One of our primary areas of practice is brain injury litigation. We offer absolutely free legal consultations and you do not pay until we win your case.
The statistics for brain injury are staggering. Approximately 450 Canadians suffer a brain injury every day. For Canadians under 40, acquired brain injury is the leading cause of death or permanent disability. Most people who sustain a brain injury are never able to return to work.
At Handel Law Firm, we take an active role in developing a community health care team dedicated to your rehabilitation, care, and the welfare of your family.
Drawing on our extensive network of health care providers in the community, we ensure that you not only have the best legal representation but the best health care team available. We will connect you with a rehabilitation team that is fully committed to your treatment and long-term well-being.
- WE UNDERSTAND fully that communicating with a personal injury victim who has suffered a brain injury presents significant obstacles which a lawyer must overcome to ensure that the victim receives proper compensation, which can only be done if a lawyer fully understands the situation of the brain injured victim.
- WE UNDERSTAND that a traumatic brain injury victim may have a lot of functional challenges impacting their communication, but it does not mean they are necessarily any less intelligent. The best place to start is by asking where to start. Not all individuals with a brain injury have the same problems.
- WE UNDERSTAND that the lawyer should be aware of the client support network and work with that support network to ensure proper communication with the brain injury victim, and add to that support network where necessary. Brain injury societies throughout Alberta have been helping individuals and families deal with the effects of traumatic or acquired brain injury. Often founded by families whose children sustained brain injuries, these brain injury societies are registered charities which provide support and services free of charge to individuals and families who are living with the effect of acquired brain injury.
- WE UNDERSTAND figuring out what works best for both sides is essential. We are aware through extensive experience that it typically takes longer for a brain injury victim to get information in, to understand it, sort it out, and come up with a response. Thus, telephone calls should be kept short and simple and it is better for the personal injury lawyer to communicate with the brain injury victim in person.
- WE UNDERSTAND that when communicating in person it is important that there be a quiet and uninterrupted environment as distractions or noisy environments can cause far greater disturbances for the brain injury victim than for the average person. Another option is we will come to the brain injury victim’s home during any communication requirements.
- WE UNDERSTAND memory can be affected in individuals with a traumatic brain injury and there are several approaches which may be taken to alleviate this problem. One, we ask the brain injury client to write down any issues or questions they have in advance of the meeting so nothing gets overlooked. Two, WE DO NOT RUSH. Rushing is not an option when a person has a brain injury. Extra time will be required to ensure the brain injury victim is fully informed and understands what is going on.
In communicating we will maintain a natural volume of voice and natural relaxed rate of talking. At the same time the victim should not pretend to understand when they didn’t understand. Seek clarification from the lawyer. We will recap what has been talked about. If necessary, we will repeat the message as required or present the message in a different way.
Finally, it is always helpful for the brain injury victim to have the trustee or guardian present, or if there isn’t one appointed, then to have a friend or family member there to assist with the understanding and communication process. We are here to provide help and hope.
Mild Traumatic Brain Injury
WE UNDERSTAND that not all brain injuries are severe or moderate brain injuries and that many brain injuries are less severe – known as Mild Traumatic Brain Injury (MTBI). In our opinion this medical label is misleading as when it comes to the brain there is no such thing as a “mild” brain injury!
A patient with mild traumatic brain injury is a person who has had a traumatically induced physiological disruption of brain function, as manifested by at least one of the following:
- Any period of loss of consciousness;
- Any loss of memory for events immediately before or after the accident;
- Any alteration in mental state at the time of the accident (e.g. feeling dazed, disoriented, or confused);
- Focal neurological deficit(s) that may or may not be transient; but where the severity of the injury does not exceed the following:
- loss of consciousness of approximately 30 minutes or less;
- after 30 minutes, an initial Glasgow Coma Scale (GCS) of 13-15;
- posttraumatic amnesia (PTA) not greater than 24 hours.
This definition includes:
- The head being struck;
- The head striking an object;
- The brain undergoing an acceleration/deceleration movement (i.e.: whiplash) without external trauma to the head.
