By J. Thomas Anderson
Could numerical ratings mislead the insurance industry? Hurricane categories may be fair readings of one storm factor, wind, but that categorical ranking may be an irrational interpretation of an entire hurricane damage system. Just as the National Hurricane Centers (NHC) category system of rating a hurricane's wind power does not adequately prepare the public for the storm's effects, the Glasgow Coma Scale (GCS) system of rating a brain injury does not adequately rate the medical complications of traumatic brain injury (TBI). Neat little one to fifteen GCS ratings hardly tell the whole story of brain injury, as illustrated by the seventy-one common TBI symptoms listed below which are overlooked by the GCS rating system.
STORMS RESIST RANKING
Louisiana residents know how deceptive numerical storm ratings can be. Katrina roared toward the mouth of the Mississippi River as a Category Five hurricane and everyone knows what to do about a Category Five storm: full alert, check the neighbors, and leave. But when Hurricane Isaac blew ashore as a Category One we allowed it to rest comfortably in the public consciousness at the bottom of the threat ladder. As it turned out, Isaac was brutal in ways mere categorical wind measurements fail to appreciate.
In 1971, the NHC introduced storm category ratings based on the Saffir-Simpson scales assessment of top wind speed and storm surge estimates. Partly because of its complexity, the storm surge calculation was removed in 2010. Thus, the National Weather Service storm categorization system does not account for many devastating and/or fatal storm factors such as: 1) surge, 2) size, 3) angle, 4) speed, 5) economic damage, 6) inland flood damage, 7) the number of homes or structures destroyed, 8) the percent of the population displaced, 9) livestock killed, 10) coffins unearthed, 11) rooftop rescues, 12) the length or extent of power outages, 13) tornados thrown, 14) extent of debris fields, 15) spoiled refrigerators, 16) mold, 17) poisonous FEMA trailers, 18) poisonous drywall, and such very real collateral damage. NHC storm surge specialist Jamie Rhome states, People have got to stop thinking about hurricanes as simple numbers from 1 to 5. Isaac's Category One gave no hint of the factors mentioned above. South Louisiana was taken aback by big, lazy Hurricane Isaac's destructiveness, which Miami categorized as minor, but proved much more akin to storms associated with a stronger rating.
SIMILAR TO STORMS, TBI RESISTS CURSORY RANKING
As with storms, traumatic brain injury is also too complex to fit neatly into a numerical category. A medic's quick checklist of gross symptoms in an ambulance simply does not take into account many factors, such the chemical cascade that may occur over the hours, days, or months which follow a brain insult and which may prove fatal. Natasha Richardson bumped her head during beginner ski lessons on the gentle slopes of Mont Tremblant outside Montreal in March 2009, but she was able to act and talk normally and refused medical treatment twice. Her GCS rating was the mildest fifteen. About three hours later an ominous headache began. The medical community rose to the occasion about seven hours later when Natasha was admitted as critical. We know tragedy followed. Natasha was dead of an invisible epidural bleed within forty-eight hours.
After Natasha's spill on the bunny hill she was lucid, laughing, ambulatory, and taking care of herself. Her GCS rating did nothing to warn of the dangerousness of her condition and sent up no red flags regarding medical treatment which could have saved her life. If anything, a misleading rating may have delayed Natasha's treatment and ultimately contributed to her preventable death. Ratings are especially deceptive and tragic because outcomes (fatality rates) are tied to speed of medical treatment (trepanation, in Natasha's case).
The GCS was devised by Graham Teasdale and Bryan Jennett in 1974 as a method of identifying organ donors. Even corpses get three points. It was not intended to rate long-term levels of neurological wellness for any purposes within the current body. GCS ratings made by medics and/or emergency room doctors simply does not account for many factors in TBI. The interior of the skull has sharp ridges on which a moving brain can be injured, causing subsequent swelling over hours or months. The GCS fails to account for ongoing brain damage. Neither does the GCS account for the fatal heart damage which may result from invisible chemical cascades in the brain in the months following brain insult.
