Concussion Workup Increasing in the Emergency Department: An Update for Personal Injury Attorneys
An interesting article was released this week regarding how emergency department visits and head CT utilization have increased over the years (the study time frame was 2006-2011). This article was published in the Journal of Academic Emergency Medicine (2015 June 25; Zonfrillo et al.). What are the implications for personal injury attorneys who aim to understand these records in light of their cases?
It may be that people are increasingly identified as having a concussion and workup is occurring at the time of concussion after being transported to the ER. Public awareness of concussion has certainly increased (just think about the discussion of concussion in the NFL). On the plus side, we may more easily be able to determine severity of injury in a legal case if some type of assessment is occurring close in time to the onset of injury. I have always found it helpful to examine emergency room (and even paramedic) records at the time of injury. There is no substitute for gaining some sense of injury severity at the time of injury. All too often individuals misremember details later, and diagnosing TBI retrospectively (especially years later) is extremely difficult. A person’s memory of what occurred at the time of injury is not necessarily representative of what actually happened in all cases.
As the article points out, concussion is now the most common type of traumatic brain injury for which patients present to the emergency department (ED). Yet, this epidemiological study also noted that ED visits for concussions have increased over time, with a corresponding increase in head CT utilization despite a decrease in injury severity. The authors posit that increased visits may be due to more concussion awareness and recognition of subtle injuries. It is also true, in my experience, that we live in a litigious society where people do want to document such occurrences.
I have also observed variability in multiple physicians’ takes on the same case at time of injury (in the ED). Some providers have received training in concussion assessment and management during their medical training, and others less so. It may be worthwhile to consider bringing the ED physician into the courtroom to expand on his/her training in concussion diagnosis and workup, and why their conclusions were drawn regarding concussion in a particular case. The article concludes that evidence-based clinical practice guidelines for brain imaging in head-injured patients and management of concussion should be reviewed by emergency medicine providers, so this is also a potential line of inquiry (e.g., continuing education, understanding of evidence-based clinical practice guidelines). It is also important to understand what the patient was told about his/her concussion, as this can influence outcomes and persistence in symptoms. It is important to consider these factors when relying on emergency room records for concussion diagnosis.
Emergency department records at time of potential concussion are a rich source of information and at the same time should be reviewed by personal injury attorneys with the above in mind. This is a critical record that should be forwarded to the neuropsychologist expert in your particular case. The neuropsychologist is most commonly involved with the case only months to years later and therefore frequently does not have the benefit of assessment at time of injury. Hence, records are invaluable.
About the author. Dr. Messler is a board certified clinical neuropsychologist and licensed psychologist who has provided thousands of evaluations where the question of traumatic brain injury was raised. She has also served as expert consultant and witness. She believes it is critical to provide an objective, scientifically defensible opinion, and to help the jury and court understand the implications of the neuropsychological aspects of cases before them.