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Why Kids Leave The E.R. With Concussions


I'm Michel Martin and this is TELL ME MORE from NPR News. Brain injuries like concussions have got a lot of attention in professional sports lately. But there's also a new focus on concussion in children, especially those who play sports at a young age. A new study suggests that emergency rooms could be doing much more to find and treat concussions in children. It's published online in the journal Pediatrics Today.

One of the lead authors, Dr. Shireen Atabaki, is back with us now to tell us more. She's an associate professor of pediatrics and emergency medicine at Children's National Health System, and she's been teaching us about concussion over the years. Thanks so much for joining us. Welcome back.

SHIREEN ATABAKI: Thank you for having me, Michel.

MARTIN: Just for those who have not been following our conversations on this, would you just remind us what is it a concussion, and why is it such a big deal, especially in younger athletes?

ATABAKI: A concussion is a result of a significant blow to the head and results in a neurometabolic cascade that really changes your behavior. It affects you. It can cause headache, prolonged symptoms like depression, anxiety, insomnia. Basically, the brain shakes, and in a young athlete, it can lead to prolonged symptoms that can last up to two months, even up to two years if unrecognized and poorly managed.

MARTIN: One of your findings is that emergency departments are not consistent in how they diagnose and treat concussions in children and that in fact, some kids are walking out of ERs without getting diagnosed. Can you give us an example of the kind of cycle that you are trying to intervene in?

ATABAKI: Yeah, that's absolutely correct. Historically, what we're seeing is the young athlete playing on the field, a young man maybe 15 years of age, and has a head-to-head impact during football with another player, develops loss of consciousness, falls to the ground, has a headache, is pulled out of the game and taken to an emergency room. And at that point, the training we've had as physicians is really to assess this patient, traditionally, as to whether or not they have a bleed in their brain.

And we often get CAT scans. We are not screening these young people for concussion, and our management plans for concussion are not very good. We've recognized this in a survey we did of emergency departments around the country and noted that nobody had concussion screening tools in their emergency room. And in addition, about 80 percent had very poor concussion management plans.

MARTIN: So is it a vital piece of equipment that's missing, or is this a human interaction? Is this the doctor - a doctor being able to look for certain signs?

ATABAKI: Absolutely. It's absolutely a human interaction. And it's really based on the history and physical exam of your patient, talking to your patient, asking the correct questions. And that's the tool we've developed in this study.

MARTIN: And why is that, though? I mean, is it that there are millions of kids playing sports in this country - a lot of them are contact sports - including sports that many people don't even think of as contact sports like soccer, where, you know, you can, you know, head the ball and stuff? I mean, millions of kids are playing. I mean, why is it that these tools don't seem to exist? Why is that? Do people assume that kids don't go to the ER, or what is it? I don't understand.

ATABAKI: You know, it's similar to what happened with the football players a decade ago when we were not recognizing or managing concussion. And the players sometimes say one of the gifts they've given to children is really this increased recognition nationally. And it wasn't part of our training, traditionally, as doctors. So the tools we've created in the study to screen and manage concussion are very novel, and we're hoping to apply them around the country.

The program that you had here at NPR, the hour-long concussion program, really helped public dissemination of this knowledge. And we talk about knowledge translation - when a new study comes out in a manuscript, in a medical journal, it takes about 10 years for it to translate. Something like this with the type of work that NPR does and now with health informatics solutions really makes this translation much more rapid so that it can happen in a period of two months. And doctors can absorb that information and use it for their patients.

MARTIN: Well, you know, in the spirit of public service, I do want to mention that if people are interested in going back and reviewing that hour, you can find it at, you know, NPR.org/TELLMEMORE. Could you just tell us what are some of the tools that you're recommending as part of this most recent study?

ATABAKI: One is the Acute Concussion Evaluation-Emergency Department. It was a part of a study funded by the Centers for Disease Control. And at Children's National, we've been working on this for over a decade trying to get concussion diagnostic tools and screening tools. And we adopted this tool for use in the emergency department. As you know, it's a really busy setting, fast-paced. You need a tool that you can utilize very quickly.

And so we modified this tool for use in the emergency department so it allows a doctor to quickly screen for a concussion. And now we've put these tools into our electronic health record, and a multidisciplinary team, including the nurse at the time of triage, can start recognizing and screening for concussion.

MARTIN: I - you know, most of the people who are listening to our conversation are not going to be doctors, let's say, and they're not going to be emergency room personnel. What about parents and coaches? Are there things that they should be looking for in the next - after the child leaves the emergency room 'cause you can easily see a scenario where a student athlete would not want to tell you the truth about how he or she is feeling 'cause he or she wants to get back into the game or wants to go back to practice? So are there things that parents and coaches should be looking for?

ATABAKI: Yes, definitely. There's really, you know, interesting hundreds of stories that - where almost every student athlete that comes in with a concussion, bad signs and symptoms, the first question they ask you is, can I go back to the game on Saturday? You know, when can I play next? They really want to move in. The key is, you know, to play or continue their athletics. The key is for parents to take a step back and follow the recommendations of their physician for graduated return to play a sport and even cognitive work until the patient is symptom-free at rest and exertion.

MARTIN: But what are the some of the symptoms that parents should be looking for? 'Cause one of the other findings of your study is that children who are uninsured are less likely - much less likely to go back to the doctor for a follow-up. So what are some of the symptoms that parents should be looking for?

ATABAKI: Symptoms that I mentioned. One of the most common ones is headache. And we are seeing problems with cognitive performance, schoolwork, executive function, I mentioned depression even, and there have even been a few cases of suicide. So it's really important to be very cognizant and aware of your child and advocate for them in the school setting.

MARTIN: Anxiety.


MARTIN: What are some of the other findings that you'd like to call our attention to?

ATABAKI: With this concussion tool, we've also developed a very nice management plan with our colleagues who are wonderful neuropsychologists that have been doing this work for years. And it really allows for communication with the school and a concussion checklist, things for parents to watch and communication with the primary care physician. What we're seeing is these children are going back to schools.

They're developing symptoms maybe a week or two later - headache. They get called - the parents get called, bring them back into an emergency department one or two weeks later. And these children end up getting CAT scans, and they end up going on to have chronic symptoms of concussion that go on, often unrecognized. So the key for parents is really to advocate for their children to follow these management plans. We're very excited to have these plans now, and we're hoping to disseminate this information to emergency rooms throughout the country.

MARTIN: So you're saying that symptoms can reemerge even as long as a week after the initial contact, and that's something that people maybe - that by that time you've forgotten about it. You've - so I think what you're telling us is attentiveness, you know, throughout the process and just staying on top of it. Dr. Shireen Atabaki is an associate professor of pediatrics and emergency medicine at Children's National Health System. The piece that we are talking about is published in the journal Pediatrics Today, and she was kind of to join us here in our Washington, D.C. studios. Dr. Atabaki, thanks so much for joining us.

ATABAKI: Thank you. Transcript provided by NPR, Copyright NPR.

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