a few bad days, a few bad weeks or keep you disabled the rest of your life.
Attorney Gordon Johnson
Past Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
Evolution in the Understanding of Concussion: The Need for Periodic Followups
Continuing on with the discussion of my Concussion Clinic videos, today’s topic is the Need for Periodic Follow-ups. Today’s video is here: http://www.youtube.com/profile?user=braininjuryattorney#p/u/11/dEWHgwRywtY
When the sport and concussion guidelines are applied properly there is a 15 minute post-injury evaluation to determine whether this concussion or “ding” was serious enough to require further follow-ups. An injured player is not supposed to return for at least 15 minutes. At 15 minutes, if they continue to be symptomatic, they are not to return to play in that game and not until the expiration of 7 days from the date they cease to be symptomatic.
While the 15 minute rule is not quite good enough, it is important that an athlete is at least required to wait that long before he or she returns. As brain injury is a process not an event that can take 72 hours to manifest itself, the 15 minute rule isn’t perfect. Yet I realize that 15 minutes is a compromise, that generally protects the player. While there are exceptions, the concussion that is completely asymptomatic at 15 minutes is probably not going to be serious. But keep in mind, that Natasha Richardson could likely have passed a superficial orientation test at 15 minutes and she died before they could get her to a hospital. Also with non-professional sports, there is a strong movement to not allow any return to play.
The truly important part of guidelines is the “no play for seven days” if the concussion continues to be symptomatic at 15 minutes. Thus if there is symptomotology of brain injury at 15 minutes, the professional team’s medical staff will do follow-up testing each day to determine whether the athlete continues to be symptomatic. (What happens in amateur sports may be entirely different but is a topic for a different blog.)
If we could take that model of periodic follow-ups and apply that to the brain injuries that happen in accidents, we would then likely identify almost all concussions that are likely to be disabling. Add two more levels of inquiry to that process and we could have an excellent concussion diagnosis system.
Distinguish between Confusion and Amnesia. I have discussed this issue in depth earlier in this series, but absence of confusion does not mean absence of amnesia. Amnesia is the real litmus test for concussion. Remember that amnesia is not a black curtain of memory, but the inability to remember the amount of information we would normally remember. What does “normal memory” mean? Take this an example.
At a real world hospital, if you aren’t bleeding when you get to the Emergency Room, you start your time there with a 20 minute conversation with the billing department. Then you sit in the ER waiting room for a while, normally too long. A normal person’s memory might not include the name of the person who was taking their insurance information. But a normal person would remember the process. They would remember filling out a form, even if they didn’t remember what the form said. A normal person would remember fishing the insurance card out of their wallet. Likewise, a normal person would very clearly remember how long they waited in the ER. A normal person would remember the most seriously hurt person who was waiting with them. People tend to remember blood, etc. If the doctor or other ER person would ask these kind of questions, evidence of amnesia would likely be clear.
Next Day Follow-up. Even more important than asking better questions on the day of the accident, is to have a medical professional ask them something about their memory the next day. Amnesia at 24 hours is far easier to spot. How much they remember of the pervious 24 hours events will show how severe this particular concussion is. With all of the momentum for better diagnosis for NFL and amateur football players, we must also clearly recognize that the care they are getting is infinitely better than the million plus other people a year who suffer a concussion, most who are at much higher risk of a bad outcome. See http://www.tbilaw.com/blog/2010/01/nfl-football-concussions-versus-real.html
Attorney Gordon Johnson
Past Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
When the sport and concussion guidelines are applied properly there is a 15 minute post-injury evaluation to determine whether this concussion or “ding” was serious enough to require further follow-ups. An injured player is not supposed to return for at least 15 minutes. At 15 minutes, if they continue to be symptomatic, they are not to return to play in that game and not until the expiration of 7 days from the date they cease to be symptomatic.
While the 15 minute rule is not quite good enough, it is important that an athlete is at least required to wait that long before he or she returns. As brain injury is a process not an event that can take 72 hours to manifest itself, the 15 minute rule isn’t perfect. Yet I realize that 15 minutes is a compromise, that generally protects the player. While there are exceptions, the concussion that is completely asymptomatic at 15 minutes is probably not going to be serious. But keep in mind, that Natasha Richardson could likely have passed a superficial orientation test at 15 minutes and she died before they could get her to a hospital. Also with non-professional sports, there is a strong movement to not allow any return to play.
The truly important part of guidelines is the “no play for seven days” if the concussion continues to be symptomatic at 15 minutes. Thus if there is symptomotology of brain injury at 15 minutes, the professional team’s medical staff will do follow-up testing each day to determine whether the athlete continues to be symptomatic. (What happens in amateur sports may be entirely different but is a topic for a different blog.)