Just as Hurricane Isaac in Category One failed to warn Louisiana residents of their potential for predictable flood damage and a host of other storm damages, a head injury in GCS rating of fifteen fails to warn of many predictable problems. None of the GCS ratings give any information about such foreseeable TBI symptoms as: 1) dizziness, 2) headaches, 3) axonal shearing, 4) neurochemical axonal disconnection, 5) balance problems, 6) vision problems, 7) nausea, 8) insomnia, 9) post traumatic stress syndrome, 10) memory problems, 11) hearing loss, 12) fatigue, 13) sensory overload, 14) sensitivity to light or 15) noise, 16) lowered reading comprehension, 17) attention deficits, 18) distractibility, 19) concentration problems, 20) slowed thinking, 21) forgetfulness, 22) emotional changes, 23) social changes, 24) appetite changes, 25) navigation problems, 26) impulsivity, 27) irritability, 28) changes in sense of smell, 29) anxiety, 30) changes in sense of taste, 31) changes in fine motor skills & 32) coordination, 33) loss of grip strength, 34) increased nightmares, 35) tearful episodes, 36) organizational difficulties, 37) difficulty organizing & planning financial information, 38) avoidance of trauma site, 39) word slurring, 40) muscle weakness, 41) reduced inhibition, 42) reduced judgment, 43) motion sickness, 44) increased aggressiveness, 45) abrupt mood swings, 46) poor work or school performance, 47) seizures, 48) changes in habits, 49) apathy or 50) depression, 51) low self-esteem, 52) restlessness, 53) inappropriate behavior, 54) substance abuse, 55) difficulties relating to co-employees, 56) hypervigilance, 57) super startle reflex, 58) easy frustration, 59) quick temper, 60) reduced reasoning, 61) inability to solve problems, 62) problems prioritizing, 63) decreased emotional responsiveness, 64) confusion and 65) misunderstanding, 66) difficulty expressing thoughts, 67) decreased insight, 68) difficulty establishing or maintaining normal relationships, 69) numbness, 70) tingling, and/or 71) increased suicidal ideation.
Nevertheless, a medic may take a brief assessment of your client in the ambulance or an overworked, par 78 emergency room doctor may stop by your client's gurney in the process of clearing his department and assign a high GCS score, which sticks to the patient like a cottonmouth without consideration of any of the possible symptoms mentioned above.
Wind ratings introduce the story of a hurricane. GCS introduce the story of a head injury. Defense attorneys hope to stop the story at the moment of impact and ignore the sequelae, just as the insurance industry tried to stop paying hurricane damages for anything other than wind. Fortunately, the courts stopped the insurance industry from pursuing this wrongful interpretation.
Just as a wind categorization of hurricanes misses much of the damages Louisiana has come to know occurs after the initial impact of wind, there are residual effects of TBI which a GCS entirely ignores. Dismissing these damages is the equivalent to pretending that the only thing that happens in a hurricane is some wind goes by. Insurance companies may look the other way, but Louisiana knows better. Data shows that 10 to 15% of mild TBIs result in permanent brain damage, often with tragic lifelong effects. It is our job to protect brain injury victims from the insurance industry which seeks to use the GCS as a tool to wrongfully stop damages at the moment of impact.
Louisiana juries understand hurricane analogies, especially on the heels of storms such as Isaac, Gustav, Ike, Rita, and Katrina which resonate vividly in the minds of jurors and may provide an important stimulus in reaching verdicts in personal injury cases. Defense arguments in TBI cases often emphasize the mild or moderate classification of the brain injury, along with the high GCS. However, just as the lowest hurricane rating of Category One can wreak havoc on our state causing millions in property damage, so can a mild? traumatic brain injury with a GCS 15 score devastate your client's life and require millions of dollars in rehabilitation costs.
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