Primary care physicians and first responders are ill equipped to treat potential PTSD and TBI victims and should have a standard protocol to diagnose them and help them find continual care.
“But You Look Fine.”
Following my last major traumatic brain injury, I regained consciousness in the back of an ambulance. Disorientated and not knowing what happened and or where I am, I am questioned by an emergency medical technician whose words are incomprehensible to me (Charlie Brown teacher voice). The lack of training and experience encouraged the technician to continue asking pertinent questions to a person that suffered a TBI instead of focusing on getting oxygen to the brain and preventing hyperventilation which are the same methods followed by the U.S. military and initiatives pushed by the Brain Trauma Foundation. Dr. Ben Bobrow, co-director of Excellence in Prehospital Injury Care (EPIC) stated, “Nobody mandates it, but the public expects it… John Doe, he expects if he has a head injury that somebody’s going to respond and know exactly what to do, and be able to do it really well.” (EPIC) That is not the case with 1.7 million TBI victims annually in the United States (Center of Disease Control). There is an abstract between actual care and what is expected. The lack of a standard requirement further disadvantages the victims and the people that are treating those victims. Primary care physicians and first responders are ill equipped to treat potential PTSD and TBI victims and should have a standard protocol to diagnose them and help them find continual care.
Primary care physicians (PCP’s) have a limited amount of exposure to PTSD and TBI victims. PCP’s have a general knowledge of medical care but often defer to a specialist if an injury is outside of their scope of practice. PCP’s without a focus in sports medicine, psychology, or neurology rely on different techniques to help diagnose PTSD and TBI. One of the standard assessments tests is called the Sports Concussion Assessment Tool (SCAT 2) (Stoler and Hill 34). The steps to this test are as follows: 1: Physical signs, 2: Balance assessment, and 3: Glasgow Coma Scale. Without the concentrated knowledge outside of the SCAT 2 test and proper equipment (x-rays, EEG, and CT scans), PCP’s often misdiagnosis victims and prescribe painkiller medication as a way to fix the symptoms.
The primary function of first responders, consisting of emergency room physicians, law-enforcement, fire-rescue, and emergency medical service personnel, is to assess and treat visible injuries while preserving life. They are trained to focus on acute care, intervention, and stabilization (Stoler and Hill 34). Their focus is not on chronic conditions and limited provision for continuing care; it is to provide efficient and immediate care to ill and injured patients. Some of the duties include, but are not limited to, opening and maintaining an airway, ventilating patients, providing emergency medical care of simple and multiple system traumas, and managing general medical complaints. While helping injured victims with altered mental status is included, an estimated 300,000 victims are never diagnosed for the invisible wounds of PTSD and TBI while receiving treatment for visible injuries (CDC).
Post-traumatic Stress Disorder or PTSD as it is commonly referred to be is a psychiatric disorder that is difficult to diagnosis without in-depth information about a victim. If someone has experienced or witnessed a life-threatening event such as military combat, natural disasters, terrorist incidents, serious accidents, or physical or sexual assault in adult or childhood could potentially develop PTSD (U.S Department of Veterans Affairs). About 8 million adults have PTSD during a given year (USDVA). The diagnoses are not given until the victim has passed a screening and has continually had the same feelings for over three months from the date of injury. Consequently, the time constraints and the lack of personal knowledge about victim trauma history place PCPs and first responders at a disadvantage.
The often-misdiagnosed Traumatic Brain Injury also known as TBI is usually not taken seriously unless there is a visible wound. TBI is caused by a bump, blow, or jolt to the head or a penetrating head injury that disrupts the normal function of the brain (CDC). Over 1.7 million Americans experience a TBI every year in the United States and 53,000 die from their injuries. The often-misdiagnosed injury affects every sex, race, and age (CDC). A Traumatic Brain Injury is often an invisible injury with lifelong ramifications, the treatment of which requires a strong support system, therapies that encourage the best possible quality of life and clear expectations on how to rebuild life after it falls apart. The difficulty with diagnosing a TBI is that not all blows to the head result in a lingering symptoms. The severity of a TBI may range from “mild”, known as concussions, to “severe” which is an extended period of unconsciousness or memory loss after the injury. Brain injury victims’ level of necessary care depends on the priority of PCPs and first responders’ visible observance.