If we could take that model of periodic follow-ups and apply that to the brain injuries that happen in accidents, we would then likely identify almost all concussions that are likely to be disabling. Add two more levels of inquiry to that process and we could have an excellent concussion diagnosis system.
Distinguish between Confusion and Amnesia. I have discussed this issue in depth earlier in this series, but absence of confusion does not mean absence of amnesia. Amnesia is the real litmus test for concussion. Remember that amnesia is not a black curtain of memory, but the inability to remember the amount of information we would normally remember. What does “normal memory” mean? Take this an example.
At a real world hospital, if you aren’t bleeding when you get to the Emergency Room, you start your time there with a 20 minute conversation with the billing department. Then you sit in the ER waiting room for a while, normally too long. A normal person’s memory might not include the name of the person who was taking their insurance information. But a normal person would remember the process. They would remember filling out a form, even if they didn’t remember what the form said. A normal person would remember fishing the insurance card out of their wallet. Likewise, a normal person would very clearly remember how long they waited in the ER. A normal person would remember the most seriously hurt person who was waiting with them. People tend to remember blood, etc. If the doctor or other ER person would ask these kind of questions, evidence of amnesia would likely be clear.
Next Day Follow-up. Even more important than asking better questions on the day of the accident, is to have a medical professional ask them something about their memory the next day. Amnesia at 24 hours is far easier to spot. How much they remember of the pervious 24 hours events will show how severe this particular concussion is. With all of the momentum for better diagnosis for NFL and amateur football players, we must also clearly recognize that the care they are getting is infinitely better than the million plus other people a year who suffer a concussion, most who are at much higher risk of a bad outcome. See http://www.tbilaw.com/blog/2010/01/nfl-football-concussions-versus-real.html
Attorney Gordon Johnson
Past Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
Evolution in the Understanding of Concussion: Distinguish Between Confusion and Amnesia in Diagnosing Concussion
Continuing on with the topic “The Evolution of Our Understanding of Concussion, Otherwise Called Mild Traumatic Brain Injury,” our next point of emphasis is the importance of distinguishing between confusion and amnesia after a brain injury. The video on this topic is at: http://www.youtube.com/profile?user=braininjuryattorney#p/u/6/xuO69e9Vv_c
You can have significant amnesia and not be confused. How do we know that? On this specific issue, the sports arena is the ideal laboratory – NFL quarterbacks the perfect test subject. We know from hundreds of reported cases that a football player can finish the game, a quarterback can finish the game, and have no memory for the game when asked about it later. Thus, we know they were amnestic.
We also know that they were not confused while they were playing the game because football, especially quarterbacking, is not something someone can do while confused. Think of all the sequential, memory and processing intensive things an NFL quarterback must do on every single play. If he were confused, he wouldn’t survive a single play. While one can argue that a boxer can fight on auto-pilot, a quarterback cannot. A quarterback must remember the plays and make differential decisions under high stress, with instant processing.
The reason I make this point over and over is that in the vast majority of cases, the inquiry at the scene, in the Emergency Room is an inquiry only to determine whether a person is confused. If a person is not confused, they are presumed not to have suffered a brain injury. If the inquiry does not include a test for amnesia as well as confusion, then the diagnosis of brain injury will likely be missed.
The diagnostician, be it an EMT, an ER doctor or primary care doctor must put on the sports writer hat and ask about the events since the injury, not just about what happened before the injury or what is happening now. What we want to know about is what happened “during the game” – the period of time between the concussion and now. Tell me about the ambulance ride. Tell me about who else was in the Emergency Room.
And doctors, don’t be in such a hurry to decide there was no concussion. Amnesia often materializes in the hours after an accident – not the minutes – because brain injury is a process, not an event. For more on that topic, see the general treatment of that topic found on my website http://subtlebraininjury.com/ and the specific treatment at http://subtlebraininjury.com/tbiprocess1.html
At times the world of sport is a useful laboratory for us to learn about concussion, such as with this issue, but we must remember that the average person with an accidental concussion, is not an extraordinary physical specimen, who expected to get hit. More on the distinction between real world brain injury and sport concussions on my Brain Damage Blog, http://tbilaw.com/blog
Attorney Gordon Johnson
Past Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
You can have significant amnesia and not be confused. How do we know that? On this specific issue, the sports arena is the ideal laboratory – NFL quarterbacks the perfect test subject. We know from hundreds of reported cases that a football player can finish the game, a quarterback can finish the game, and have no memory for the game when asked about it later. Thus, we know they were amnestic.
