That's gonna leave a mark.
While grabbing dinner one night, your friend kneels down to tie his shoe and, as he sits back up, smacks his head against the table—hard. He feels a little dazed, but insists he's okay. It doesn't help that the restaurant has the game on—he’s heard enough about the "concussion crisis" among NFL players. But your buddy didn't get sacked by some 350-pound lineman. He just rang his bell in a totally average, klutzy way. So how worried should he be?
Here’s a caveat that’s often lost in news coverage of concussions: A "concussion" is not a medical diagnosis. It’s not like a stroke or a heart attack where the body undergoes a process that has a set path, during which medical professionals, in all cases, must intervene to mitigate damage.
"Saying you 'have a concussion' doesn’t mean anything specific," says Douglas H. Smith, director of the Center for Brain Injury and Repair at the University of Pennsylvania’s Perelman School of Medicine. "It’s more like an opinion that there is damage to the brain’s network." Because of this, the term "traumatic brain injury" is sometimes preferred.
The personality-transforming, mentally-stagnating effects of head trauma so often in the news usually refer to the effects of repeated concussions endured over years by wrestlers, boxers, and football players. A single instance is a different type of medical situation, Smith says. Some reports estimate that there are four to five million new cases of traumatic brain injury in the US each year. But doctors are still learning how to record and universally classify such injuries, Smith says, so those numbers are probably low. The effects of most of these are not severe and pass in a few hours, Smith says.
There are rare cases where a single hit to the head causes cerebral hemorrhaging (more on that in a moment). Bleeding within the skull presses down on the brain, requiring immediate emergency care. Generally, your friend will know when he’s experiencing this—from the seizures, incoherence, and vomiting that can accompany it. “It’s a lot rarer than a typical concussion and the symptoms are usually more extreme,” says Richard A. Figler, co-medical director of the Concussion Center at the Cleveland Clinic.
If your friend is experiencing dizziness and headaches and is unsure if it's serious enough to warrant a copay and a doctor’s time, he has a luxury that victims of heart attacks and strokes don’t: He can wait and see if things persist or get worse. “See how symptoms are in an hour or so,” Figler says. “It doesn’t make a difference in the outcome.” In most cases, the damage from a concussion is over after the whack. Even though the effects can linger and necessitate months of rehab, there’s usually not much an emergency physician can do in the immediate aftermath of a mild head injury.
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Symptoms to monitor include headache, dizziness, confusion, fatigue, nausea, slurred speech, ringing in the ears, temporary loss of consciousness, and amnesia about events leading up to the injury. The concussion-determining “sidelines tests” of sports teams often include the Maddocks Score questionnaire, which asks some basic short-term memory questions: “What venue are we at today?” “Who scored last in this match?” “Did your team win the last game?”
The effects of a concussion can also come on days after the event. “While you might feel okay the day after bumping your head, symptoms could later develop the next couple days with different activity,” says Alicia Sufrinko, a neuropsychologist in the University of Pittsburgh Medical Center’s Sports Medicine Concussion Program.
In some cases, Sufrinko says, the person will not notice serious impairment until attempting an activity requiring focus, like reading or using a computer. Symptoms may also emerge when the person enters an environment requiring more mental engagement, like a workplace or crowded street.
For those with long-term damage from a concussion, there’s an exhaustive schedule of rehab work and medical intervention ahead. Smith says that because the brain is so mysterious and neurologists are just beginning to understand the effects of trauma, there’s no definitive prognosis or set of expectations.
The Worst That Can Happen
In 2009, actress Natasha Richardson was skiing near Quebec when she tumbled and hit her head. She seemed fine and casually returned to her hotel, where she walked and conversed normally. Hours later, Richardson complained of a severe headache. She was airlifted to a New York hospital and, a few days later, died from hemorrhaging in the brain.
The Richardson case horrified many people into thinking a tiny fall could silently start a mechanism towards death. Some news stories included the terrifying non-medical term "walk and die syndrome."
While there are other cases like Richardson's, usually cerebral hemorrhaging does not play out in such a quiet way, Figler says. Seizures and vomiting are not uncommon when blood is putting pressure on the brain. It's particularly important to look for hemorrhaging in elderly patients and people taking blood-thinning medication, he adds. But in most instances, you’d know if you have a situation as dire as a cerebral hemorrhage.
What You Should Tell Your Friend
Lay down for a while. You aren’t losing precious time as you would be if this were a stroke. If, a few hours after you hit your head, you still feel dazed, can’t focus, can't recount the day’s events, or you feel some other powerful and persistent symptom, get a ride to the ER.
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