It excludes stroke, anoxia, tumor, encephalitis, etc.
Computed tomography, magnetic resonance imaging, electroencephalogram, or routine neurological evaluations may be normal. Due to the lack of medical emergency, or the systems, some patients may not have the above factors medically documented in the acute stage. In such cases, it is appropriate to consider symptoms that, when linked to a traumatic head injury, can suggest the existence of a mild traumatic brain injury.
Brain Injury Symptoms
The above criteria define the event of a mild traumatic brain injury. Symptoms of brain injury may or may not persist, for varying lengths of time, after such a neurological event. It should be recognized that patients with mild traumatic brain injury can exhibit persistent emotional, cognitive, behavioral and physical symptoms alone or in combination, which may produce a functional disability. These symptoms generally fall into one of the following categories, and are additional evidence that a mild traumatic brain injury has occurred:
- Physical symptoms of brain injury (e.g. nausea, vomiting, dizziness, headache, blurred vision, sleep disturbance, quickness to fatigue, lethargy, or other sensory loss) that cannot be accounted for by peripheral injury or other causes;
- Cognitive deficits (e.g. involving attention, concentration, perception, memory, speech/language or executive functions) that cannot be completely accounted for by emotional state or other causes;
- Behavioral change(s) and/or alterations in degree of emotional responsiveness (e.g. irritability, quickness to anger, disinhibition or emotional lability) that cannot be accounted for by a psychological reaction to physical or emotional stress or other causes.
Some patients may not become aware of, or admit, the extent of their symptoms until they attempt to return to normal functioning. In such cases, the evidence for mild traumatic brain injury must be reconstructed. Mild traumatic brain injury may also be overlooked in the face of more dramatic physical injury (e.g. orthopedic or spinal cord injury). The constellation of symptoms has previously been referred to as minor head injury, post concussive syndrome, traumatic head syndrome, traumatic cephalgia, post-brain injury syndrome and post-traumatic syndrome.
- Thomas Kay, PhD, Senior Contributor
- Douglas E. Harrington, PhD, Committee Chair
- Richard Adams, MD
- Thomas Anderson, MD
- Sheldon Berrol, MD
- Keith Cicerone, PhD
- Cyntkia Dahlberg, MA, CCC
- Don Gerber, PhD
- Richard Goka, MD
- Preston Harley, PhD
- Judy Hilt, RN
- Lawrence Horn, PhD
- Donald Lehmkuhk, PhD
- James Malec, PhD
Limitations of the Glasgow Coma Scale in MTBI Cases
The Glasgow Coma Scale (GCS) was developed by Jennett and Teasdale and was first published in the journal Lancet in 1974. The GCS has become the universally accepted measure of the level of impaired consciousness following a brain injury and is graded as follows:
Glasgow Coma Scale
Eye opening (E)
- Spontaneously = 4
- To verbal stimuli = 3
- To pain = 2
- Never = 1
Best motor response (M)
- Obeys commands = 6
- Localizes pain = 5
- Flexion withdrawal = 4
- Flexion abnormal = 3
- Extension abnormal = 2
- No response = 1
Best verbal response (V)
- Orientated and converses = 5
- Disoriented and converses = 4
- Inappropriate words = 3
- Incomprehensible words = 2
- No response = 1
Coma score (E + M + V) = 3 to 15
A GSC score of 13 or higher generally correlates with a mild brain injury, 9 to 12 is a moderate injury and 8 or less a severe brain injury. However, the originators of the GCS have recognized its limitations at the higher range of the scale.
The Extended Glasgow Coma Scale (GCS-E)
It is now recognized that an altered state of consciousness can result in MTBI that is not detected by the traditional GCS due to its insensitivity to milder brain damage. The greater sensitivity of post traumatic amnesia (PTA) as a more reliable measure of MTBI has led to the creation of the Extended Glasgow Coma Scale (GCS-E) by the authors of the original GCS.
