Updated June 9, 2015
You are getting ready to clear your EMS unit from a fire standby when the truck captain asks you to check out Chuck, one of the members of his company.
He was walking around the side of the truck when he walked into an open cabinet door, striking his head pretty hard. He did not pass out, but has been feeling dizzy for the past 20 minutes since the incident.
His fellow members of the company tell you he seems a little "dazed" and although you don't know Chuck very well, he does some a bit slower than normal. He tells you, "I think I just got my bell rung — I'll be fine."
So, what do we do with Chuck? In emergency medical services, we need to consider the worst-case scenario. In the case of a traumatic head injury, the worst-case scenario is bleeding in the brain.
Assuming he does not have a neck injury (which is always possible, but we have discussed that in previous columns), the next consideration is a concussion.
Let's take a look at both of those conditions so we can convince Chuck what to do and what to expect over the next few days and weeks.
Even surprisingly mild trauma such as a fall from standing can cause bleeding in or around the brain. There are some situations where the risk is greater than normal.
Patients that are elderly have an increased risk because the human's brain shrinks slightly with age. This means that there are blood vessels between the brain and skull that are somewhat stretched and have an increased tendency to be damaged and bleed.
In addition, this potential space between the smaller brain and the skull allows blood to accumulate before symptoms can be present.
A younger patient would have symptoms more quickly because of the pressure on the brain. In older patients it takes some time for this pressure on the brain to build up.
To CT or not
If Chuck takes any blood thinners, the risk of bleeding is also increased. These include warfarin (Coumadin), Plavix, heparin and possibly full dose aspirin, although aspirin is much less of a risk than the other three.
While if he was taking these medications he probably should not be working as an active firefighter, that is a discussion for another time, and there is always the possibility that he is not completely honest with everyone — he may want to hide that he is on these medications so he can continue to work, so make sure you ask.
In emergency medicine, we try to figure out which patients need imaging such as a CT Scan and which patients do not.
We can't CT every patient with a bump on the head or we would be irradiating a lot of healthy brains and clogging up the emergency department.
It is beyond the scope of this article to discuss the specific rules that are sometimes used, but it is helpful to know some of the symptoms or conditions on the list so we can use that information to convince Chuck that he really needs to go to the hospital and likely will need a CT scan to rule out bleeding.
Some of these conditions include:
- Persistent headache.
- Age over 60.
- Drug or alcohol intoxication (hopefully not applicable in this case but intoxicated patients are difficult to accurately assess).
- Persistent anterograde amnesia (cannot remember new things).
- Not fully alert, or a Glasgow Coma Score 14 or less (15 is normal).
If these conditions are present in Chuck or any patient with a head injury, use this information to convince them to go and get checked out, as the risk of bleeding is higher.
OK, so let's assume Chuck does not have bleeding in his head. But he continues to be a bit dizzy and is speaking more slowly than normal. Thus, he likely has a concussion.
The definition of a concussion is controversial because of the implications for athletic activity, work and liability.
One feature often debated is if a loss of consciousness is needed for a patient to have a concussion. In general the consensus is now that loss of consciousness is not required.
So the best definition of a mild concussion is a transient alteration of mental status after a blow to the head that can include headache, dizziness, nausea and unsteadiness.
A more severe concussion includes a loss of consciousness and amnesia.
Who to transport?
Does every concussion need to go to the hospital? Probably not — we see a number of protocols in the athletic arena that indicate that if the symptoms are very brief and there is no loss of consciousness, and the athlete is back to normal in less than 15 minutes, they may even be able to return to the field.
Now this varies significantly based on the level of play — a little leaguer would likely not return to play, but a pro hockey player in the Stanley Cup probably would.
How does this apply to our firefighters? Well, it does give us a number of cases to study to try and figure out what is the best course of action — a lot of athletes are experiencing concussions so there is a lot of money and research looking at them.
But the immediate issue is that we don't really know the risks of allowing patients who have had a concussion to return to play or work.
We believe that if a person who has had a concussion has another one while still symptomatic, it might be bad, but we don't know specifically why.
Based on a number of the classifications of concussion and the recommended actions, I believe that if our firefighters still have any symptoms that last longer than 15 minutes, or have any of the risk factors for bleeding listed above, then evaluation in the emergency department is definitely indicated.
What about long term? There is a "Post Concussion Syndrome" that is the constellation of symptoms that can continue for weeks or months after the initial trauma.
These symptoms can include headache, difficulty concentrating and dizziness. This syndrome is not often seen in children or in countries where there is little to no litigation and compensation issues, so maybe there are some exacerbating circumstances.
But one could see how a firefighter with these continued symptoms would have a hard time returning to work.
Back to Chuck. He has already had symptoms for longer than 15 minutes so he should be checked out at the hospital. He may or may not get a CT scan, but I think it is clear he has had more than just having his "bell rung."
The National Hockey League and the National Football League are finally realizing that concussions are a serious threat to their players so we should recognize the threat to our firefighters. I believe we do, so let's stay vigilant.