Rousmaniere: Should We Declare War on Brain Injury?

The more we learn about brain injury, the more we find we need to learn — and act.

The scope of the brain injury problem in America, even after what has been learned from the Iraq and Afghanistan wars and from studies of football players, remains disturbingly clouded. One study published in 2011 estimated that 1.4 million people per year sustained a traumatic brain injury.

But a nationwide program of monitoring and studying brain injury more recently estimated that in 2013, 2.8 million TBI-related emergency department visits, hospitalizations, and deaths occurred in the United States. Roughly 2% of the American population is believed to suffer from the consequences of a brain injury.

It was only in 2011 that the first systematic accounting for work related brain injury was published.  Reviewing the years 2003 through 2008, the authors estimated there were about 1,200 work-related fatal brain injuries per year. That’s roughly about one out of every four work fatalities. Half of them befell workers in construction, transportation, farming, forestry and fishing.  About 30% were motor vehicle-related; another 30% were due to falls; 20% arose from physical assaults, and the balance was due to being struck by an object.

Brain-related work fatalities appear to be dropping, probably due in part to better work safety but also due to better treatment. We’ve learned a lot in the past 25 years about how to prevent deaths due to brain injury.

I spoke in September with Elizabeth Sandel, a physician with decades of experience with brain injury treatment and a medical director of Paradigm.  She is aware of what has and has not improved over her career.

An important advance in fatality reduction has been the growth of highly credentialed trauma centers.  When she was practicing in New Jersey in the 1980s, she recalls, there were only two so-called level I trauma centers in the state. Today there are four Level I facilities and six Level II trauma centers, each aligned with its region’s public safety and emergency medical systems.

And, she told me, we know a lot more about the quality of care and the chances of recovery for brain-injured persons. But we do not know for sure if a survivor of a brain injury in 2018 has a markedly better chance of greater recovery today than 25 years ago. 

The great majority of brain injury among the public, and almost certainly among workers, is mild traumatic brain injury, often referred to as concussion. A national research program, TRACK, which is tracking some 2,300 actual patients and surveilles practice, estimates that

22% of patients with concussion remain functionally impaired one year after the injury. Concussions may also contribute to loss of employment, homelessness, and incarceration.

There is a big question about how treatment of concussions has improved, notwithstanding heightened awareness due to news from wars and sports. Moderate and severe cases are almost always admitted into intensive care units.  But a study published this year in the Journal of the American Medical Association reported on emergency department treatment for the less severe concussion cases they received between 2014 and mid 2016. The authors reported that more than 60% of these cases received no more services than they would have received in the late 1990s.

Of the 831 patients the authors tracked, “less than half self-reported receiving TBI educational material at discharge or seeing a physician or other health care practitioner within three months after injury. The provision of educational material varied from 19% to 72% across sites. Among patients with a positive finding on a CT scan, 39% had not seen a medical practitioner three months after the injury. Among the patients with 3 or more moderate to severe post-concussive symptoms, only 52% reported having seen a medical practitioner by 3 months.

And yet — there is evidence we know more about treatment, even if the treatment provided today may not be confirmed up by the highest quality research. Take, for instance, how doctors relieve the brain of pressure due to swelling. Craniotomies, or surgical opening of the skull, have been widely accepted, but not yet proven, as a means to prevent death and severe brain damage.  The medical community has done much more than in the past to bridge between disciplines of care, including neurology, neurosurgery, psychiatry, and physical medicine and rehabilitation.  Since 2010, the disciplines have cooperated in creating a certification in brain injury medicine.  Treatment guidelines are being updated.

One thing we have learned from the recent history of football and brain injury is that it takes a decade, or more, for a major medical hazard to be recognized widely enough to stimulate broad, concerted action. And it takes ten years for such a response to be broadly impactful.

Could not the workers’ comp industry “declare war” on occupational brain injury, as a collaborative campaign to greatly reduce fatalities and to ensure better recovery?

ABOUT THE AUTHOR

Peter Rousmaniere is widely known throughout the workers’ compensation industry, both for his writing and consulting experience. Based in the picture perfect New England town of Woodstock, VT, he is a regular on the conference circuit, and is deeply in tune with trends and developments within the industry. His passion is writing and presenting on issues largely related to immigration, and he maintains a blog on the subject at www.workingimmigrants.com.

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