Is a Patient With a Concussion Admitted to the Hospital?

Recently, I finished a book that included the following medical scenario. The main character fell into a river and suffered a broken arm and concussion. During her ER visit, the doctor tells her she needs to be admitted overnight for observation because of the concussion.

This is a common medical myth (along with the one that a CT scan is required in all instances of head injury– it’s not.)

A simple concussion does not need an overnight hospital stay. Let me qualify what I mean by simple. You receive a hit on the head and have one or some of the following global symptoms (dizziness, headache, nausea, vomiting, and amnesia to the events.) Global symptoms mean more than just the bump on your head hurts.

This is really how concussion is diagnosed. CT scan is reserved for concerns of bleeding and/or fracture that might require a neurosurgical intervention. Typically, symptoms associated with bleeding and fracture are persistent and more dramatic. Headache pain is not relieved with medication and/or worsens. There is more than one episode of vomiting. Persistent confusion. Perseverating– saying the same thing over and over. Inability to move part of the body. Decreased responsiveness. Amnesia that doesn’t improve.

A patient with a simple concussion is monitored in the ER for several hours. Typically, we’ll give them medication based on their symptoms to see if they improve. For instance, a patient that has nausea, headache and dizziness will get an anti-nausea medication and an over-the-counter pain reliever like Tylenol or Ibuprofen. If their symptoms improve and/or resolve and they can hold something down to eat then they are discharged home with instructions on when to return to the ER.

In order to be admitted into the hospital the patient must exhibit severe, persistent symptomology and/or have bleeding and/or fracture.

In absence of these, the patient will be discharged home.

Head Injuries: Jason Joyner

There was that time when the editor saved the medical professional.

As a physician assistant, I enjoy having medical aspects in my story. But even medical folks can slip up and have errors in our fiction.

I have a scene where my heroine gets head trauma and wakes up later in the clutches of the villain. The freelance editor, Ben Wolf, wondered about that. He had read that if there was significant time of loss of consciousness (LOC), then it suggested a serious injury that would be hard for the victim to bounce right back from to be active.

One of my pet peeves is when characters are injured and recover too fast, so I had to look into this again.

Basically, my heroine suffered a concussion, also known as a Traumatic Brain Injury (TBI). Symptoms of a concussion can include headache, confusion, dizziness, visual changes, a blunted affect, and may or may not include LOC. (People always flash lights in pupils to check for concussion. If the pupils are affected, it is a serious sign and they won’t be up and active soon.)

LOC usually is only for a few minutes, and as my editor noted, will mean a much more severe injury if it lasts for hours.

Blast. Foiled by the editor.

Except, you can use the amnesia angle.

A concussion with LOC may have retrograde (before the incident) or antegrade (after the incident) amnesia. According to one research article, the antegrade amnesia can last for a few hours after the incident. I can attest – I had a concussion in 5th grade and couldn’t remember a couple hours afterwards.

So if you need your protagonist to be out of it for a while, keep the actual LOC on the short side and use the amnesia angle to get you where you need to be. The victim may be incoherent, unsteady, with a blank expression during this time. Use these symptoms to add drama to the situation.

When your protagonist comes to, it is actually the end of antegrade amnesia. I remember with my concussion it was like I “woke up” after lunch during our quiet reading time at school. I was confused, unsure of what happened. I could remember part of the morning, but about two hours was blank. I even found a goose egg on my head later, but I didn’t know how it got there.

So that was my work around. My heroine didn’t have LOC the whole time. But there was enough injury to cause confusion and amnesia, keeping her from attempting escape. There you go Ben. A few minor tweaks, and all is well. Except for my heroine, who’s tied up and threatened. But that’s another story.


Jason loves good stories and wants to use words to make a difference. When he’s not writing, playing soccer, or losing in fantasy football, he works as a physician assistant in southeast Idaho. He also tries to keep up with his awesome wife, three high-energy boys, and his little princess. He writes suspense and YA supernatural, and likes to use his medical experience to punch up the stories. You can find him on Twitter @JasonCJoyner or his blog at

Author Question: Assault Injuries

Author Question: My MC, a 17 year old female, is beaten up by her father. He was drunk, angry, so backhanded her across the face, which knocked her into a bookcase. Then while she was on the floor he kicked her repeatedly with sharp-toed cowboy boots, though runs out of steam fairly quickly and goes off to his bedroom. (She managed to curl herself into a ball to protect her internal organs.)

So right now this is what I’m looking at for her injuries:

1. Mild concussion (from hitting a shelf with her head — this would also possibly produce a small cut/gash because the edge of the shelf is sharp.)
2. Bruising to the face (from where he backhanded her.)
3. Broken ribs (I have 3 for now — is that too much?)
4. Pneumothorax from one of the ribs — just punctured, NOT collapsed.
5. Crack in the mid-shaft humerus of her right arm (from being kicked.)
Lots of bruising (obviously.)
First of all, are these injuries plausible given the scenario?
Jordyn Says:

These are a “good” array of injuries that would be plausible as a result of this type of beating. However, you can’t have a punctured lung without some amount of air getting out. It may be a small amount that would not require chest tube placement but there would likely be some if the lung were “punctured”. That’s likely the only way the medical team would know the lung was punctured was by evidence of air on the chest film. So, it might be easier to just go with cracked ribs.

