The consultant signalled the code to me through the locked hospital door, four numbers for the combination lock. I couldn’t interpret the hand signals so they opened the door, and we laughed it off. It was 1 week after I was in a significant car accident; I was euphoric at being alive and back at work again (although limping). I had just started my last hospital rotation as a hospital medical officer prior to becoming a general practice registrar.
Later that day as the shift came to a close, I struggled to multi-task. As the week progressed, I deteriorated until my working memory could hold just two digits. I felt slowed and couldn’t interact spontaneously. Something was very wrong, and I began to realise that I had post-concussion symptoms.
I knew very little about the potential consequences of concussion. Which was unfortunate, because for me a major trauma of my concussion was that it impacted my ability to research and problem-solve. By that point even reading a patient information leaflet was beyond me. I recognised headache, confusion, nausea/vomiting and dizziness as possible symptoms – but not the photo- and phono-sensitivity, vestibular-oculomotor symptoms, sleep disturbance, irritability, autonomic dysregulation, and I vastly underestimated the disabling fatigue and headaches to come.
My symptoms fluctuated. I didn’t appreciate the ‘boom-bust’ cycle then, and it was my custom to push through with a ‘mind over matter’ mentality. Eventually I learned that, for me, attempts to push through led to days of excruciating headaches, extreme fatigue, and any noise (even a car passing by) was tortuous. I couldn’t listen to music or audiobooks, I couldn’t read or look at screens; communication was difficult. I lay in bed and survived the minutes, hours, and days of each symptom flare-up until I was able to get out of bed for most of a day … only to unwittingly make the same mistake again. Optimistically expecting each flare to be the last I was frustrated and impatient to get back to normal – mum to three children, organising Christmas, summer and back to school, and trying to get back to work to complete my hospital rotation and begin my general practice work as scheduled.
These experiences inspired me to use my time at the Australian Journal of General Practice (AJGP) to compile a focus edition on concussion, a form of a mild traumatic brain injury (mTBI). This focus issue highlights aspects of acute and post-acute concussion care. The paper by Bhasin, Huang and Scoble1 discusses the management of common symptoms, as well as key concepts in promoting recovery. The RACGP-endorsed Australian and New Zealand (ANZ) concussion guidelines provide general practitioners (GPs) with evidence-based strategies appropriate to each step of the patient journey, as described by Barlow et al.2
There is growing recognition of longer-term effects of concussion; even at 6 months post-injury, half of the adult patients presenting to hospital with mTBI have not recovered to their pre-injury health.3 Starting rehabilitation, albeit almost 2 months after my accident, helped enormously. My rehabilitation team educated me about my symptoms, identified issues I hadn’t appreciated and validated ones I had. The team reassured me that although I felt cognitively slowed and quite frankly completely stupid and useless, I probably didn’t seem quite that bad to others and I would get better. My own GPs have supported me through it all. The role of the GP as a coordinator of care and the value and challenges of multidisciplinary care are discussed by Barlow et al.4 Where recovery is delayed, or there are risk factors for delayed recovery, referral to a neuropsychologist should be of benefit, as outlined by Anderson and Adronis.5
Concussion as an mTBI is a very individual and potentially isolating experience – and the effects can be invisible to others. For me, there was nothing mild about this experience – it impacted every aspect of my existence, physical and psychological. It smothered my sense of self as an independent capable adult, while impacting my ability to process what was happening to me. Normal experiences were distorted – suddenly I couldn’t watch my child’s tennis match or tolerate the complex and busy environment of a supermarket or a hospital. I couldn’t take my son to a concert, couldn’t play football or even run, couldn’t climb over rocks on the beach and had no chance of quipping a witty observation.
I was unable to evaluate my condition and advocate for myself. It wasn’t hard to describe improvement in my symptoms compared to my worst days, and I would often downplay my symptoms as ‘improving’. Perhaps as doctors we are attuned to how much worse things could be. It is only in retrospect that I can appreciate how much I still needed to recover even 12 months post injury.
As GPs we identify and explain post-concussion symptoms to patients and their carers. Specific issues for paediatrics are addressed by Charles et al6 from the Murdoch Children’s Research Institute (MCRI) and also by Bhasin et al1 in their section on return to study. I recall a teenager describing classic symptoms at school in the week after a known concussion; when they tried to leave the overstimulating classroom environment they were stopped and labelled as trying to skive off. How might this situation be different if it were a child of 8 years dealing with persistent post-concussion symptoms that were recognised only as behavioural issues – what impact might that injury have on their subsequent development and life potential?
This focus issue highlights timely and multidisciplinary concussion care for adults and children, with contemporary practical resources for GPs and lay people referenced throughout these papers. Emerging research3 may change how we identify and triage patients with concussion/mTBI in the future – for example early detection using biomarkers, screening for pituitary dysfunction, and recognition of longer-term health and quality of life impacts of concussion. What won’t change is our role as GPs in offering informed, evidence-based guidance, treatment and patient-centred care to individuals experiencing an mTBI.