• Jane Crenshaw[1] suffered life-altering spinal cord injuries at a local ski resort. When she was admitted to a nearby Level 1 Trauma Center for treatment, however, the focus was not on whether she had suffered a traumatic brain injury (TBI), too.  There were other, more immediate and obvious injuries to treat at the time.  Jane was eventually stabilized and moved to in-patient rehab—where she continued to struggle.  Jane had difficulty engaging with her family, and trouble staying on top of her physical therapy exercises.  Providers questioned whether she was taking her rehabilitation seriously.  Even after being discharged, Jane was never able to find a “new normal.”  Her marriage deteriorated, as did many of her friendships.  She was moody, and said things that left loved ones stunned.  Even the most patient members of Jane’s inner circle began distancing themselves.  It was not until much later that she was finally evaluated for a possible brain injury – which it turned out she had.  But sadly, by this time, Jane’s window for substantial healing and an improved outcome had mostly passed.  When Jane was forced to bring legal action against the parties responsible for her injuries, it was also more challenging for Jane to connect her TBI with her original injuries.

    According to a 2019 study[2], Jane is not alone.  Indeed, more often than not, mild traumatic brain injuries (mTBI’s)[3] are missed early in the treatment process.  In the Koval study, patients were admitted to a Level I trauma and emergency care center and asked the following two questions during nursing triage:

    • Was there a blunt force trauma to the head or did your head move back and forward with a lot of force?; and
    • Was there a change in mental status or level of consciousness as a result of the event (including fogginess, confusion, disorientation or the like)?[4]

    Of the 98 patients who answered yes to both—confirming a potential mTBI—less than half had a clinical evaluation performed or had any of their symptomology documented.  What’s worse, only 15 of these 98 patients received brain injury-specific discharge instructions from the emergency care center.

    Unfortunately, this is consistent with prior studies.  A 2008 study in the Archives of Physical Medicine and Rehabilitation drew a similar conclusion: 56% of participants who met the CDC mTBI criteria “did not have a documented diagnosis from the ED (emergency department) physician indicative of a mild TBI.”[5] [6]

    These studies suggest a few important principles.  First, and to borrow from other contexts in life, if you see something, say something.  Everyone maintaining contact with someone like Jane, from treatment providers, to family, friends, and even co-workers should be keeping an eye out for possible mTBI symptoms.  They include, but are not limited to:

    • An altered state of awareness;
    • Headaches that get worse and don’t go away;
    • Weakness, numbness, drowsiness, or decreased coordination;
    • Vomiting or nausea;
    • Slurred speech, slow processing, or a “deer in the headlights” look;
    • One pupil larger than the other;
    • Convulsions or seizures;
    • Problems recognizing people or places;
    • Confusion, restlessness, or agitation;
    • Unusual behavior;
    • Loss of consciousness.[7]

    The fact that no diagnosis is made in the emergency department does not, in and of itself, preclude the condition.  The symptoms may have been missed with all of the focus on other more obvious injuries, or symptoms may have simply not presented themselves at the time of the emergency treatment.  This is not to suggest that anyone should practice medicine without a license, but making a medical referral—or even a suggestion—may go a long way toward getting a person with a brain injury access to care they need.  Time is often of the essence; the sooner a survivor can secure appropriate care, the better their chance at a good outcome.

    Second, more resources and training are still needed.  The fact that two studies, in two different journals, a decade apart, reflect almost identical mTBI miss-rates in emergency departments suggests that processes and training can still be improved.  Though there are fantastic organizations working every day to raise awareness of this “silent epidemic,”[8] there is still more to be done.

    And lastly, it bears emphasis that brain injury survivors deserve grace, not skepticism.  A diagnosis later in the recovery process is more common than not.  It should not be treated as a sign of malingering or exaggeration.  If anything, the fact that a survivor may have to suffer through an undiagnosed brain injury, without treatment, is reason for additional sympathy, not suspicion.

    We understand the importance of access to care and its challenges. We also understand the critical importance in getting your patient on the proper road to recovery.  We are always ready and willing to assist you in any and all questions.  Please don’t hesitate to contact us.


    [1] For privacy, names and other identifying details have been changed.

    [2] see Koval et al, Concussion Care in the Emergency Department: A Prospective Observational Brief Report, Annals of Emergency Medicine (2019),

    [3] “Mild” TBI is neurologic distinction, indicating a brain injury does not require surgery as a form of treatment.

    [4] These questions reflect the CDC’s clinical definition of a mild traumatic brain injury.  See Traumatic Brain Injury & Concussion, https://www.cdc.gov/traumaticbraininjury/get_the_facts.html (last visited November 18, 2019).

    [5] Powell et al, Accuracy of Mild Traumatic Brain Injury Diagnosis, Archives of Physical Medicine and Rehabilitation (Vol. 89, August 2008).

    [6] As the most recent study itself acknowledges, emergency clinicians face unique challenges which include balancing patient flow, triage, and disposition.

    [7] Traumatic Brain Injury & Concussion, https://www.cdc.gov/traumaticbraininjury/symptoms.html

    [8] Julie Louise Gerberding and Sue Binder, Report to Congress on Mild Traumatic Brain Injury in the United States, Steps to Prevent a Serious Public Health Problem (September 2003).


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