We also know that they were not confused while they were playing the game because football, especially quarterbacking, is not something someone can do while confused. Think of all the sequential, memory and processing intensive things an NFL quarterback must do on every single play. If he were confused, he wouldn’t survive a single play. While one can argue that a boxer can fight on auto-pilot, a quarterback cannot. A quarterback must remember the plays and make differential decisions under high stress, with instant processing.
The reason I make this point over and over is that in the vast majority of cases, the inquiry at the scene, in the Emergency Room is an inquiry only to determine whether a person is confused. If a person is not confused, they are presumed not to have suffered a brain injury. If the inquiry does not include a test for amnesia as well as confusion, then the diagnosis of brain injury will likely be missed.
The diagnostician, be it an EMT, an ER doctor or primary care doctor must put on the sports writer hat and ask about the events since the injury, not just about what happened before the injury or what is happening now. What we want to know about is what happened “during the game” – the period of time between the concussion and now. Tell me about the ambulance ride. Tell me about who else was in the Emergency Room.
And doctors, don’t be in such a hurry to decide there was no concussion. Amnesia often materializes in the hours after an accident – not the minutes – because brain injury is a process, not an event. For more on that topic, see the general treatment of that topic found on my website http://subtlebraininjury.com/ and the specific treatment at http://subtlebraininjury.com/tbiprocess1.html
At times the world of sport is a useful laboratory for us to learn about concussion, such as with this issue, but we must remember that the average person with an accidental concussion, is not an extraordinary physical specimen, who expected to get hit. More on the distinction between real world brain injury and sport concussions on my Brain Damage Blog, http://tbilaw.com/blog
Attorney Gordon Johnson
Past Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
Evolution in the Understanding of Concussion: Adrenaline Increases Memory and Masks Post Traumatic Amnesia
Our next lesson on the topic “The Evolution of Our Understanding of Concussion, otherwise Called Mild Traumatic Brain Injury,” is the role that adrenaline plays in masking the most reliable marker for brain injury, that of Post Traumatic Amnesia. The video on this topic is found at http://www.youtube.com/profile?user=braininjuryattorney#p/u/9/N0K2K-lqW18
When a concussed person does find his or her way to the Emergency Room, the first thing that typically gets asked is what do you remember of what happened. The second was did you get knocked out. Both questions are seriously flawed in methodology. Starting with the second, if you presume that someone who is knocked out will have amnesia of the event, how can you ask them what happened to them at a time they were amnestic? We would hope that most experienced ER doctors see the inherent conflict in relying on the answer to such a question from the concussed person.
The more subtle but more significant problem is assuming that because someone has memory of an event, that means they weren’t concussed in the event. This is simply not true and it ignores the well recognized principle that concussed individuals can have islands of memory during otherwise periods of significant amnesia. Amnesia is not a total loss of memory, it is a loss of any period of memory. The islands of memory a concussed person will most likely remember are those things where adrenaline played the greatest role, such as the accident itself. If you have ever been a car wreck that you do remember, especially a serious car wreck, it is something you will remember for the rest of your life. I have been in two serious wrecks and I remember exquisite details of what I was doing just before and in the hours after the wreck. One of those wrecks was in 1975 and the other in 1993. I even remember the date and hour of the 1993 wreck.
My brain remembers them best because they were most important to me. It also remembers them best because they were the most scary. What I don’t remember about the more serious of those accidents, is the ambulance ride. And I should because I was in pain and strapped to a board. In 1975 if I could walk and talk in an Emergency Room and didn’t have any broken bones, that was all they were concerned with. I was discharged home. No one ever asked me a single question about amnesia.
Our concern about concussions has improved dramatically since 1975 but the inquiry with respect to the most likely period of post traumatic amnesia, the period from 5 minutes post accident to 48 hours post accident, is still largely ignored. Since amnesia is the single most reliable symptom in the diagnosis of concussion, that needs to change.
Attorney Gordon Johnson
Past Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
When a concussed person does find his or her way to the Emergency Room, the first thing that typically gets asked is what do you remember of what happened. The second was did you get knocked out. Both questions are seriously flawed in methodology. Starting with the second, if you presume that someone who is knocked out will have amnesia of the event, how can you ask them what happened to them at a time they were amnestic? We would hope that most experienced ER doctors see the inherent conflict in relying on the answer to such a question from the concussed person.
