Unlocking the Mysteries of Brain Injuries: Diagnostic Tests Explained

0:00:06 - Shane Smith Hey, I'm Shane from Shane Smith Law. I'm here on Mind Matters, our podcast, and I'm here with John. He's one of the attorneys here at Shane SMith Law in the brain, or concussion and brain injury group. John, we were going to talk about some of the diagnostic tests they do to determine somebody's got, basically a traumatic brain injury. Is that right?

0:00:25 - John Mobley That's correct, Shane, and that's one of the key areas that we focus on is getting our clients into the correct doctors to receive the correct testing to determine if they've actually sustained a brain injury.

0:00:37 - Shane Smith Why don't we need all this stuff? Because, like a concussion, it seems like I've seen EMTs on TV shows diagnose concussions, right, they just shine the light in your eyes and they're different. What's the difference in these kind of things we're going to do versus that?

0:00:49 - John Mobley Absolutely, and I wish it was that easy because it would make our jobs a whole lot easier. But there are definitely layers to this, and technology, and specifically medical technology, has come a tremendously long way in just the past few decades that allow us to even know more about the brain that we didn't know previously.

0:01:11 - Shane Smith And I've heard, you know it's been said before brain injuries are the silent injuries, because you can't see it, you can't even touch it. I mean it's in somebody's head. So a lot of times we've had clients who they begin to doubt themselves right and doubt they really have a brain injury or not, or doubt they think it's all in their head and I guess it technically is because the brain is there. But it's a real, legitimate injury and some of these tests show it and prove it right?

0:01:37 - John Mobley That's absolutely right. You mentioned the silent injury. It's also been referred to as the invisible injury and that's because, you know, we used- before we had access to these incredible tests, we just only knew that someone was different than the way that they were before the accident. If it was your uncle or your father, they just acted differently and we didn't really know. Yeah, we didn't know why? Right, we had no idea. And as medical technology has advanced and we can now see parts of the brain that are actually damaged and injured, we can now pinpoint the part of the brain that has either an abnormality or an injury, or a lesion or a bruise with, you know, so much more detail than we could 20 years ago.

0:02:16 - Shane Smith So, would it be fair to say, and not that doctors do this. But could a doctor pretty much look at some of these tests and the results and say I bet your uncle Joe is acting this way, or I bet he's lost his ability to talk, or I bet he's having trouble hearing, or can- are the tests that good?

0:02:33 - John Mobley That's, that's correct. At this point, the tests are that good where we can pinpoint the area of the brain that is responsible for whatever function the injured person now has a deficiency in. So if all of a sudden they start not being able to find certain words or slur their speech or have memory issues, we can now corroborate that with the actual brain scan and see if that part of the brain that controls memory and speech has been affected or has a bruise on it or a lesion. So we pair the two things up and it gives us pretty darn conclusive evidence.

0:03:20 - John Mobley That's right. Well, we don't know everything about the brain. We've got it pretty down pat what each portion and segment of the brain does to control certain parts of the body, behavior, cognitive function. We feel pretty confident, and the medical specialists do, about what the brain does in each one of those areas.

0:03:31 - Shane Smith So they broadly they know about what it is, but, and even more specifics, I guess, and they're going to continue to learn more and more, obviously, I mean, yes in the last 10 years alone, they've mountain of knowledge about the brain continues to grow exponentially, I would say.

0:03:49 - John Mobley That's right. It seems as though it's speeding up at this point, as we realize and uncover these things every year, we're just learning more and more at a much faster pace.

0:03:57 - Shane Smith All right. Well, what are some of the tests they would do on here? Because, like I say, I know the EMT test with the flashlight, but I mean, these are fancier tests, right? So right fancy or more expensive, and probably much better than that one.

0:04:08 - John Mobley Oh yeah, the one you mentioned is is something called the Glasgow Coma Scale and this is a test that you know, it's used to measure the initial severity of the injury. It's not so much used to assess if someone is sustained a mild traumatic brain injury. It's more to assess consciousness and the you know the level of emergency. So EMTs use it a lot, first responders, and the scale actually has a whole criteria list of you know- it measures eye response, verbal response, motor response and specifically, like with eye stuff, it'll look at spontaneous eye movement to speech, to spain, to pain, and it'll give you a score number and at the end, when they go through all of them, if your score is around a 15, you have a mild, mild potential brain- excuse me, mild injury. Comatose, it means that it's like eight or less and then severe would be like you're completely unconscious.

0:05:10 - Shane Smith Right. SO the lower it is, the worse it is.

0:05:10 - John Mobley That's right and we see that a lot of the times that initial score may be worse than what the EMT grades it. So sometimes we have to go back with a specialist, or if the attorney is kind of the first line of defense for some of these clients when they get a Glasgow Coma score and the defense is very quick to point well, it didn't look that bad. And then we say, well, witnesses were saying at the scene that they saw rigid arms, which is called a fencing response or some other things that would indicate a much worse score. So by the time sometimes we get them to the correct doctors they say that Glasgow Coma score was way worse.

