My Experience with TBI

by Noel Blanco, DO

Why at sixteen years old would I repeatedly surf on a car? And how would this end? Probably unfavorably. I suffered a traumatic brain injury (TBI) outside of a typical sporting environment. Reflecting on that event has inspired this essay to reflect on the changes of the Return to Learn and Return to Play protocols provided by the International Conference on Concussion in Sport (ICCS), American Medical Society for Sports Medicine (AMSSM), and the American Academy of Neurology (AAN).

Recalling to a cloudy October Friday of my Junior year in high school, I “car-surfed” for the last time. One afternoon, I hopped on my classmate’s parked sports utility vehicle’s running board with both feet and gripped the roof rack with my right hand. He quickly reversed the car into the lane, placed the car in drive, and hit the gas; and the next several minutes were a blur. Was it several minutes? I do not recall.

I slowly regained consciousness seeing a gray sky and a gentleman, maybe a firefighter or paramedic, who asked the standard orientation questions:

“What’s your name?”

“Noel.”

“Where are you?”

“I do not know.”

“What time of the day is it?”

“I do not know.”

“Who is the president?”

“Bush.”

Then, everything faded. I do not remember my parents coming to my side promptly as they intended to pick me up to attend my younger brother’s football game. Fortunately, his team won and he ran the ball exceptionally well.

The EMS staff took me to a familiar emergency department (ED). Two years earlier an orthopedic surgeon repaired my right humerus Salter-Harris fracture, and before medical school, this ED became my employer as an Emergency Medical Technician. Several hours later, I woke up with my parents and the ED physician excitedly crowding me. I only suffered abrasions, and fortunately, I had no intracranial bleeds or fractures. Approximately thirty minutes later, my parents drove me home, but we briefly stopped at a friend’s party to alert my friends of the events and my health before retreating home for rest.

Over the weekend, I watched TV, talked with my parents and brothers, and completed my homework assignments. As an eager and disciplined student with a strong desire to attend a great college, I returned to my typical rigorous learning environment of honor and advancement placement classes that Monday. On that morning’s announcements, I heard my school principal educating my classmates and I about my horseplay in the parking lot, which led me to embarrassingly hide my head into my books. That fall, I was not involved with any organized sports, and a return to play protocol was unnecessary. With permission from my parents, I opted against a follow up appointment as I only wanted to return to my school work.

One would say that this action was typical of a “role model” student of my high school: ASB Student Council, Honor Student, Football and Track athlete, multiple clubs, and maybe a single detention. My health history had no significant abnormalities: asthma, allergic rhinitis, atopic dermatitis, and minor musculoskeletal injuries.

Gratefully, I had a quick recovery and did not suffer any post-concussion symptoms or difficulties with my studies. In addition, I did not have any long-term effects from my TBI, such as seizures, headaches, or neurological deficits.

In the last several years, it has been exciting that physicians, mid-levels, athletic trainers, athletes, parents, teachers, and coaches were and are still learning about recognizing concussions, post-concussion syndrome, and the protocols to recovery. Cognitive and physical rest are given to patients to ease back into their learning and playing environments. During my time as an Army General Medical Officer, I attended multiple symposiums and conferences to apply Military Acute Concussion Evaluation (MACE) and neurobehavioral symptom index for my soldiers.

I do not plan to emphasize the acute management of a TBI but I would like to emphasize the focus on Return to Play and Return to Learn protocols. It would behoove medical health staff to include educational material for the patient’s family.

Each student athlete will require individualized plans for returning to learn and play. Recommendations from ICCS include this simple 4 step process to regular neurocognitive function and advance when asymptomatic:

1. Home daily activities (i.e. texting, screen time, reading) that do not cause symptoms
2. Outside school assignments such as cognitive activities, reading, or homework
3. Part-time return to school or with increased breaks
4. Full-time return to school to include missed work

For return to play, the patient should approach these 6 steps in order and advance each step when he/she have been asymptomatic for at least 24 hours:

1. Recovery period of no activity
2. Light aerobic activity (elevate heart rate) when the athlete has not symptoms
3. Sport specific activity (incorporate movement) when the athlete has no symptoms
4. Non-contact training drills (elevate exercise, attention, and coordination)
5. Full contact practice (functional skills assessment and confidence)
6. Return to play

I was fortunate to not suffer any long-term effects from my TBI. It is imperative as physicians that we provide clearly defined guidelines for our student-athletes and modify appropriately for each patient to prevent long-term complications.

*Disclaimer: This is the opinion of the author and does not reflect my employer, Geisinger.

References

1. https://now.aapmr.org/sports-concussion/
2. McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport — the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med 2017;0:1–10.
3. https://www.uptodate.com/contents/concussion-in-children-and-adolescents-management?search=concussion&source=search_result&selectedTitle=2~74&usage_type=default&display_rank=2#H13513897

Noel Blanco is a PGY1 at Geisinger Commonwealth School of Medicine in the Department of Physical Medicine and Rehabilitation. He is also a veteran and American Ninja Warrior. He also has a blog. Follow him on Twitter @DrNoelBlanco.