The authors of the GCS-E stated:
A severity index that is more sensitive to the nuances of mild TBI would help resolve the controversy with regard to the sometimes severe consequences to which mild and even very mild brain injuries may give rise. A person with a GCS of 15 on admission or soon thereafter, even if amnesic and hypo-aroused [diminished arousal], may be prematurely discharged. Symptoms such as irritability, unreliable memory, and greater fatigue that develop in the days and weeks after discharge are likely to be attributed to malingering or post-traumatic stress rather than to a concussion syndrome. In developing countries, where there is especially high reliance on the GCS, an admitting score of 14 or 15/15 will often result in a denial of compensation claims, even if the victim is unable to return to employment.
Nell, V.; Yates, D.W.; and Kruger, J. “An Extended Glasgow Coma Scale (GCS-E) With Enhanced Sensitivity To Mild Brain Injury”. Arch Phys Med Rehab, 2000, Volume 81, 614-617.
The GCS-E was developed with the support of the World Health Organization Advisory Group on the Prevention and Treatment of Neurotrauma that has adopted the GCS-E as an optional diagnostic variable for the revision of the “Standards for the surveillance of Neurotrauma”.
The GCS-E defines 8 levels of PTA and assigns a score that is added to the traditional GCS score. The levels of amnesia are set out in the “Amnesia Scale”:
- 7 No amnesia: client can remember impact, can remember falling and striking a solid surface, etc.
- 6 Amnesia for 30 minutes or less: client regained consciousness while still in vehicle, in street at scene of incident, in ambulance, or on arrival at hospital.
- 5 Amnesia of 30 minutes to 3 hours: remembers arriving at emergency room, admission to ward, etc.
- 4 Amnesia of 3 to 24 hours: determine duration by content of the first memory, which will be for an event in the ward or other hospital procedure.
- 3 Amnesia of 1 to 7 days.
- 2 Amnesia of 8 to 30 days.
- 1 Amnesia of 31 to 90 days.
- 0 Amnesia greater than 3 months.
- X Cannot be scored: e.g. can speak but responses are inappropriate or unintelligible, cannot speak because unconscious, intubated, facial fractures, etc.
In applying the GCS-E, the GCS is first taken in the usual manner. The “Amnesia Score” is then taken and entered after the GCS. For example, if the GCS was 15 and the PTA was 30 minutes, the GCS-E score would be 15:5. The GCS-E recognizes that the duration of amnesia (PTA) is an indicator that a person is not laying down permanent memory and accordingly has suffered an alteration in brain functioning. This information is important in more accurately assessing the degree of brain damage. As Jennett and Teasdale stated in their text:
Altered consciousness soon after injury is the clue to the brain damage already suffered. When first seen in the emergency department it is useful to record whether the patient is talking. If he is talking, is he orientated and rational? And if he is, can he remember everything about, and since, the accident? Amnesia for even a few minutes after a blow to the head is evidence of diffuse brain damage.
Jennett, B. and Teasdale, G. “Management of Head Injuries”, Contemporary Neurology Series, Vol. 20, F.A. Davis Co., 1981, 96.
Since 1989 the limitations of the GCS in the assessment of MTBI have been noted and published by its creators, Jennett and Teasdale. Yet in the following 12 years the GCS has continually been applied to exclude diagnosis of MTBI. Clearly there may be legitimate differences of opinion between qualified experts as to whether some individual falls into the category of the 10 to 15 percent of victims who do not recover from a MTBI (sometimes referred to as the “walking wounded” or the “miserable minority”). However, with advances such as the GCS-E the medical community will be better equipped to accurately diagnose MTBI following a traumatic event. Hopefully this will lead to fewer false negatives in the diagnosis of MTBI, which can leave the victim of a MTBI without recourse to appropriate treatment or adequate compensation.
At Handel Law Firm we will ensure you receive the appropriate compensation that your situation deserves based on the best medical evidence and our extensive knowledge of legal case precedents for brain injury compensation.