Traumatic Brain Injury 101


U.S. Public Health Service Lt. Sherray Holland, clinical education and outreach specialist at the National Intrepid Center of Excellence (NICoE) at Walter Reed National Military Medical Center, demonstrates how providers evaluate individuals for potential mild traumatic brain injury or a concussion during a lunch and learn session March 31 at NICoE.

U.S. Public Health Service Lt. Sherray Holland recalls walking toward the store while looking down at her phone and texting. She also recalls tripping on the curb, but her last memory was “flailing to try to keep from falling and embarrassing myself,” before she lost consciousness after suffering the fall and a concussion.

Holland, a certified physician assistant (PA) and the lead clinical education and outreach specialist for the National Intrepid Center of Excellence (NICoE) at Walter Reed National Military Medical Center (WRNMMC), said when she woke up on her back, someone was standing over her saying, “Wow! That was a bad fall!”

Holland said she got up, picked up her purse and went into the store to do her shopping thinking she would not be in there long, grab a few things, go home and take care of herself.

“I thought, ‘I am a PA and [treat TBI patients] for a living, so I should be OK,’” Holland said.

While in the store, Holland said a security guard approached her and asked, “Ma’am, are you OK? Do you need to go to the hospital?”

“I said, ‘No, I had a tumble in front of the store, but I’m OK.’

“He said, ‘But you’ve been wandering around in the store for two hours.’”

That news came as a shock to Holland, and it “snapped [her] out of a daze,” because she had no recollection of being in the store for that long, she said. “I really thought that I had just walked into the store. I looked in the shopping cart and there was nothing in it. I looked in a mirror and I was bleeding from my head and knee.”

Holland explained her symptoms of loss of consciousness, confusion, disorientation, and difficulty focusing, are common for many who suffer a mild traumatic brain injury (mTBI), or concussion, such as she did that day.

Early TBI education, intervention and positive expectations have a direct effect on recovery, Holland said. She explained the sooner the intervention, the better the chances are for recovery.

Holland defined a TBI as a blow or jolt to the head disrupting the normal function of the brain, adding that not all blows or jolts to the head result in a TBI. She added, the severity of a TBI is determined at the time of the injury and may be classified as mild, moderate or severe. “Concussion and mild TBI are synonymous terms,” she continued, adding symptoms of concussion often resolve within days or weeks, whereas more serious TBI may take months or longer to be resolved.

Falls, like the one suffered by Holland, and motor vehicle accidents are the two most common causes for TBIs, she explained. Falls and motor vehicle crashes account for more than 50 percent of all TBIs, according to the Centers for Disease Control and Prevention (CDC).

Holland also served as the featured speaker during a NICoE lunch and learn session, “Traumatic Brain Injury 101,” March 31 at the NICoE. The presentation wrapped up March’s Brain Injury Awareness Month; but Holland stressed TBI education should be continuous and is the key to success in treatment.

According to the Defense Medical Surveillance System, causes of TBI diagnosed at military treatment facilities from 2000 to 2013 are falls (21 percent); motor vehicle or other transportation crashes (17 percent); assault (non-battle), legal intervention (17 percent); accidental strike by or against an object/machinery (16 percent); gun and explosive accidents (14 percent); other causes not defined (14 percent); sports/athletics (8 percent); and battle injury (8 percent).

According to numbers from the Defense and Veterans Brain Injury Center recorded between 2000 to 2015, Holland said 82.5 percent of TBI cases, or 279,898, are classified as mild; 28,701 (8.5 percent) classified are moderate; 22,417 (6.6 percent) are not classifiable; 4,944 (1.5 percent) are penetrating; and 3,502 (1 percent) are severe. In total, there were 339,462 incidents of all severities coded by defense department providers during the 15-year span, Holland said.

In the United States as a whole, Holland cited CDC numbers indicating TBI accounts for about 2.5 million emergency department visits, hospitalizations or deaths annually. Of that number, approximately 50,000 people die from their injuries, about 280,000 are hospitalized and the remaining are generally treated in the emergency room and released.

Holland said the military conducts a number of levels of screening for TBI in service members. She further explained that because a concussion or mild traumatic brain injury may not be readily identified, recognizing the importance of early detection, the Department of Defense and Veterans Affairs have established system-wide screening and assessment procedures to identify concussion/mTBI in service members and veterans at the earliest opportunity, including pre- and post-deployment health assessments.

She added not all individuals who screen positive have a concussion or mild TBI, and therefore, it is important that patients not be labeled with the diagnosis of concussion/mTBI on the basis of a positive screening test. Positive screens should always be followed by a clinical interview and examination to confirm or negate the diagnosis of concussion/mTBI, she added.

Symptom reporting is also not required when confirming a TBI diagnosis, and “it’s important to treat the patient and not the symptom,” Holland continued. She added fatigue, irritability, depression and difficulty concentrating may occur alone or in combination with the more classic signs of TBI such as headache, dizziness, nausea and other physiological problems.

Recovery from TBI is personal – each person gets better at his or her own pace, which may be influenced by age, severity of injury and other factors, Holland explained. In addition to early intervention, she said it’s important that those who suffer a TBI take care of themselves, “taking things slow and getting rest.” Family and employer understanding and support are also critical to recovery, she added.

To help prevent falls, the CDC recommends removing tripping hazards from rooms and stairs, using handrails, using non-slip mats in bathtubs and showers, using double-sided tape on throw rugs, improving lighting at home and work, wearing shoes with non-slippery soles and using step stools and ladders properly.

In addition, the CDC recommends the following to help decrease your chances of suffering a TBI: wear the proper headgear or helmet at work and play; use age- and size-appropriate car and booster seats that are properly installed in vehicles; use stair gates at the top and bottom of stairs for children; and make sure play areas have soft material under them like mulch or sand to lessen the impact of falls.

For more information concerning brain injury awareness, visit the website, or contact Lt. Sherray Holland at 301-319-3773.