The more subtle but more significant problem is assuming that because someone has memory of an event, that means they weren’t concussed in the event. This is simply not true and it ignores the well recognized principle that concussed individuals can have islands of memory during otherwise periods of significant amnesia. Amnesia is not a total loss of memory, it is a loss of any period of memory. The islands of memory a concussed person will most likely remember are those things where adrenaline played the greatest role, such as the accident itself. If you have ever been a car wreck that you do remember, especially a serious car wreck, it is something you will remember for the rest of your life. I have been in two serious wrecks and I remember exquisite details of what I was doing just before and in the hours after the wreck. One of those wrecks was in 1975 and the other in 1993. I even remember the date and hour of the 1993 wreck.
My brain remembers them best because they were most important to me. It also remembers them best because they were the most scary. What I don’t remember about the more serious of those accidents, is the ambulance ride. And I should because I was in pain and strapped to a board. In 1975 if I could walk and talk in an Emergency Room and didn’t have any broken bones, that was all they were concerned with. I was discharged home. No one ever asked me a single question about amnesia.
Our concern about concussions has improved dramatically since 1975 but the inquiry with respect to the most likely period of post traumatic amnesia, the period from 5 minutes post accident to 48 hours post accident, is still largely ignored. Since amnesia is the single most reliable symptom in the diagnosis of concussion, that needs to change.
Attorney Gordon Johnson
Past Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
Evolution in the Understanding of Concussion: Sport Concussion’s Get Witnessed and Documented
Continuing with this blog’s treatment of the “The Evolution of Our Understanding of Concussion, otherwise Called Mild Traumatic Brain Injury,” today I focus on the huge diagnostic disadvantage real world concussions have in the diagnostic process. While the sport concussion guidelines are a tremendous step forward, the single biggest problem in applying them to accidental concussion is accidental concussions are rarely witnessed by trained observers. Never is there a video tape of the forces that caused the concussion. Click here for Part IV of my Concussion Clinic Videos.
Certainly accidents have witnesses and often witnesses that are communicating with the concussed person within the first couple of minutes after the wreck or fall. But even 30 seconds after the incident may be too late.
Compare the situation where someone is in a car wreck to a boxing ring. If a fighter is knocked down by a blow to the head, the boxer presumptively has had a concussion. Yet in the vast majority of the cases, that boxer has returned to his feet within 10 seconds. If the fight isn’t stopped at that point, it means that the boxer has regained sufficient function to engage in his highly dangerous and demanding profession in less than 30 seconds. That model shows us that the window for observing the acute concussion evidence may be as short as 10 seconds.
If the same concussion occurred in an NFL or college football game, we would have a video tape of that concussion. While there isn’t a 10 second knockout rule in football, if a player is still down for 20 seconds, play has to be stopped. The concussion then gets analyzed from several different camera angles and archived for prosperity.
In a car wreck, unless there is a passenger in the car, no one is closely observing the injured person within that 30 second time frame. Certainly witnesses will congregate quickly, but not quickly enough. Almost never will there be someone trained in concussion diagnosis at the scene during the time window that the acute evidence is the clearest. If the concussion occurs in a fall, most times there are no witnesses.
Thus, the diagnosis of an accidental concussion requires either the reliance on a history from the injured person, who is likely to be unreliable historian of the event, or must be reconstructed. The only reliable measure to determine whether there was the concussion is to determine the existence and extent of post traumatic amnesia.
Attorney Gordon Johnson
Past Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
Certainly accidents have witnesses and often witnesses that are communicating with the concussed person within the first couple of minutes after the wreck or fall. But even 30 seconds after the incident may be too late.
Compare the situation where someone is in a car wreck to a boxing ring. If a fighter is knocked down by a blow to the head, the boxer presumptively has had a concussion. Yet in the vast majority of the cases, that boxer has returned to his feet within 10 seconds. If the fight isn’t stopped at that point, it means that the boxer has regained sufficient function to engage in his highly dangerous and demanding profession in less than 30 seconds. That model shows us that the window for observing the acute concussion evidence may be as short as 10 seconds.
If the same concussion occurred in an NFL or college football game, we would have a video tape of that concussion. While there isn’t a 10 second knockout rule in football, if a player is still down for 20 seconds, play has to be stopped. The concussion then gets analyzed from several different camera angles and archived for prosperity.
In a car wreck, unless there is a passenger in the car, no one is closely observing the injured person within that 30 second time frame. Certainly witnesses will congregate quickly, but not quickly enough. Almost never will there be someone trained in concussion diagnosis at the scene during the time window that the acute evidence is the clearest. If the concussion occurs in a fall, most times there are no witnesses.
Thus, the diagnosis of an accidental concussion requires either the reliance on a history from the injured person, who is likely to be unreliable historian of the event, or must be reconstructed. The only reliable measure to determine whether there was the concussion is to determine the existence and extent of post traumatic amnesia.
Attorney Gordon Johnson
Past Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.