Let’s say you are playing a game when a fellow player accidentally trips you. You fall backwards striking your head on the ground. First a “Thud!”, followed by a quick flash of darkness, kind of like when the electricity flickers out in your house. This is followed by a few visual “sparkles”. Within seconds the sparkles are gone and in their place you see the faces of your fellow athletes asking “Are you okay?” After a quick systems self-check, you otherwise feel okay so you sit up. This is when you are overcome with a sense of nausea and fogginess. Something about the voices of others just doesn’t sound right. They sound like they are a bit distant even though you can see them right next to you. Other than some mild tenderness where you struck your head, nothing else hurts. So you take the offer for a ride home thinking it will all go away soon.
At home, you still feel queasy and foggy. You rest on the couch and turn on the TV to find that you are a bit sensitive to the light and sound from the television so you turn it off along with all the other lights and just sit in a darkened room wondering if all these symptoms are something more serious than you initially thought.
Should you run to the ER or is this something that can be evaluated by an online video physician?
FIRST THE BIG WARNING SIGNS – GO TO THE E.R. FOR THESE
Head injuries can lead to some serious complications. There are some scenarios where it would be important to call 911 or go directly to the ER. A head injury plus any of these are considered a high risk factor. Therefore an in-person evaluation with a CT scan of the head will likely be needed, not a video evaluation:
- Stroke-like or other new neurological problems such as:
- facial droop
- weakness, numbness, or tingling in arms or legs
- inability to speak
- jumbled words
- inappropriate words
- incomprehensible words
- different sized pupils
- balance and coordination problems
- Any suspected or signs of broken bones of the skull
- High Impact Mechanism (getting hit by a vehicle, falling from body height > 3 feet off ground or down >5 stairs, moderate-high speed accident, and more…)
- More than 1 episode of vomiting
- Age > 60
- Amnesia with 30 or more minutes of lost time
- Blood thinners or known bleeding problems plus having symptoms
- Any worsening over time of symptoms
THEN SOME OTHER RISK FACTORS – GET CHECKED OUT
The below factors are also risk factors but do not necessarily require getting a CT scan. You may still need one, but one of these alone after a head injury does not automatically qualify you for one. Getting seen by a clinician experienced in evaluating head injuries(in-person or by video) can help determine if a CT scan is needed if any of the following are/were present:
- Getting knocked out(loss of consciousness)
- Amnesia with less than 30 minutes of lost time
- Drug or alcohol use
OTHER SYMPTOMS YOU MAY HAVE
- “Foggy”, “Distant”, “Dazed”, “Stunned”
- Light and noise sensitivity
- Difficulty concentrating and remembering
- Increased difficulty with completing physical or mental tasks
- Answering questions slowly
- Repeating questions
- Emotional, nervous, increased sadness
- Change in sleep pattern or trouble falling asleep
MAKING THE DIAGNOSIS THROUGH TELEMEDICINE
For many years, neurologists have been conducting neurological exams by camera for suspected stroke patients in hospitals around the country. It has become and extremely common practice now. What they have shown is that a good history and neurological exam can be conducted in this manner. A carefully crafted plan of taking this same manner of examination to the home or athletic field setting could potentially save a patient and family hours of time in the emergency room and thousands of dollars when applied to mild head injuries. A diagnosis of concussion depends on the ability to ask the appropriate questions and have the injured person perform particular exam components with the evaluator listening and watching the responses carefully. Outside the high-risk categories, an in-person exam in not needed for many head injuries.
Many athletic field trainers and coaches are educated in using concussion assessment tools as are many neurology, primary care, sports medicine and emergency medicine clinicians. These clinicians may be paid or volunteer on-the-field providers for organized events but they usually are not available immediately outside those scenarios. Instead, these online providers could be quickly available through a video evaluation in all scenarios where some form of internet or 4G cellular connection is obtainable.
Recently a study published in Neurology provides some evidence that a distant video based evaluator and an on-scene evaluator are able to conduct comparable exams and be in agreement about whether or not to remove a football player from play. Also, the University of Mississippi Medical Center(UMMC) has conducted projects making telemedicine equipment and evaluators available for numerous high school football teams. Implementation of telemedicine based head-injury evaluations is here and is expected to become more common over the coming years.
MINIMIZING THE RISK
Making the decision to remove an athlete from play and keeping them out of play may not go over well with that athlete or their family. However, the risk to that player of sustaining a second injury is elevated as is the potential for major or long-term complications. For on-the-field evaluation of sports related injuries, standardized tools such as the SCAT3 can be used in assessing the severity of concussion. For non-sports related head injuries, while the SCAT3 may still be useful, there are several well researched and validated guidelines for both children and adults to determine risk of serious skull and brain injury that would require a CT scan or hospitalization.
These guidelines such as the Canadian CT Head Injury/Trauma Rule and the CT in Head Injury Patients(CHIP) Prediction Rule should be used by the video evaluators to help make an evidence-based decision that keeps the patient safe. It is generally worth your while as a patient, if using a telemedicine service, to check to make sure all of the health providers have real-time access to these decision-support tools and others when they are evaluating you. These help minimize missed diagnoses and help minimize decisions being made purely by an individual providers personal “practice style” which may not be in your best interest.
MAXIMIZING THE BENEFIT OF TELEMEDICINE
Use of telemedicine services with clinicians trained and experienced in evaluating head injuries can provide you with several benefits. Not only can they make the diagnosis by video, saving you time, hassle, and money…but they could also help guide you through the recovery process. While pediatrics was not specifically addressed here, telemedicine health care providers can assist with treatment decisions and out-of-play, out-of work, and out-of school decisions. On the flip side, they could also help provide guidance for return to school, work, or play decisions. While the down-time may make you restless and be difficult to stick to, adhering to the rest, recovery, and return to activity instructions will help get your back in action quicker than not allowing your brain time to heal properly.
At Care on Location, our online doctors have experience in evaluating head injuries and have real-time access to decision-support guidelines. We do not recommend our services for high-risk scenarios but for all others, we are happy to help evaluate and guide you to a full recovery.
photo by: By Senior Airman Divine Cox, 375th Air Mobility Wing Public Affairs – http://www.scott.af.mil/News/Article-Display/Article/766937/scott-pediatrician-take-concussions-seriously/