Emergency Room Misdiagnosis

• Poor Triage
• Second Day Followup Needed in All Cases
• Never Discharge a Person if No One to Care for Them

I have become increasingly frustrated by the prevalence of missed diagnosis of brain injuries. Seemingly several times a month, I come into contact with another client whose brain injury was not diagnosed in the emergency room. Despite significant symptoms of a brain injury, survivors are discharged with no more detailed diagnosis of brain injury than an analysis of the Glasgow Coma Scale. Yet the Glasgow Coma scale was not intended to apply to concussion injuries. Dr. Bryan Jennett, the author of the Glasgow Coma Scale had this to say about it use in these cases:

"The widespread adoption of the Glasgow Coma Scale has made it easier to classify severe injuries, but it was not intended as a means of distinguishing among different types of milder injury. Many of these patients are oriented by the time they are assessed and therefore score at the top of the Glasgow scale. Yet some of these patients have had a period of altered consciousness, either witnessed or evidenced by their being amnesic for events immediately following injury. Impairment of consciousness is indicative of diffuse brain damage, but there can also be marked local damage without either alteration in consciousness or amnesia;" Mild Head Injury, ©Oxford, 1989, page 24.

The extent of neurological examinations in the emergency room are poorly suited to diagnosing the subtle brain injury, even though such injuries can have devastating consequences. The patient is typically the primary source for what is perceived to be the most significant question: Did you lose consciousness. How reliable of a source is a person with a potential brain injury, to answer such a question? Certainly not without significant examination of the persons recollection of events. More significantly, loss of consciousness is not the litmus test for brain injury. Any change in mental state can be significant. Further, headache, lack of consistency in reported symptomatology, nausea and the need for oxygen could tip off the emergency team. Even a Polaroid photo of the accident scene and cars could point towards a head injury.

Delayed Loss of Consciousness.

A Loss of Consciousness may actually occur after discharge from the hospital. In cases of hematoma, or swelling, the LOC may occur later as a result of the increased pressure. It may occur when the patient has been discharged and gone to bed. Did relatives have difficulty waking the patient? Keep in mind the standard head injury instructions, these are aimed at just such a problem.

The Case of Other Serious Injuries.

There is also a high probability of misdiagnosis of brain injury in severe accidents, when there have been other serious or obvious injuries. The more severe the other injuries, the more likely that there will be a brain injury. There is a direct relationship between the existence of other severe injuries and the probability of brain injury. If there is enough force to break a bone, lacerate a forehead, damage the spinal cord, there is enough force to injure the brain. Yet, there tends to be an inverse relationship between the severity of other injuries, and the diagnosis of brain injury. If a person is bleeding or has some other obvious trauma, the careful analysis needed to identify a brain injury may be ignored.

Mandatory Followup.

I believe that the only way to efficiently increase the acute diagnosis of brain injury, is to schedule anyone who has evidence of concussional symptoms, for a followup the next day at the same ER. Actually give the a specific appointment time before they are discharged and discuss the importance of a followup with the person they are discharged to. Under no circumstances, should someone suffering from concussional symptoms be discharged alone. If this particular brain injury is more significant than was suspected at the initial triage, this will likely become apparent by the next day. If not, the followup exam can be brief, at little cost. But if the person and the person they were discharged into the care of, come back in the next day with a familiar pattern of symptomatology, such as excessive sleepiness, confusion, amnesia, then further analysis should immediately be done. Consideration at that time of a CT scan, vestibular workup and neuropsych screening would be warranted.

Another side benefit of requiring this type of followup, is that over a period of time, the ER personnel would become far more sensitized to what they should be looking for on this initial triage, from the stories they hear on the second day followup.

It is not necessary to have a loss of consciousness to suffer permanent brain injury.

Source: Definition of Mild Traumatic Brain Injury Developed by the Mild Traumatic Brain Injury Committee of the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine. J Head Trauma Rehabil 1993:8(3):86-87

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