A concussion is a brain injury

Concussions are scary, the more you learn about them.  I like the way Brian Adler summarizes the underlying message:  “All concussions are brain injuries, and all brain injuries are serious.”  (Adler is an attorney who represents accident victims, not a doctor, but he seemed to get a lot of nodding heads at a  sports medicine conference in Seattle.)

The biggest danger is getting a second injury.

There’s been a lot of discussion among scientists and neurologists about concussions and athletics.  The most common system for many years makes a distinction between people who lose consciousness and people who don’t.  But, the latest guidelines, published this month as the “Zurich concussion statement,” says you don’t have to lose consciousness to have a serious concussion.  (I can’t find a free accessible version online.)

The new guidelines say youth athletes should never return to action on the same day as the injury (and adults should only take that risk after a medical evaluation).

Washington’s new youth concussion law (reported on KPLU) is perhaps the most advanced in the world, because one of its architects also served on the Zurich panel.  That’s Dr. Stan Herring of the UW/Harborview.  One big change is simply recognizing that each individual and each injury is different.  You can’t simplify by saying, it’s only minor because he never lost consciousness.  Instead, someone trained to evaluate head injuries needs to run the  victim through a series of tests, similar to a neurological exam.  If there are any problems with balance or coordination, for example, then the brain needs time to heal.

Technically, a concussion is less severe than a “mild traumatic brain injury.” But it can be hard to tell where one stops and the other starts.  A head injury can lead to internal bleeding, which damages brain cells by creating pressure inside the skull.  And a lot of damage happens when the “wiring” of the brain, the long axons that connect one brain cell to another, get severed.  There are bundles of axons, and a jolt to the head can rip them in clusters.  Such damage may not show up in x-rays.

Helmets?  Surprisingly, the international panel can’t agree on whether they’re a good thing in many sports, since they may encourage athletes to take bigger risks and hit things with their heads.  Helmets are definitely recommended for bicycling, skiing and snowboarding.

Oh yeah, one bit of good news.  Most concussions heal within a week and leave no lasting damage.

Flash-forward, the flu of December 09

Here are four interesting items I learned yesterday from King County’s chief epidemiologist, Jeff Duchin, MD.

  1. Lesson learned:  Closing individual schools is not effective for limiting flu transmission in a community.  Next time — if the virus appears to be more deadly — the health department will close all schools in the county, perhaps for 8 weeks or longer.
  2. Lesson learned #2: This virus spread far more rapidly than planning scenarios had predicted.  Basically, flu virus can be widespread before we know what’s hit us.
  3. Who’s first in line for a vaccine, if there’s a limited supply? Heavy-duty planning is underway for how to distribute an A-H1N1 (swine flu) vaccine next winter, assuming it’ll be available.  This will be in addition to the normal, annual flu shots.   First-responders, and most medical workers, are clearly at the top of the list.  Pregnant women, and people with compromised immune systems.  After that, it might be all children under 18, given signs that they’re being hardest hit so far.  (Normally, the elderly are considered most at risk, but not in this case.)
  4. If the virus remains less severe?  Expect simply a lot of people to be out sick, especially in schools, as everyone who didn’t get sick this spring, gets it on the second pass.   But, it wouldn’t be much different from what we’ve seen this past month.

And one note to the King County Board of Health:    Anyone watching (the meeting was recorded by King County TV) might be disappointed at the level of questioning by board members, as Dr. Duchin and other staff testified.  They asked thoughtful questions to clarify the facts.  But, nobody on the Board asked the simple questions, What parts of the “pandemic plan” did not work?  What surprises did the staff face? What needs to be improved before we face a severe pandemic?   (The lessons learned above came from a private interview, after the meeting.)

Flu reflections and questions

On Thursday afternoon, we’ll get the official “swine flu de-brief” from Public Health-Seattle & King County.  What will be the lessons learned?  Dr. David Fleming, the agency’s director, offered a possible preview back on May 4th, at a panel in Seattle hosted by the Washington Global Health Alliance (and televised by TVW).

It seems everyone involved with pandemic flu planning has been praising the response to this outbreak. Fleming said, “Boy, planning is really paying off.”  He was comparing the government reaction to anthrax and SARS outbreaks few years back, and noting that this time there was more “rational communication.”

But I don’t think the public perception is quite so triumphal.  People were confused and they see officials as being confused.  While the response may be much better than it would have been a decade ago, does it live up to the expectations of today?  After millions of dollars have been spent on pandemic flu planning, was this response good enough?

Here are a few points from the panel that struck me:

  • At the peak of concern, supplies of Tamiflu were depleted at some health care centers in King County, and Public Health had to distribute some doses from the national strategic stockpile — and this was a mild strain of flu.
  • Fleming acknowledged, “We planned for the wrong disease, a global pandemic of great severity,” or a high death rate. But it turned out to be a milder strain of flu.
  • This strain of H1N1 spread much faster than anyone anticipated.  That means the information communicated to the public has been way behind what’s actually happening in the community.  On the other hand, officials are trying not to speculate in public, and offer assurances before they’re certain about what’s happening.
  • Children and schools were a major source of transmission for this outbreak — which may have lessons for vaccinations next fall.  (A point made by Dr. Kathy Neuzil, of PATH and U.W.)
  • Agricultural workers may be a weak-link in the global surveillance system, since flu viruses can jump more easily than many realize from poultry or swine to people.  There’s now system for tracking illness among these workers. (From Ann Marie Kimball, an epidemiologist at U.W.)

Swine flu and school closures – how much longer?

Wondering if you child’s school will be next?

The top public health officials in King County — Dr David Fleming, Director, and Dr. Jeff Duchin, Chief Epidemiologist — have been hinting that school closures may not be a tactic for much longer.

As my KPLU colleague Liam Moriarty reported this morning (Friday),  “So far, none of the folks in King County with the H-1-N-1 (swine) virus have gotten any sicker than they might from any of the old familiar flu viruses. Dr. Fleming says if that trend holds in the coming days – and this bug proves to not be particularly nasty – some of the precautions such as closing schools could be relaxed ….”

On the other hand, three students at Lakes High School, south of Tacoma, were taken to Madigan Army Hospital with severe flu-like symptoms, and as of Friday morning, two of them were in intensive care units, in serious condition.  That led to closing the school, as a precaution.

Seems sensible and prudent.   If tests show that they indeed are suffering from the swine flu H1N1, then we might see school closures  as a good tactic that should continue.

I have to say, the top officials in public health agencies and school districts have seemed remarkably indifferent to the hardship the closures cause.  In particular, for single parents and parents working jobs that offer little or no sick/vacation leave, this is a whole separate crisis.

When will a leader (the Governor? a Health Director?) stand up and say to employers, “We are in an emergency situation, and I’m asking all employers in the state to give extra sick days to anyone whose child’s school has been closed for a week?”

[UPDATE, Friday afternoon: Seattle Mayor Greg Nickels deserves a prize for being the first to address the work issue.  He told a news conference today that the city is offering extra flexibility to its employees … and he called on other employers to do the same. ]

In case you missed it, in King County, four schools have been closed (as of noon Friday)(five schools as of Friday 4 pm)  because they each have a student who probably has swine flu.  (The reason for closures is to slow down the spread of the virus — to prevent a situation where lots of people are getting sick at once.  But, once the virus is confirmed to be widespread in the community, then there’s not much benefit from closing individual schools.)

If you’re like me, keep crossing your fingers that your child’s school doesn’t have a “probable” case during the next week, and maybe after that we’ll be beyond school closures.