Brain injury is one of the leading causes of death in people under the age of 45. Many who suffer mild to moderate injury do not appear to be injured and they have few outward physical manifestations of personal injuries. In short, they "look" good, despite the fact that they have suffered a severe personal injury that can mean the loss of employment, the destruction of personal relationships and the anguish that accompanies the knowledge of all that has been lost.

Mild to moderate survivors of traumatic brain injury routinely are reassured by doctors that they will recover from their fatigue, slowness in thinking, and reduced memory, just as they expect to recover from cuts, bruises and broken bones. The all too common belief is that time heals all wounds. For every rule there is an exception and unfortunately time does not heal all traumatic brain injuries. Over time doctors address objective physical injuries, but the head injury does not receive the special attention it requires and TBI goes undiagnosed. As a result, many head injury patients with permanent impairments never receive a full evaluation by a neuropsychologist, including neuropsychological testing. Without testing by a neuropsychologist, this personal injury cannot be diagnosed and these patients never receive appropriate care and treatment for their physical, cognitive, psychological, sexual and social impairments.Famili to obtain a complete copy of the survivor's medical records including the rescue and ambulance service, emergency room and hospital records if there was an admission. A complete set is critical because it contains all of the detailed evaluations and objective measurements made by emergency medical technicians, E.R. nurses and doctors and neurologists that are necessary to understand the nature and extent of this personal injury.

Since the brain regulates our state and level of consciousness, we can learn much about the extent of a brain injury by evaluating consciousness itself. If the level of consciousness is other than normal, the head injury is serious, no matter what a physical examination or other evidence may indicate. The categories of altered consciousness are:

• Confusion - The mildest form of altered consciousness, in which individuals have difficulty thinking coherently. For example, they may not be able to solve a simple math problem or remember what they ate for breakfast. Often they will seem disoriented and may not speak much.
• Stupor - At this level, individuals are often close to a comatose state and are unresponsive to normal stimuli. They can only be aroused by intense or painful stimulation, such as having their toe squeezed or being stuck with a pin. They may open their eyes, but only if they are vigorously forced to respond.
• Delirium - This intense state of altered consciousness often is the result of exposure to a toxic substance. People suffering from delirium are disoriented, afraid, irritable and over-reactive. They don't have a grasp of what they are seeing or hearing, and they are prone to visual hallucinations.
• Coma - The most serious form of altered consciousness, in which a person is completely unconscious and unresponsive to any sort of stimuli.

Physicians use a system called the Glasgow Coma Scale (GCS) to precisely evaluate and describe patients' levels of consciousness. To understand the seriousness of a brain injury, the patient's condition at the first evaluation is significant. The more severe the initial presentation, the more severe the injury and the likelihood of a full and complete recovery is reduced. The scale is based on three individual responses measuring eye, verbal and motor responses. Physicians consider expression of a total GCS score of limited interest; what is more important is the score in each of the three individual categories. Each level of response indicates the degree of brain injury.

The lowest score is a 3 and indicates no response from the patient. A person who is alert and oriented would be rated at 15.

Any period of unconsciousness is a red flag to rule out permanent brain injury, i.e. to evaluate the nature and extent of the brain injury. Loss of consciousness always should be considered significant. However, a report of no loss of consciousness does not mean that a brain injury has not occurred. Many head injuries result in a prolonged period of confusion with spotty memory. It is common for patients to be asked what they remember upon waking up. More important though is when constant, continuous memory re-started. In many cases where there is no specifically identified period of lost consciousness, continuous memory will not restart for many hours or days later.

The most common of brain injuries is a quiet and elusive one. Called post-concussion syndrome, this personal injury is most often caused by what seems to be innocuous damage to the head. Individuals may sustain a head injury, but never lose consciousness and appear to be doing just fine. The difference between a post-concussion syndrome and traumatic brain injury is that PCS is temporary. TBI is not. Days or weeks later, individuals will experience problems with memory, reasoning or judgment, or they may simply report feeling "off" and not being the same person they were before the accident. These injuries are not readily reported in the injured survivor's medical records, but they are well understood by family members, close friends, and co-workers who know that the survivor is "not the same person" s/he was before this serious personal injury changed their lives.