There is growing evidence that the management of TBI in the early minutes after injury profoundly affects outcome. Primary care physicians and first responders would have the ability to reduce the number of emergency room visits, hospitalizations, and deaths in the United States if there was a standard protocol on how to deal with brain injuries. The early minutes after an injury are the most crucial in relation to the outcome of the brain injury, yet there are currently no standard protocols. Excellence in Prehospital Injury Care (EPIC) is a statewide project in Arizona with a goal of establishing EMS TBI guidelines. EPIC believes that if first responders have the tools and training to implement in cases of brain injury, there will be an increase in successful outcomes for those that suffer a brain injury.
The unfortunate casualties of war have inadvertently helped the military create an ideal protocol for dealing with PTSD and TBI. A group of officials at the Defense and Veterans Brain Injury Center has compiled treatment and recovery guidelines for brain related injuries. New guidelines mandate a 24-hour rest period following a concussion. If abnormal symptoms are observed once the patient returns to normal activity, then a six-step treatment is put into place. The steps offer a recovery phase that very slowly transitions the patient from rest to unrestricted activity. The six-step program is an effort to give the brain time to heal without causing further trauma. “Treatment goals in the first 72 hours of care for the injured patient with TBI are to provide clinical stability, arrest any element of ongoing injury, preserve neurological function, and prevent medical complications secondary to multisystem trauma” (Lenhart 348). Although, the protocol was developed over several hundred years and multiple casualties, the military leads the way with the most efficient treatment plan.
Public perceptions have cast a shadow over returning soldiers, labeling them as broken because of their invisible injuries. There is an established stigma regarding mental injuries and diseases when compared to a visible injury. The injured face a difficult task of properly explaining their symptoms to medical staff. Oftentimes, victims do not seek help due to the stigma of their condition, and, therefore, physicians and first responders do not pursue the issue. The lack of extensive training for PCP’s and first responders coupled with the self-imposed barriers victims of PTSD and TBI face prevent adequate medical care.
The new advances in technologies, diagnosis and assessment will help PCP’s and first responders make more accurate predictions. Some of the new guidelines are development of innovative approaches and procedure for rehabilitation immediately after injury, creation of a new diagnostic procedures and assessment tools for complications that were previously difficult to measure objectively, and identification of common long-term problems that occur after TBI and the reason why they occur (Stoler 347). Hopefully with these new advancements it will help the 1.7 million Americans that encounter a TBI yearly.
All of the new advancement and safety precautions cannot prevent an accidental TBI and the potential effects of PTSD that follow. Putting new protocols in place will give victims a chance to have a better outcome. Upon analyzation of the current standard protocols, it can be said that “[a] first responder’s role is one of ‘triaging’ the needs of the individual at the scene of an incident… the focus is on preservation of life-referred to as maintenance of the ABCs (airway, breathing and circulation)” (Przymusinski). Dean Lori Przymusinski has worked in the medical field in different roles for over 33 years. In her expert opinion she stated, “Due to the brief encounter of the first responder, it may be challenging or even impossible to address the complex needs of an individual suffering from a traumatic brain injury (TBI) or post-traumatic stress disorder (PTSD) other than preservation of life.” She believes that additional training, professional development and collaboration with other health professionals are occurring already, but the low staffing levels impact a patient’s recovery. Przymusinski agrees that transporting a TBI victim to the highest level trauma center that is available as soon as possible is best but understands that, demographically, this is sometimes impossible. Primary care physicians’ and first responders’ ability to properly treat potential PTSD and TBI victims is very limited because of the standard protocol in place. Outside of keeping them alive until they get to the hospital and out of the emergency room, the responsibility to diagnose victims and help them find continual care falls upon the next doctor in line.