0:05:51 - Shane Smith It would just perform badly.

0:05:55 - John Mobley Right or stuff at the scene, and this is- it's no blame on the first responders, it's just sometimes car crash scenes are hectic, sometimes a car is on fire, sometimes it's an emergency situation. Medicine's not perfect at that level. But then once we have the benefit of hindsight as 20/20, then a neuro specialist can come in and say they probably had a much worse injury.

0:06:17 - Shane Smith Because I mean an EMT, at the scene, I mean he's primarily trying to make sure you don't die and how quickly he's gotta get you to the hospital, or can he cut you loose? Not really long-term neurological effects. I mean that's not his job, I would argue at the scene.

0:06:30 - John Mobley That's exactly right, and that's not the purpose of the test either. Just to determine hey, is this person gonna make it by the time we can get them to the ER? Gotcha, that's really the case. That's the goal of that test, huh? So that's kind of the first line defense test, and then second is the CT scan, computerized tomography. We see this test done a ton, especially in the ER. Its primary purpose is to rule out neurological emergencies as well, so typically skull fractures, swelling, bleeding in the brain, hemorrhages, the real serious stuff. So this is the stuff that's gonna kill you if it's not addressed in the next hours or minutes or days, I mean that's correct and that's really the big purpose of the test, because it's not as high resolution and as strong as some of the other tests. It's equated to about like several hundred X-rays, which may seem like a lot, but when it comes to the brain there's more powerful tests out there. So it's another frontline ER test.

0:07:28 - Shane Smith So it's not also not used to determine long-term effects basically. That's not it's goal?

0:07:37 - John Mobley Correct, in terms of determining like what they deem a mild to moderate TBI. Now, it may very well diagnose a very severe TBI, like if your, you know your skull is caved in. That's obviously a very severe situation and a CT scan would pick that up.

0:07:54 - Shane Smith But I think the EMT could diagnose that too. That's pretty severe right, I mean, dude's gotta caved in skull, he's gonna- I mean so obviously it pinpoints it and makes it you know you need it. But those severe cases that are that bad, the EMT is probably gonna be pretty- and this is serious case too, everybody knows, right.

0:08:09 - John Mobley Yes, I mean that can definitely be a case where you know outward injuries to the skull or you know cave-in injuries. Those are gonna be pretty evident. I will say that you know, if the CT scan does not find a traumatic brain injury, that is not necessarily a sign that there is not a TBI. The defense attorneys and defense experts love to sometimes point to the fact that a CT scan are- not finding any significant findings means there's no traumatic brain injury. We just know that that is not the case. We just need different types of scans to show the correct injury. So unfortunately, I have to be the bearer of bad news sometimes for my clients when they say, hey, I got the CT scan at the ER, it came back clean, I'm good to go, but I'm still dizzy, still having trouble finding words. My loved ones say I'm still acting differently. So we have to explain to them: unfortunately, you may not be out of the woods yet. You may just be beginning your journey to recovery.

0:09:12 - Shane Smith If a client or somebody was in a car accident, went to the hospital, had a CT scan and it came back quote clean. That isn't, I mean, I don't want to say it doesn't mean anything, but it's certainly if you're showing symptoms of a brain injury, you definitely need to get care. You're not out of the woods.

0:09:26 - John Mobley That's right, it's great at finding those serious things we talked about, but the the long-term injuries from a mild to moderate TBI, which are very serious things themselves, are going to be caught with other imaging. That type of imaging is the MRI or the magnetic resonance imaging. Yeah, way more powerful than a CT scan and it has multiple different types of sequencing depending on what sort of thing we're looking for. Too much to get into here, but there's a lot of them out there, a lot of sequences.

0:10:00 - Shane Smith So the doctors that your specialist usually a neurologist is gonna say exactly what kind he wants or how strong that MRI needs to be. Is that what it is?

0:10:09 - John Mobley Yes, and that's why getting to a specialist is crucial, because they will have the expertise to basically prescribe the correct sequencing. Okay, because you could order the wrong sequencing, it could miss your type of injury. Okay, so a lot of times we'll see where the doctors will order a whole battery of different sequences of MRI just to make sure we don't miss anything. Okay, because this stuff is so important, lifelong permanent injuries. We just don't want to miss anything. And one of those types of-

0:10:36 - Shane Smith I was gonna say, when you talk about different sequencing, is that a different type of MRI or is it a different way? Is it the same machine, it just does a little differently? What's the different sequencing?