Question: Would she be able to drag herself a few feet across the living room to get her father’s cell phone (left on a table), then crawl out the front door to the porch (the living room is just inside the front door)?

Jordyn: Yes, she should be able to do this.

Question: What might she experience? (Obviously pain, but I would assume she would have a great deal of trouble breathing, get oxygen-deprived, light-headed, nauseated …)

Jordyn: Yes, great pain. Rib fractures are quite painful and inhibit a person from taking full breaths so the patient tends to take more shallow breaths to prevent the pain. This could lead to lightheadedness (as well as the head injury), increased breathing rate, and increased heart rate (from pain, anxiety, fear.) If you go with a more serious lung injury (like a collapsed lung) then this could lead to lower oxygen levels, increased work of breathing, and diminished level of consciousness.
Question: What would be the ER procedure when she is brought in by her best friend’s family? It’s a very small-town medical center that barely qualifies as a hospital. When she’s brought in the staff is already busy on a multiple-patient car accident. Would it be plausible for the ER team to keep her waiting for a while after they take her back to an exam bay? Or would they worry about internal injuries and get her x-rayed right away? (As I said, it’s small-town, so goof-ups are possible.)

Jordyn: It depends on her presenting condition. If she’s awake, alert and oriented and doesn’t appear to be in imminent distress (such as significant difficulty breathing from whatever lung injury you choose) then it is plausible for her to wait while the car accident victims are being taken care of.

An ER evaluation is going to include vital signs, a medical history and history of the event, and then targeted x-rays for everything that hurts. So, chest film and right arm films at the least. Her head wound wound be irrigated and stitched closed if needed. Staples would be used if the wound is in the scalp. Tetanus shot needs to be within five years. CT of the head isn’t necessary for her head injury unless she has a focal neuro deficit (like I can’t move one arm) or unconsciousness. Depending on the x-ray results– her arm, at a minimum, would be placed in a sling until pain resolves. A stable fracture to the humerus can’t be splinted– only placed in a sling. 
This is the basics any ER should cover. 
This beating is a reportable injury so if the police haven’t been contacted– the ER staff should do so.
Question: The way I wrote it in the original draft was that she was taken to an exam bay right away, but then left to wait for a couple of hours. Then she was x-rayed and because of the pneumothorax, was taken back to a procedure/operating room to be intubated. The doc and a nurse came in while she was being prepped, to tell her friend’s family what her injuries are. (Would they put a cast on her arm? At what point would that happen, before or after the intubation?)
And then, how long would she be in the hospital?

Jordyn: Intubation is not the primary treatment for a collapsed lung– otherwise known as a pneumothorax. Placement of a chest tube is. This is what is required to safe the patient’s life. If you intubate and don’t place a chest tube the patient will die anyway because they will continue to accumulate air into their chest– especially with positive pressure ventilation– the machine forcing air into your lungs. Usually, just placement of a chest tube is enough.

A sling to her arm as noted above.

And then it depends (as with all things in medicine) how long the chest tube would stay in. I would say three-five days at the shortest. The lung has to re-expand, it has to stay expanded off suction, then the tube is removed. The patient is watched maybe one more day to make sure the air doesn’t come back.

Author Question: What Type of Injury?

Pat I. Asks:

I needed help with a scene for my book and Bonnie said you might be willing to share your nursing expertise.

The scene– in an early American historical:

 A young woman has a sack thrown over her head. In the next instant, her head is pushed down and she’s driven forward into a tree trunk face/head-first.

She’s found a few minutes later unconscious and the sack is removed. What kinds of injuries would she sustain?

I’m hoping such a blow is not hard enough to kill her or give her a skull fracture (attacked by another woman of equal strength), but wonder about sustaining a concussion? Also what kind of bruises on face or nose?  

Thanks so much for taking the time to help me out with this!

Jordyn Says:

The frontal bone is the thickest part of your skull and therefore hard to fracture. A concussion is reasonable to give her if you’d like. These would include global headache (not just pinpoint to the area her head hit the tree trunk), nausea, vomiting, confusion, balance problems etc.Also a broken nose would be reasonable if she took the brunt of this blow there.

The covering over her face will provide a barrier to direct injury from the tree especially if it’s just one quick smack and not repeated. What I would imagine would be some bruising/swelling to the area that was hit. Maybe some abrasions. You can get burst type lacerations (like when a kid pops his chin open) just from pressure so this would be reasonable, too. You have some leeway with what you’d like to do.