Brain Injury Misdiagnosis Begins in Emergency Room

ER Brain Injury Misdiagnosis can Create Obstacle for Treatment and Recovery

By Gordon S. Johnson, Jr.

Brain injury misdiagnosis often begins in the emergency room, where the wrong diagnostic tools are used to triage severity of injury. Getting treated in an emergency room is sadly often worse than the treatment on the sideline of a sporting event. Unlike those who get hurt where the diagnostician witnesses the trauma, the emergency room personnel often have no clue as to the severity of the trauma, whether the injured person was unconscious, dazed, confused or amnestic.

Rarely are the most sensitive measures for detecting brain injury used in the emergency room. In a significant subset of mild traumatic brain injury cases, the ER will call for a CT scan, but often that only compounds the brain injury misdiagnosis, because the CT scan will only spot relatively severe pathology.

A peer reviewed research study published in the Archives of  Physical Medicine and Rehabilation  (Vol 89, August 2008) found that more than half of those with Mild TBI’s were not diagnosed in the emergency room. See Powell, Accuracy of Mild Traumatic Brain Injury Diagnosis, Arch Phys Med Rehabil Vol 89, August 2008. The two most significant reasons found for the misdiagnosis were reliance on the CT scan to do the doctoring and overemphasis on lack of evidence of loss of consciousness (LOC). At page 1553;

On the other hand, it appears that the ED medical personnel focused on ruling out a more severe brain injury for patients who arrived at the ED with a likely mechanism for TBI. It appears that negative CT scan findings were probably given the greatest weight, followed by determination of LOC, as appropriate for this purpose.

Sometimes it feels like the medical world can’t avoid taking two steps back for every one step forward in getting the brain injury diagnosis right. CT scans do not diagnose. They help doctors, who are considering the full clinical picture, make a diagnosis. In the case of MTBI, the CT scan offers almost no clinical value. All it is really good at is ruling out a very serious injury. Even when there are signs of injury on the CT, those are ignored because they do not appear to be life threatening.

If the goal of the emergency room is to prevent deaths from brain injury, then the current approach might be sufficient. But if the goal is to identify the vast majority of brain injury so that education and treatment can help the survivor deal with the aftermath, then the ER is doing an abysmal job. The too often heard argument in support of this poor expectation of care is that so what, if the condition isn’t life threatening. While there exist dozens of reasons why I could explain why it makes a difference in outcome to know, it all comes down to the injured brain needs considerably greater protection than the uninjured brain. If no one identifies the injury, then that protection cannot be provided.