0:10:48 - John Mobley Yeah. So an MRI uses a combination of magnets and radio waves to basically show what's going on in the brain, and they are slightly different, but that definitely gets into the weeds. The sequencing will vary to prove different things. One of them is like a DTI, it's a diffusion tensor imaging. This is rapidly becoming the gold standard for proving MRIs. There's about over 20,000 peer-reviewed articles basically supporting it as a good way to identify brain injuries. Essentially, it measures how water moves in the brain tissue and where any of that water movement is restricted, it can pretty much clearly illustrate which part of the brain has been injured, and we find that out because it uses a 3D model. These images are just fascinating. I mean the brain is illuminated and it's greens and pinks and oranges highlighting the brain, and the specialists can literally compare each side of the brain and where one part where the water has been restricted, we know the injury is right there and then we match it up to the symptoms. And I said it before, it provides such conclusive evidence of the brain injury because we can clearly see it now on 3D imaging. The future is here.

0:12:08 - Shane Smith I was going to say it sounds like something right out of Star Trek.

0:12:12 - John Mobley It really is. It's almost to that level. It's really eye-opening, and when we first saw these reports and this type of imaging, just everyone in the industry and the community was very excited.

0:12:22 - Shane Smith Now I want to go back just a little bit to the different type of sequencing, because are you basically saying, though, if the doctor ordered the wrong sequencing, you could have a clean MRI, and if he'd ordered the right sequencing it would have shown the brain injury? Is that?

0:12:36 - John Mobley Unfortunately, that is the truth, and what that means is that a lot of the times, if your case is in the hands of someone who's not a specialist, who's not actively doing these types of cases not the right doctor, then the wrong type of sequencing could be ordered.

0:12:54 - Shane Smith Really? Okay.

0:12:54 - John Mobley And your injury. You may still have it, but we just haven't identified it yet.

0:12:58 - Shane Smith So I get my quote clean MRI. My regular doctor refers me for a brain MRI three months after the wreck and it comes up clean. I don't want to say it doesn't mean anything, but it certainly doesn't mean I'm all better and everything's in my head.

0:13:11 - John Mobley That's right.

0:13:12 - Shane Smith Just want to put that out there, because I see a lot of MRIs that are ordered and they come back clean and people are like, well good, and they feel so much better, but their family still says you're acting crazy, you're forgetting things, you're you're dizzy and they're like, yeah, but it I got an MRI that says I'm good, right.

0:13:27 - John Mobley That's right and that's why there are just so many diagnostic tests to be done, because we really have to keep striving to identify the injury, especially when the client is still complaining of these very serious symptoms. Because we know we haven't done our job and the specialist usually knows this too if we haven't identified what the injury is, especially if the person is completely different after the accident.

0:13:50 - Shane Smith And I know that's something we've strived here and our group here at the firm is making sure people are seeing not just neurologists, but neurologists who spend a lot of time on traumatic brain injuries, basically, and making sure the best specialist we can get somebody to right, who's familiar with these acute injuries and the long-term consequences of it and familiar with the science too right?

0:14:15 - John Mobley Absolutely. And that's really why we strive to find the absolute top people in their area, because we've unfortunately seen situations before clients have come to us and gone to their own neuros where they reach a dead end and it's very frustrating and you can imagine if you're in this serious injury. You're a high-performing professional or you used to be a top performer at your job and now you can hardly do half the hours you used to do. Your family says you've completely changed. Stuff at home is tough, you're forgetting appointments and you're neurologist who's supposed to be the strongest advocate for you in your corner is saying there's nothing more I can do. Or here's a handful of pills, come back in two months. That doesn't fit a lot of people's schedule and recovery schedule and that's why we try and find the best neurologist and just know the network and be familiar with the area.

0:15:07 - Shane Smith I was gonna say that's one of the things that frustrates me the most is when somebody says: "my doctor said there's nothing else to do" and I'm like, well, we don't have answers yet, we gotta keep digging or we gotta keep doing something, or we need to see a different doctor or see a fancier doctor, I mean a more specialized doctor or something, and because "there's nothing else I can do and here's some pills" is terrible, right. That's a lifelong sentence.

0:15:29 - John Mobley That's right. We're not really in the business of allowing our clients just to mask pain with pills. We wanna find answers. We owe it to the client. The client wants that, we all want that. So these diagnostic tests allow us to kind of push further and further to get those answers that we need, because that's what we need to prove our damages in the case. That's what we need to, just when the client is going home at the end of the day, just to know what is causing these symptoms is such a relief, so they didn't know that, like you said, it's not just in their head. These are very real things and we can actually point to it because we now have the correct image order that shows where the injury is.

0:16:35 - John Mobley So there's actually some additional tests out there. One is the VNG, which is the videonystagmography, and that is one that is used in order a lot when we see our clients have balance issues, or it can be used to assess abnormal eye vision. You may have heard of this word, nystagmus. It's the same test actually, the horizontal gaze nystagmus that officers use when they're assessing a DUI, because the eye will actually flutter a little bit. And that happens too when you're drinking, but it also happens when you have a brain injury. Crazy.

