What Are the Components of a Brain Injury Assessment?
A brain injury assessment, for multiple concussion injury or second impact syndrome, involves first obtaining the history of the injury and determining whether or not the patient lost consciousness, and if so for how long. The physician will want to find out if the patient was hospitalized and obtain the medical records. The physician should review the patient’s Glasgow Coma Scale (used to assess the level of consciousness after the head injury) at the time of admission to the hospital. Also, the physician should interview family members or anyone else that the person lives with that can give a description of the injuries. Next, a neurological examination should be performed. And, more importantly, a full mental status examination should be done that includes frontal lobe testing and a Mini Mental State exam (a standardized psychiatric interview).
It is important to find out what period of time the patient does not remember. An estimate of the retrograde amnesia has prognostic significance indicating how severe the injury actually is. The physician wants to find out how long the patient lost consciousness or how long they had a change in their mental state because of the injury and how far the loss of memory goes back.
Amnesia can be either anterograde or retrograde. Retrograde amnesia, after a person has a brain injury, means the person blocks out a lot of the activity and perceptions they had prior to the injury because it hasn’t solidified in the person’s memory banks. Anterograde amnesia means that after a head injury, for a period of time, the person doesn’t record new information. Retrograde is the loss of memory that the person had before the injury and anterograde is the loss of the ability to lay down new memory for a period of time.
The retrograde amnesia period has the most prognostic value because the brain cells are still a little sick from the shock of the trauma and it takes a while for those to recuperate. During that period of time when they are not functioning the way that they should, the person is not able to lay down new memory as effectively and as efficiently as that person could before.
An MRI is helpful to essentially rule out a more severe condition than a concussion. There are also some new specialized MRIs, which are not yet widely available but will be in a few years. These will help determine injury to the nerve axons or reveal small accumulations of blood in the brain.
For physicians who are diagnosing and treating a multiple concussion injury, the most important protection against a claim of malpractice is to get all of the medical records and statements. The attorney should obtain the statements of all witnesses and the testimony of family members. Family members should be available to testify about the progression of the injury and the problems the injured person had. An independent neuropsychiatric evaluation should be performed, which may include neuropsychological testing.
One of the most important aspects to focus on is the patient’s social dysfunction because that is what leads to the patient being isolated. A patient with multiple concussion injury or other brain injury frequently has very poor social graces and may suffer attention deficit or have a change in personality, such as losing their sense of humor. There often is a loss of the ability to abstract, so the humor is different. There is difficulty with the subtleties we take for granted, like puns or double meanings to words. Proverbs that people use sometimes in their common language are hard for a person who has a brain injury to interpret.
Personality change like this alienates the people around the patient. The patient may feel isolated because of this alienation. There is a high incidence of suicide when a person reaches that isolation stage because of depression. So an important focus if you are the physician of a brain injured patient is to focus on the patient’s social functioning and do what you can to assist them with their reality testing.
One other concern to be aware of with multiple concussions is the incidence and risk of future epilepsy, migraines, headaches, dementia and Parkinsonism. Patients who have had multiple traumatic brain injuries have a higher incidence of experiencing those impairments later in life. Generally, 95% of the patient’s improvement occurs within the first year after the injury and the majority return to baseline within three to six months.
Marvin Firestone, MD, JD, FCLM, DLFAPA is a Past President of the American College of Legal Medicine and a certified specialist in Legal Medicine/Medical Jurisprudence by the American Board of Law in Medicine. He is a frequent lecturer at national legal medicine and medical law conferences. Dr. Firestone holds a medical degree from Temple University (1964) and a law degree from the University of Colorado (1980). He was the Editor-in-Chief of Medical Legal Lessons, is Editor-in-Chief Emeritus of Legal Medicine Questions and Answers, and is on the Editorial Board of the Journal of Legal Medicine and Textbook of Legal Medicine, publications of the American College of Legal Medicine. He formerly held the Hirsh Chair at the George Washington University in Washington, D.C. where he was professor at its Medical and Law Schools and School of Health Services Administration, teaching Legal Medicine, Psychiatry and the Law, and Legal Aspects of Hospital Administration.
Dr. Firestone provides medical-legal consultation and practices medical law. His legal practice primarily involves representation of physicians in cases involving hospital staff privileges, licensure, medical practice disputes and other complex medicolegal issues.
Dr. Firestone is admitted in California, Colorado, Texas and the District of Columbia.