What is the Glasgow Coma Scale?

Often times on television and in movies, you’ll hear a medical character exclaim, “His GCS is 5!” or some other variation. What is this score? What does it mean for the patient?

The Glasgow Coma Scale (GCS scale) is one way to gauge the significance of brain injury. There are three components to the measurement. Eye Opening. Verbal Response. Best Motor Response. In general, the highest score is 15. The lowest score is 3. You can be dead and still score a 3 so the higher the score the better.

Eye opening looks at four components and each is given a score:
4: The patient opens their eyes spontaneously.
3: The patient opens their eyes after being spoken or shouted to.
2: The patient opens their eyes to a painful stimulus.
1: No eye opening at all.

Verbal response looks at five components:
5: The patient knows person, time and place.
4: The patient can speak but is not oriented.
3: Speaks unintelligibly.
2: Moaning.
1: No verbal response.

Best motor response looks at six components:
6: The patient can obey a two part request such as touch your nose and then your shoulder.
5: The patient moves to push away a stimulus. For instance, if I’m starting an IV in your left hand, you take your right hand to push it away. This is called localizing pain and the patient usually needs to move across their midline or above their clavicle (if the stimulus is placed to the head) to score here.
4:  Pulls extremity away from pain.
3: Abnormal flexion.  Also referred to as decorticate posturing.
2: Abnormal extension. Also referred to as decerebrate posturing.
1. No motor response.

Initially, we might look at the overall score to determine whether or not a patient needs to be placed on a breathing machine. Generally, a score equal or less than eight is used as a cut off point. The lower the initial score, the more likely the patient will be intubated. Over the long term, the GCS can be used to trend improving or worsening neurological status.

Have you ever heard this scale used on television or in a movie?

Medical Review of the Movie Flatliners 1/2

Flatliners 2.0 released in October, 2017. If you haven’t seen the movie (or the original from 1990) then you may not want to read this post as there will be spoilers involved.

Flatliners centers around a group of medical students who become curious with the phenomenon of near death experiences (NDEs) to the point that they “flatline” one another so that they can purposefully have one.

This first post will deal with a medical scenario that happens in the first ten minutes of the film. We’ll look at two screenshots from the movie.

Here is the conversation among the medical students when their new patient arrives.

Paramedic: “Transfer from Holy Cross. Thirty-eight year old construction worker fell off a beam. Persistent coma. GCS 6.”

Marlo: “Standard procedure for a GCS 6 admit calls for 2 large bore IVs and diazepam on standby.”

Ray: “Seizure meds won’t do any good. Whatever is wrong is in his spinal column and not in his brain.”

Marlo: “And what medical protocol are you citing?”

Ray: “The protocol of actually living in the real world. Where guys with crappy HMO’s go undiagnosed with spinal injuries.”

Marlo: “Actually he’s on seizure meds which is a medical protocol of reading his chart.”

 

At this point an alarm sounds and the students begin to panic. This is the screen shot at the moment of panic. It shows the monitor. The patient’s heart rate is a nice steady 73. His oxygen level is 100%– can’t get any better than that. His respiratory rate is 19– the patient is on a ventilator. I don’t know– things looks pretty good to me for this patient.

An attending doctor arrives.

Attending: “What is it?”

Student: “Respiratory failure.” (Based on the screen shot, there is no basis for this. Also, nothing is quite hooked up correctly at the head of the bed for an ER.)

Attending: “He might be hemorrhaging. Page neurosurgery, call a code, and get CT on standby. Students, clear the room!”

They then show another monitor in the room which appears to show ventricular fibrillation (V-fib) which is a lethal, but shockable rhythm. Yet, no one starts CPR.

End Scene.

Issue #1: I’m not sure how a medical student within the first ten seconds of getting this patient can know if the problem is in the brain or the spinal cord. For me, the problem seems likely to BE in the brain considering his persistent vegetative state.