0:17:26 - Shane Smith And you say that I've had clients before where their neurologist would actually give them a card that said they've been received a brain injury, because they got pulled over and had to go through the whole test and the client got arrested. Oh wow, so that particular neurologist started giving out cards that said I've got a brain injury, and it was like if you're you know, could pull over for something. Give this to the officer, so they you know, know it's legitimate kind of deal. Because, like you say, it's the same evidence either you're inebriated or you've got a brain injury. Wow, yeah.

0:17:58 - John Mobley That's interesting, and another test they used to is something called an EEG, which is an electroencephalogram. That's where they put little wires on your head and they will monitor brain waves to see if there's anything abnormal there. We see that one less, but some neurologists use it quite a bit. I've heard that it's- it's good to distinguish PTSD symptoms from TBI symptoms. Sometimes there can be some overlap there and it's good to distinguish. One area that we're all and some of my colleagues are excited about is the blood test, because sometimes these, what we're finding out more and more is that these brain injuries can cause actual hormonal changes in the brain and that can present as biomarkers in the blood, and a lot of people, a lot of specialists, think this may be the future brain injury test because it's quick and easy.

0:18:45 - Shane Smith I mean I don't want to say I mean, but it is they take some blood and send it off, right?

0:18:50 - John Mobley And if you think about it, I mean with some of these diagnostic tests you know there's some exposure to, a little bit of exposure radiation, but it's considered worthwhile to take the brain injury. With blood type style testing, you're right, way less invasive, probably cheaper. So we're kind of crossing our fingers and are holding our breath that some of these newer tests that are blood related have some good results and may be the future.

0:19:13 - Shane Smith And I would think honestly, if it's a blood type test, your primary care doctor, if they thought you had a concussion, could take the blood and set it off right. You wouldn't even have to see a neurologist if your doctor was trained and aware and, I guess, looking for those types of injuries right.

0:19:27 - John Mobley That would absolutely honestly be the hope. It means that we would catch so many more brain injuries if it was just more readily available, cheaper and easier, to the point where it's like a standard panel that your primary care physician or even who knows an urgent care, go over for you. That would make our jobs way easier in terms of catching these things.

0:19:46 - Shane Smith All right, yeah, so we've talked about a ton of tests here that could be used to diagnose and find a brain injury, from the general, you know, early stages, to something much more specific and more focused is what I would say. We missed any of them?

0:20:02 - John Mobley Really, the last one that we see used a lot of is something called a Neuropsych Test. This is the test before we had all these fancy, expensive imaging devices. It's basically like a PhD or a PsyD. Those are the credentials of these very smart people that conduct these. They implement, a standardized test and that standardized test is done and it looks at all forms of cognitive abilities like memory recall. It's a long test and it's expensive and clients would do these. This is before these imaging. It is actually still done today and supported. Now the issue is that the test is very run-of-the-mill and standard. However, the interpretation of it is up for heavy debate, and what I mean by that is that a lot of times our client will have a treating doctor or the defense will go out and they will hire a, hired gun a defense expert to basically interpret those results in a way that were to say you do not have a brain injury. You're making all this up. We see it time and time again so it becomes a real battle. That's why we're loving these new tests, because they are way hard to argue against. It's way harder for the defense to muddy the water when I have a clear 3d model image showing the part of the brain that's injured and it matches up to my client's symptoms at the scene.

0:21:25 - Shane Smith Because and I'm just gonna play the other side right or ask this question: we usually have correlation. I mean we have the client's symptoms before the test is run right, so these are in the records. Everything is documented, what the client is struggling with. Then they get the test results and they confirm everything's going on with the client. It's not like you just go in and get this fancy test and then afterwards you're like oh well, I can't remember anything, but it would be hard to fake all that in advance, right?

0:21:51 - John Mobley That is, that is truly the key Shane, and that's the thing is that you know, we have these clients that give us all these symptoms at their first or second doctor's visit. They don't get this imaging usually for months down the road, and so it's very insincere sometimes when the defense says that our clients, you know, aren't as injured, or they say they are, they don't have the symptoms. Because it's very hard for someone that doesn't have all these degrees and is a specialist to know all the parts of the brain that they were having injuries in complaining of those complaints and then later get an image and it's that exact part of the brain that controls the symptoms they complain about Sounds a little ridiculous when you uh, when you spell it out like that, yeah, and it. That's why the defense does not like these imagings and they fight, fight to keep them out, because it's, it's very conclusive.

0:22:37 - Shane Smith John, one thanks for coming on the show and talking on Mind Matters and it's always great to learn about, you know the the brain and concussions and TBI and how it affects the law. For our listeners, hit like and subscribe down below for more future updates from Mind Matters. And I'm Shane from Shane Smith Law.