[This is the first of two articles on Mild Traumatic Brain Injury.  Part 2 will be published in the next few weeks.]

Mild Traumatic Brain Injury (mTBI) is a difficult condition to diagnose and to treat, a complex issue with high-stakes legal and medical consequences.  It’s a condition MKC sees regularly in litigation, insurance claims, bill audits and elsewhere…and one that deserves the attention of business owners, insurance executives, claims administrator, attorneys and others.

The Atlantic Claim Executives Association (ACEA) recognizes the topical currency and financial importance of mTBI.  That’s why the professional association put mTBI front and center at its October 2019 meeting in Norfolk, Va., inviting Burton Bentley II, MD, FAAEM, CEO, Elite Medical Experts, and me to conduct a panel presentation, “Understanding and Defending Mild Traumatic Brain Injury Cases.”

This article on mTBI –­­ the first of two parts ­­– outlines the data and insights Dr. Bentley and I covered last fall at the ACEA meeting, laying the foundation for understanding and defending mild traumatic brain injury cases.  

Intro

Let’s start with a little context and background.  A recent scholarly article summed up this thorny topic beautifully…

“Traumatic brain injury (TBI) has drawn national attention for its high incidence and mechanistic complexity. The majority of TBI cases are “mild” in nature, including concussions and mild TBI (mTBI). Concussions are a distinct form of mTBI where diagnosis is difficult, quantification of the incidence is challenging and there is greater risk for subsequent injuries.”  Mechanisms underlying vulnerabilities after repeat mild traumatic brain injuries, inExperimental Neurology (Volume 317, July 2019, Pages 206-213)

Citing various variables –­­ including the nature of the injury along with age, gender and hormones ­–­ the authors continued, saying…

“Understanding how these factors collectively contribute to concussion and [repeat TBI] recovery is critically important in establishing age/sex appropriate return to play guidelines, injury prevention, therapeutic interventions and mitigation of long-term consequences of rTBI.”

These take-aways track what we’ve observed and presented publicly.  At the ACEA meeting, Dr. Bentley and I showed how mTBI has been in the news, movies, and courtroom, rising to the status of the “new” carpal tunnel, whiplash, or Complex Regional Pain Syndrome (CRPS).

We also addressed how mTBI is a condition on which many claims are now focused.  It has become a big dollar business.  mTBI is a source of litigation and — depending on what side you are on — can result in large payouts.  This level of exposure demands a critical and careful analysis of ALL the medical data points, often with a high cost to businesses and insurers.

Head Trauma 101…for claims professionals and attorneys

Here are the general parameters of mTBI, including concussions:

•        Mild TBI:  Normal imaging, LOC 0-30 minutes, GCS 13-15, brief amnesia

•        Moderate TBI:  Normal or abnormal imaging, LOC >30 minutes to 24 hours, GCS 9-12, amnesia 1-7 days

•        Severe TBI:  Imaging often abnormal, LOC > 24 hours, GCS 3-8, prolonged amnesia

•        Any head injury ­­ whether open or closed ­­ that alters brain function

TBI accounts for 40 percent of all acute injury deaths, with 1.5 million people annually experiencing some form of TBI.  Eighty-five percent of people with mild TBI have no long-term symptoms, 15 percent have lingering or long-term symptoms, and many people don’t realize they have sustained a mild TBI.

Here’s a recent breakdown for concussions, by age:

The most common symptoms of mild TBI include headache, confusion (varying from minutes to hours depending on the severity of the injury), nausea (due brain swelling and release of neuro-chemicals) and mood changes.  It’s important to note that within the meaning of mood changes, there may be depression requiring counseling or medication due to brain dysfunction.

A mTBI/concussion (terms often used interchangeably) can occur when a trauma causes damage to the brain/head/skull.  But remember that not ALL head injuries result in a concussion or mTBI. Additionally, symptoms can be vague and/or non-specific thus making them very challenging.  It is because of the often non-specific symptoms that cases evolve into a much bigger problem with higher dollars at stake than originally assessed.

The importance of Mechanism of Injury (MOI) to diagnosis, treatment and claims involving mTBI

MOI is an all-important factor when assessing and treating mTBI.  MVA is the leading cause, at 50 percent of all claims, with other leading cases, as follows:

•        Falls (20-30%)

•        Firearms (12%)

•        Work-related TBIs (40-50%) with over half related to transportation

•        Alcohol is a major contributing factor

MKC has covered the basics of MOI and its significance to legal nursing in several articles.  These include a post on our website, Mechanism of Injury (MOI) and its Role in the World of the LNC, where we provided the following definition of a mechanism of injury: “Describes a particular set of circumstances that caused a given injury. An example: The mechanism of an injury from a car crash will often be described in terms of the speed, angle, and direction of the crash.”  We write that emergency medical professionals typically take MOI into consideration when assessing and describing the circumstances and causes of an injury.

Here’s a hypothetical with attention to MOI and mTBI.  Let’s say I assess a person involved in a motor vehicle accident.  When I’m reviewing the record for an injury claim, I would expect that the receiving medical team ­­– including the EMT and emergency department staff ­–­ would make a record of the following:

  • The type of impact
  • The speed at which the impact occurred
  • The amount of  intrusion into the vehicle
  • If the patient was restrained or not.

We don’t hold ourselves out to be biomechanical engineers.  Nevertheless, as we stated recently in a post about MOI and fall-related injuries, it’s important to have “… a complete story about what happened and a full assessment of what’s inside those complex medical files.” 

But it is imperative to understand how the body, spine and head moves in a MVA.  All areas will move differently depending on speed, impact, restraint system, etc.  Take the time to understand these issues as best you can; and, where indicated, seek assistance from medical consultants.  Additionally, ALL reported versions of the incident should remain consistent throughout the record.