Issue #2: Because of the patient’s insurance, he didn’t receive an accurate diagnosis. Mmmm . . . I know this myth get’s perpetuated. You don’t necessarily need expensive tests ALL the time to get an accurate diagnosis. CT scans and MRI scans aren’t really seen as extreme measures anymore. Though they are expensive the cost has come down.

Issue #3: Nothing these medical people say makes any sense medically. What evidence is there that the patient is in respiratory failure? The photo of the first monitor doesn’t suggest that. What evidence is there that the patient is hemorrhaging into his brain? Fixed and dilated pupils? Unequal pupils? A worsening coma score? None of that is presented in the scene.

Issue #4: The one medical problem they seemingly show is the V-fib in the second screen shot. Good to call a code, but research has shown that early and effective CPR is the one thing that is best at bringing people back. The next is early defibrillation which no one seems to anxious to accomplish.

Is it that hard to find good medical consultants for movies?

Treatment for Amnesia

Marissa Asks:

How do doctors proceed if they suspect amnesia? In my novel, the patient was brought to emergency after being found on the side of the road (in the snow.) The patient shows signs of physical torture: multiple rapes, bruises, lacerations, glass embedded mainly in his hands, hypothermia, and a cold (because obviously my character needs to be ill on top of everything).

burnout-384086_1920The patient has just woken up and had a panic attack. Been settled down. You asked for his name and he seemed uncertain as he gave his first name. You asked for his last name and the patient shook his head. What next? I mean obviously the glass would have been removed from his hands and a drip put in for painkillers but what next? Who does the nurse call? Or what does she ask now? And if memory loss is confirmed, how do they find out it’s amnesia like which SPECIFIC tests do they do? Who is contacted and brought in to liase?

I just sort of need a timeline rundown because my character is going to be going through that.

Jordyn Says:

Thanks so much for sending me your question. First of all, it sounds like this patient has a period of time where he is unconscious in the ER. You make it sound like he wakes up on his own and not in response to an exam by a doctor.

So an unconscious patient found with these injuries would have a CT scan of his head. Hypothermia could be determined simply by taking the patient’s temperature and warming him up with something as simple as warm blankets to more complex as heated IV fluids. Regarding the IV drip for pain— this is actually unlikely in the ER. This is referred to as a PCA pump (patient controlled analgesia) and I’ve never seen them used in any ER setting. Would we treat the patient’s pain? Yes. But, you might be surprised that we may choose not to use a narcotic (for many reasons) and instead try something like Toradol which is an IV form of an NSAID (which is in the same drug class as Ibuprofen.)

The glass embedded in his hands would be removed. The wounds irrigated and stitched closed if necessary. The lacerations would be treated the same way. Keep in mind, not all lacerations can be stitched closed if they’ve been open too long due to the risk of infection.This patient would also receive a tetanus booster if he hasn’t had one in the last five years (even if he can’t remember the last time he had a shot.) If anything looks infected, he would receive IV antibiotics.

If the patient wakes up and doesn’t know who he is (and doesn’t have any form of identification on him) then we would involve the police. Likely, they are probably already involved considering the circumstances— that he was found unconscious and beaten. Plus, you mention that the character has been raped several times so a sexual assault kit should be collected, but the patient’s consent is required, so we’d ask him if he wants this when he’s awake. Yet another reason the police would be involved.

If the doctors think the amnesia is related to a brain injury from the beating, they may just see if it improves with time.

I think it’s reasonable to admit this patient to the hospital and I speak a lot here about how it is actually rare to admit a patient with concussion, but considering the amnesia (it sounds like you want it to persist), the beating, the rapes, the wounds to his hands (as well as additional lacerations), and the hypothermia then some watchful observation is warranted. The doctors could consider a neurological and/or some type of psychological evaluation considering the circumstances of the case to see if his memory loss has a non-medical cause. Neuro might request an MRI of his brain to look for additional injuries not as easily discerned via CT scan.

In the end, if he never remembers, there’s little treatment to “correct” amnesia. This is good for the writer because you have a lot of leeway in what you want to happen to the character. Your time frame can be what you wish.