In today's world of short medical visits, doctors don't have the time, and in many cases the training, to ask the patient about detailed changes in their ability to cope after a head injury. Since many people improve over time, reassurance is the common form of medical care provided by a family physician or general practitioner. The result is that "reassurance" denies the patient treatment because it fails to secure an honest diagnosis.

Family members are the first to recognize deficits and changes caused by a head injury, well before the patient is prepared to admit to chronic deficits, but unfortunately this significant information is not fully reported to doctors. In addition, by definition, asking a memory impaired person details of their cognitive losses is problematic. It is the equivalent of asking a patient "how long were you knocked out?" Once you lost consciousness, you don't know and rarely does anyone instantly regain full consciousness. Coming in and out of acute consciousness is common. For the same reasons, asking a memory-impaired person what they don't remember is not helpful. And there is no bright line between depression, fatigue, irritability and memory lapses caused by brain injury or from other causes, although these symptoms are the hallmarks of a brain injured patient. This is why it is so very important for a spouse, parent or sibling with first hand knowledge to attend follow up medical exams.

After 3 to 6 months, if deficits persist, or improvement is slower than expected, report the most significant deficits in writing to the primary care provider and request a referral to a neuropsychologist.

In many cases, as the attorney for the head injury survivor, I have worked with family members to prepare a detailed letter to a treating doctor that identifies changes in learning and communication skills, among others, suffered by the patient and as a result have obtained a referral to a neuropsychologist for evaluation and testing. Obtaining proper medical care and treatment, especially for TBI survivors, requires the intervention and support of family members, and often times a skilled attorney who knows and understands the signs and symptoms of brain injury.

A word of caution. Do not be deterred by a physician declining to order neuropsychological testing because a CT Scan, or an MRI, does not show injury, i.e. the images are read as being within normal limits.

First, CT Scans cannot be used to diagnose TBI except in the most aggravated cases of fractures and hematomas. Second, the same is true for most MRIs. Unless the MRI was performed on a T-3 MRI machine, which employs sophisticated software to provide diffuse tensor imagery and fiber tracing which is studied and interpreted by a neuroradiologist trained in this protocol, the MRI report is not definitive.

Note that an MRI utilizing a T-3 by itself is not sufficient unless software providing diffuse tensor imagery and fiber tracing is used. This combination of the hardware and software allows specially trained professionals to identify axonal shears and other finite injuries, otherwise unseen on MRIs conducted on T-1 or T-1.5 machines. More importantly, MRIs are not the first step in diagnosing traumatic brain injury. The recognized method for diagnosing the residuals of traumatic brain injury is through testing by a neuropsychologist trained to evaluate TBI.

When should you expect a recovery and to what extent? The general rules is that the shorter the time it takes for recovery, the more complete the recovery will be. While every person is different, patients tend to recover sensory, motor and language skills faster and more readily than writing and math skills, memory, attention, general intelligence and social/emotional balance. In addition to the longer recovery time, the loss of these skills and abilities are usually more devastating.

Motor and speech recovery usually occurs within three to six months of injury. Attention and memory tend to be the most difficult to recover.

The pace of recovery is usually greatest during the first three months. Recovery then tends to slow over the course of the balance of the first year. This is one reason why it is valuable to obtain a neuropsychological evaluation shortly after the head injury is suffered and to use this baseline for comparison with later tests to measure changes and to understand the extent of improvement.

In general, after six months some improvement can occur, but usually it is not significant. After that point, there is no healing in the conventional sense. Damaged brain nerve cells and pathways do not regenerate. People can and do learn to compensate for their injuries by using other skills and that is where rehabilitation specialists are very helpful.