© The Medical-Legal News, 2007
By Dorajane Apuna, BSN, MA, RN, CCM, CNLCP
The CDC (Centers for Disease Control) has stated that the major cause of brain injuries in the U.S. (50 percent) is motor vehicle accidents (MVAs). Twenty-one percent of TBIs (traumatic brain injuries) were related to falls, 12 percent were related to assaults and violence, and 10 percent to sports and recreation.
Unfortunately there are many victims excluded from these statistics — they have long-term problems but failed to be linked to the head injury because of other injuries that were more severe.
During a study performed in Great Britain (King, Nigel, “Post-Concussion Syndrome: clarity amid the controversy.” British Journal of Psychiatry, Vol. 183: 276-278) it was discovered that out of 250-300 admissions per 100,000 population, only 8 percent had severe head injuries, while 75 percent were mild injuries. It was also discovered that the percentage treated in the emergency room (ER) was 4-8 percent higher than this number.
Reasons for oversight of brain injuries
The majority of post-concussive injuries are missed due to them being evaluated during the acute phase by ER physicians, orthopedic physicians and primary care physicians who fail to diagnose this common disorder when other injuries seem more critical.
Unless the brain injury is severe, rarely is a neurologist called in to the ER to evaluate the patient. There is also the assumption that the injury is indeed minor and will heal rapidly.
More obvious injuries, such as a broken leg, arm, shoulder or back injury, receive the attention.
The CDC, in its efforts to assist physicians in diagnosing brain injuries, has developed an evaluation form on its web site to be used in the patient care centers.
It is true that most of the mild traumatic injuries recover within weeks to months without treatment or discovery of causation, but about 15 percent of the concussion injuries have symptoms or disabling symptoms that are still present after a year.
Since life expectancy is not affected by mild brain injury problems, the younger injury victims have the possibility of enduring decades of symptoms and disabilities.
Symptoms of concussions are similar to a mild brain injury, and include:
• post-traumatic amnesia less than an hour;
• Glasgow coma scale score of 13-15;
• loss of consciousness greater than 15 minutes.
The hallmarks of a concussion include some or all of the following symptoms, including:
• poor memory,
• poor concentration,
• sleep disturbance,
• sensitivity to noise,
• blurred vision,
• double vision,
• nausea and tinnitus.
The client does not have to have all the symptoms, but these factors earmark further investigation. See http://www. medscape.com/viewarticle/ 498507_print.
So as an attorney, what kinds of things should you be looking for to present this injury for consideration when asking a life care planner to ensure the care for the concussion diagnoses?
One accepted strategy is that the severity of the brain injury is defined by the characteristics of the injury, not by the severity of the symptoms that the patient exhibits initially at the first evaluation.
A checklist during the initial intake interview should be part of the work product in establishing a case. Many times the injured client does not think about the relationship of his injuries until he is reminded of his ongoing symptoms. The following questions are a sample of what should be asked:
• When the injury occurred, did you receive any contact to the head, whether a direct blow, hitting the dashboard or door, or did you suffer whiplash (acceleration/deceleration) movements?
• Do you vividly remember the accident or can you not remember parts of it?
• How long were you unconscious?
• Do you remember who arrived first to help you?
• Do you remember what happened in the ER?
• What happened when you first went home?
• Did you feel dazed immediately following the accident?
• What was the Glascow coma scoring when admitted to the ER initially and later after treatment? (You may have to get this directly from the ambulance or ER records). The score should be at least 15 to represent a true mild TBI, whereas a score of 13-14 is a common level describing confusion or disorientation, which is associated with a longer period of amnesia.
• Were images, either by a CT scan or MRI completed, and what were the results? (The patient usually does not know the complete results, but the physicians should have shared them).
• Do you have problems with headaches, nausea or vomiting?
• Have you noticed problems with balance, dizziness or hearing?
• Since the accident, have you noticed sensitivity to light or noise, or do you fatigue more than usual?
• Do you feel like your thinking is clear, foggy, moving in slow motion, or have difficulty in remembering?
Plan of action
Neuropsychological testing should be done, and evaluations taken by a neurologist and a physical medicine and rehabilitation physician.
If your new client has answered “yes” to the above questions, they need a referral to a neurologist to further evaluate the medical symptoms. If your client has any of the above signs, then he or she should be told to go, or taken, to the ER at the nearest hospital immediately.
How does this diagnosis affect your case?
Often, may items that a client needs to provide a reasonable quality of life are dependent on obtaining the needed medical evaluations and treatments for the symptoms of his injuries. In discovery it is important not to overlook what the client needs based objectively on his symptoms presented and diagnosed.
In addition to the more acute injuries, if the secondary diagnoses include a concussion or mild brain injury, the life care planner will need to add the appropriate medical needs related to the injuries, which may include visits to a neurologist on a regular basis.
If balance, dizziness or hearing are problems, then extra visits to an otolaryngologist and a therapist for vestibular dysfunction therapy are likely.
If the client has visual problems, then he or she should be evaluated by a neuro-opthalmologist.
An occupational therapist may be needed to provide special assistance with memory loss and activities of daily living.
Special glasses, hearing aids and supplies may be added to the overall life care plan.
Often the client will need short-term psychological assistance for coping and management of his daily acceptance of a mild brain injury.
In mild brain injuries, crucial evidence can be overlooked early in the case due to the elusiveness of symptoms.
Medically, a successful outcome for the client often depends on how quickly the problem is diagnosed and the treatments are made available. Legally, how well the documentation is found to support the diagnosis of the brain injury both for the case and for presentation to the jury, is key.
In resolving these issues for a jury, it will depend on how well relevant facts relating to the client’s care are documented and established following the injury. •
Dorajane Apuna, BSN, MA, RN, CCM, CNLCP is a nurse consultant and life care planner based in Sacramento, Calif.; firstname.lastname@example.org.
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