I think if he were stable in the hospital for a few days and the neurological/psychological evaluation didn’t warrant anything that required further inpatient treatment, he could be discharged home even if the amnesia persists with outpatient neurological follow-up and perhaps outpatient therapy if he consents.

Obviously the police would be very involved with this case.

Treatment for Multiple Concussions

This question came to me via my blog comments section.

Melody asks:

ice-hockey-1084197_1280I’m working on a hockey injury scenario where it’s the second hit to the head in a matter of a week, with a dull headache that hadn’t really went away to begin with (but he kept it to himself).

The second hit knocks him out for a few minutes, and he has confusion (and afterwards his demeanor is now very mean vs his nice personality before the hit). Would a second hit to the head with confusion, headache (and I’ll add nausea) require the CT scan? Would they be worried about brain swelling? Would they keep him or send him home with a headache that is extremely sensitive to every little sound (like a baby crying would send him through the roof)?

Jordyn Says:

Hi Melody. Thanks for submitting your question.

Yes, shame on this character for not being honest about his symptoms because if he had persistent headache then he shouldn’t be playing hockey until that resolves— like at all.

To be honest, if this is an adult patient, he’s going to get a CT scan of his head. In reality, CT scanning is much more prevalent in an adult ED (or community ED) than in a pediatric ER run by specially trained pediatric ER physicians. There are many reasons for this that I won’t go into here.

The CT scan will show if there is brain swelling. Depending on the extent of the brain swelling then medical decisions would be made. If mild, then admission to the hospital and observation. If significant, this could require specialized medications, going on a breathing machine, and ICU admission. Though if the swelling were severe the patient would likely be unconscious.

Sometimes headaches associated with concussion are treated like migraine headaches to see if that will improve the pain. But no, a patient wouldn’t be sent home until his headache pain is significantly improved, but it doesn’t have to be entirely gone. We just want to make sure it improves with medications. In some more serious medical conditions like brain tumors and brain bleeds, medications have little effect on the pain.

Then again, in this patient, CT scan would have shown whether or not these other things are present.

Forensic Medical Question: Forensic MRI for Child Abuse

Susan Asks:

mri-782459_1920Is there such a thing as a forensic MRI? Not to be done on a dead person, but in a child abuse case? Can one tell if a child has been beaten and see healed bruises, etc?

Jordyn Says:

Thanks for your questions.

The only indication I can think of using MRI to discern abuse would be for head trauma. MRI is the most sensitive study when it comes to differentiating old and new bleeds (as in possibly discerning two episodes of shaking), but still an exact time of the bleed could probably not be given. We just would know there were two separate instances of injury that caused bleeding.

Also, it wouldn’t be called a forensic MRI on a live child. We would just call it by the study we’re doing. In this case, a brain MRI, but the reason for doing the study would be concern for child abuse and/or intracranial (inside the brain) bleeding.

You can’t really tell healed bruises because they’re healed after all. The skin would have normal appearance. We could at least take a history of where the bruises were because we know normal versus abnormal bruising patterns in children, but pictures are always more impressive so seeing current injuries will always be better if trying to build a child abuse case.

Perhaps you’re thinking about healed fractures which you could possibly see some evidence of healed fractured on x-rays depending on how significant the fracture was. However, not all healed fractures are visible on x-ray. Healing fractures can be seen on x-ray.

Historical Medical Question: Head Injury 1870s

April Asks:

skull-476740_1920I have a question regarding medicine in the 1870’s.  What would brain/cranial surgery consist of then?

I’ve tried to find some information on this type of operation from this time period, but have had very little luck so far.  In a quick scenario, there’s been a serious buggy accident, and the heroine of the novel has bleeding on the brain. I know one proposed procedure for this was to actually drill a hole into the skull to let out the influx of blood. Was this happening and being practiced in the 1870’s? Also, what would the medical instruments of the day have been to achieve such a surgery?

Jordyn Says:

This could definitely be a set up for a craniotomy (drilling a hole into the skull or creating a burr hole) to be used to relieve pressure within the cranium. The procedure would have been called trephining and was definitely used during your time period. Two resources for the procedure can be found here and here.