NOVEL MALPRACTICE

Concussions by Ronda Wells

As writers, you’re supposed to research your topic. Unfortunately, I joined the School of Hard Knocks. Stepping in a sidewalk crack won’t break your mother’s back but it can trip you and smack your head on concrete. One visit to the E.R., head CT, and X-ray later, I was diagnosed with a mild concussion, contusions, and muscle strains.

I’m thankful to confirm what my brothers have always said: I have a hard head.

Authors love head injuries and concussions because they want a character to be “out of it” for a certain time frame. In medicine though, we deal with ranges rather than precise number of days of symptoms or healing. Medical science knows the least about how our complex brains work and so surprises aren’t unusual.

Concussions are the mildest form of TBI, or traumatic brain injury. TBI has been in the news a lot of late due to the unsettled issue of sports players who suffer repeated hard hits to the head. The concern is a new entity called Chronic Traumatic Encephalopathy, or CTE. The jury remains out on this, but studies are ongoing.

Medicine loves scores almost as much as the NFL, especially ones that involve emergency treatment. A simple scoring tool helps triage injured or ill patients to the correct next level of care. You may be familiar with a widely used scale for head trauma called the Glasgow Coma Scale. Because of the recent increased interest in head injuries, numerous other scoring systems have been developed. Scoring systems are also used to track the follow-up of head injuries (Post-Concussion Syndrome), similar to how pain is tracked after surgery.

A mild concussion can cause no symptoms, or any or all the following:

  • headache
  • blurry vision
  • issues with slow memory or cognition
  • balance problems
  • dizziness or seeing stars
  • ringing in the ears (tinnitus)
  • nausea and/or vomiting
  • issues with sleeping, either too much or too little
  • irritability and personality changes
  • sensitivity to light and noise (like a migraine)
  • disorders of taste and smell
  • depression and psychological problems
  • small children may not be able to say what’s wrong, so excessive crying, dazed appearance, unsteady gait, and lack of interest in playing with toys are signs

More severe concussions can cause loss of consciousness, confusion or feeling like your brain is in a fog, or amnesia surrounding the event—not recalling how or where you fell—or worse, seizures.

I was stunned but otherwise able to walk and talk. I suffered a humdinger of a headache that lasted off and on for a couple of weeks. My brain also hurt directly opposite of where I struck my head, something called a contrecoup injury.

Brains are solid but squishy like gelatin. (Not saying my brain is Jello, FYI.) A thin fluid-filled space exists between the surface of the brain and the skull. Due to abrupt deceleration or acceleration, the opposite side of the brain gets forced or bounced against the skull. This can causes a brain contusion (bruise) or even bleeding on that side, in addition to a contusion or bleed on the side of the injury. In some cases, this contrecoup brain injury ends up being worse than the area that was struck.

The risk for serious brain bleeding with a head injury is increased by advanced age, drugs such as blood thinners or aspirin, or by diseases that cause issues with clotting such as hemophilia, alcoholism, cirrhosis and liver diseases. NSAIDs, non-steroidal anti-inflammatory drugs like ibuprofen pose a lesser risk.

If you want your character to suffer a head bleed due to a minor head injury, you could have them taking aspirin or be on a blood-thinner for a condition such as blood clots/artificial heart valve/other medical condition.

If you want your healthy and/or young character to have a severe concussion or skull fracture, a trip and fall won’t accomplish that. Severe concussions result from high-speed injuries, hard blows of a weapon such as pipe, fist, golf club etc., gunshot, car wreck, explosions, fall from a great height, or hitting the water hard e.g. from a speeding boat. (Prime example? Young, healthy Connor Fields suffered a head bleed in his BMX crash in the Olympics, reportedly with no skull fracture.)

*Remember: A simple fall or mild knock to the head rarely results in a skull fracture, serious head bleed or coma unless underlying health issues are present.* 

Points to take home about Traumatic Brain Injury:

  1. The scoring and evaluation of a concussion depends on where your character is. The military uses the MACE (Military Acute Concussion Evaluation). Sports doctors and trainers will typically use the ACE (Acute Concussion Evaluation) score. ER doctors can choose from a variety of common scoring systems.
  1. The Glasgow Coma Scale was developed to determine the predicted outcome of a severe head injury that results in an obtunded mental status. The GCS was not designed for concussion scoring, however if someone remains unconscious after a head injury, the Glasgow or modified Glasgow scale comes into play.
  1. The most common standard ranking of concussions is Grade 1, 2 and 3, with 3 being the worst.
  • Grade 1: may have symptoms, but those disappear within fifteen minutes.
  • Grade 2: No loss of consciousness, but symptoms persist longer than fifteen minutes.
  • Grade 3: Brief loss of consciousness accompanied by other symptoms.
  1. Sports TBI scores go far more in-depth and can even include a physical performance test or computerized visual reaction testing, similar to a video game.

If you google “concussion severity,” you will find no lack of information.

If you want a deeper dive, a great free reference is Institute of Medicine (IOM) and National Research Council (NRC). 2014. Sports-related concussions in youth: Improving the science, changing the culture. Washington, DC: The National Academies Press at ncbi.nlh.nci.gov.

And please, always watch where you step.

An award-winning writer, Ronda Wells hails from the Midwest and is married to a physician. Board-certified in Family Practice, she switched to Occupational Medicine after a stint in private practice. For the last thirty years, she has been a medical director in the health reinsurance industry and case-manages transplants. She has written and published medical policy and guidelines for multiple companies under their name, but her real love has always been fiction. She has just received an offer on her first novel, Harvest of Hope, and is developing a medical suspense series.