Each year, nearly 5 million Americans are evaluated for traumatic brain injury in emergency departments across the country.
These injuries can occur in many different ways – from car accidents and military conflicts to falls and daily activities – and they are diagnosed in about 2% of all emergency room visits in the United States.
Awareness of the extent of traumatic brain injury has increased over the past decades, especially in sports and the military. But a group of experts from across the country say the country’s current care system often fails to meet the needs of individuals, families and communities affected by traumatic brain injury.
“As physicians, we are frustrated that there are significant limits to what we can do for our patients for an injury that has real and debilitating consequences,” said Frederick Korley, MD, Ph.D., associate professor of emergency medicine at Michigan. Medication. “Many important structural changes need to be made to provide better care for patients who often go through a protracted recovery process.”
Korley is part of a select team of researchers who recently authored a report analyzing the health system response to TBI for the National Academies of Science, Engineering, and Medicine. The study, funded by the US Department of Defense, found that the lack of a comprehensive framework for classification, care and research places a significant burden on everyone involved, leading to unnecessary deaths, wasted human potential and skyrocketing costs. Their report contains many recommendations to improve TBI care and research.
When those nearly 5 million Americans arrive at the emergency room each year to be evaluated for brain damage, they are classified into one of three categories: mild, moderate or severe.
It sounds simple. The driver who is in a coma after a devastating car accident would be considered serious, while the student who has a headache after slipping on ice might be considered mild. For Korley, who sees many of these so-called “mild” cases in the emergency department, the classification is inadequate — and, in some cases, insulting to patients.
“Some people considered ‘light’ can’t go to work; they have horrible headaches and memory problems that can lead to job loss or dropping out of school,” he said. he declares. “Conversely, some people are classified as ‘severe’ but actually do much better than expected. Not all of these cases result in death or devastating disability.”
This lack of distinction, the report notes, leads to suboptimal care across the spectrum of TBI and can include the withdrawal of life-sustaining treatment for patients who may have improved.
Instead of shorthand, the researchers recommend using the Glasgow Coma Scale Full Score, a system that ranks the severity of TBI on a scale of three to 15, in addition to results from brain CT scans and tests. blood to classify patients. This approach provides a more accurate and nuanced assessment of the injury, Korley said.
“Let’s say we have two ‘mild’ TBI cases,” he said. “One is a patient who has a concussion and experienced light sensitivity but felt fine shortly after, and the other is someone who is awake but so out of it that he asks the same question repeatedly. The first would be a GCS 15, and the second would be a GCS 13. To call both patients “mild” is an oversimplification. To say that one is a TBI GCS 15 and the other a TBI GCS 13 is more descriptive and will inform additional treatment plans.
Emergency physicians also rely heavily on CT neuroimaging to find evidence of brain hemorrhage and determine if surgery is needed. Recently, they have started using blood tests to justify neuroimaging and reduce the number of unnecessary tests. These blood tests can also help doctors better characterize the severity of the injury. The research team advocates a classification system using all three methods.
“This full range of scans will allow for a more accurate and sophisticated description of the injury that will inform individualized treatment and help more accurately predict long-term outcomes,” Korley said.
Provision and Continuity of Care for TBI Patients
For many, “traumatic brain injury” suggests an isolated event. A dramatic scene of an accident victim or injured soldier receiving life-saving medical intervention, eventually cured.
That’s a misleading view, says Korley. Think of TBI like COVID-19.
Many people hospitalized with the virus do not die, which could be considered a “cure”. But nearly half of these people experience significant functional decline after discharge from hospital. And dozens of people with “mild infection” end up with lingering symptoms of long COVID that can impact their lives.
Like COVID-19, many who “recover” from a TBI experience a chronic phase of the injury. However, only 13-25% of patients with moderate to severe traumatic brain injury eventually benefit from interdisciplinary rehabilitation in a hospital setting.
“There’s the idea that once you leave the hospital after a TBI, it’s as good as it gets, but that’s just the start of the battle,” Korley said. “The acute phase is when you’re trying to limit secondary brain damage. The chronic phase is a much longer healing process.”
For an injury that the researchers say is vastly underestimated, they note that the United States has no mechanism for TBI long-term care. And for what is available, many survivors do not have access or cannot afford it.
“A lot of people maximize their benefits at this point. [of inpatient rehab]“, said a TBI patient quoted in the report. “Then when they are at home, they have problems and do not have the insurance funds to help them. To me, it’s just plain criminal that so many TBI victims are forced by insurance companies to stay in bed, which simply kills their chances of a good recovery.”
Korley and the committee recommend creating a national framework for TBI care. They say it should build on the successes of regional trauma systems by establishing local and regional integrated care delivery systems through the acute, rehabilitation and recovery phases of injury. They also want health insurers, Medicare and Medicaid to provide coverage for TBI care that aligns with clinical guidelines, ensuring equity of access and affordability.
“[Taking these steps] would require a level of continuity and acceptance of responsibility that American health care often does not achieve for chronic diseases,” the researchers wrote.
Research and innovation
To date, there is no FDA-approved therapy that can on its own treat the damage caused by traumatic brain injury. Several promising therapies have failed to promote recovery in large clinical trials.
Meanwhile, the committee says research on TBI is weak compared to other important conditions, such as cancer or heart disease. They called on government organizations – the National Institutes of Health, the Department of Defense – and private sector funders to commit to much greater investment in basic and clinical research to improve health and well-being. – be survivors of TBI.
In collaboration with the Department of Defense, the Weil Institute for Critical Care Research and Innovation at the University of Michigan organizes an annual Massey TBI Grand Challenge, which provides funding for early-stage, innovative and high-risk research to develop the next generation of diagnostics, devices and therapeutics for severe TBI. Researchers make “Shark Tank”-style presentations to a panel of clinicians and commercialization experts for innovative ways to advance early care. In six years, 39 teams have been funded and more than $4 million has been awarded.
“This program provides a unique and vital mechanism to bring together diverse expertise across UM to propose and develop the near science fiction solutions and technologies that will be needed to have a meaningful impact on the care of TBI sufferers,” said Kevin Ward, MD, executive director of the Weil Institute and professor of emergency medicine and biomedical engineering at Michigan Medicine. “The program encourages collaboration between medical sciences, engineering, basic and computer sciences, and it really helps us to shorten the research and development cycle through strategic risk reduction.”
Without an entity taking charge of clear target setting and oversight, experts say, progress is unlikely.
“We want to drive more progress as we create a blueprint for clinicians, researchers, and stakeholders who are committed to solving this problem,” Korley said. “We hope that government leaders will pay attention and help redirect funding priorities. Many of the recommendations we offer will require significant funding to implement. This is how our nation will begin to show up for survivors. traumatic brain injury, their caregivers and communities.”
This activity was supported by Contract No. W81XWH20C0126 between the National Academy of Sciences and the US Army Medical Research and Development Command of the Department of Defense. Any opinions, findings, conclusions or recommendations expressed in this publication are those of the authors and do not necessarily reflect the views of any organization or agency that has provided support for the project. The views, opinions and/or conclusions contained in this report are those of the authors and do not necessarily reflect the views of the United States Army Medical Research and Development Command (USAMRDC).