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A Novel Tool to Guide Reintegration of Anesthesiologists Into Clinical and Academic Work After Concussion

Hatton, Kevin W. MD, FCCM*; Bacon, J. David MD*; McKinney, Katherine MD, MS; Schell, Randall M. MD, MACM*

doi: 10.1213/XAA.0000000000000957
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Concussion is a common form of mild traumatic brain injury that can cause somatic, cognitive, and behavioral impairments lasting days to weeks. There are no published guidelines or recommendations to facilitate the safe and successful reintegration of anesthesiologist clinicians and trainees into clinical and academic work after concussion. We developed a simple 4-phase postconcussion recovery protocol for anesthesiologists who have suffered concussion and describe the successful use of this postconcussion recovery protocol to support reintegration of an Anesthesiology Critical Care Medicine fellow who developed mild concussion during vacation leave.

From the Departments of *Anesthesiology

Medicine, University of Kentucky, Lexington, Kentucky.

Accepted for publication November 26, 2018.

Funding: Internal support from Department of Anesthesiology only.

The authors declare no conflicts of interest.

Address correspondence to Kevin W. Hatton, MD, FCCM, Department of Anesthesiology, University of Kentucky, N-222 UKMC, 800 Rose St, Lexington, KY 40536. Address e-mail to kevin.hatton@uky.edu.

Concussion is a form of mild traumatic brain injury that can cause somatic, cognitive, and behavioral impairments.1 Symptoms may persist for days, weeks, or longer after the initial trauma, a condition known as postconcussive syndrome. While concussion is underreported in the literature due to subjective diagnostic criteria and potential social stigma, it occurs commonly, with up to 15% of student-athletes suffering ≥1 concussion per year.1–4

The incidence, severity, and outcomes of concussion in anesthesiology providers and trainees are unknown. Moreover, there are no guidelines to guide the successful recovery of providers or trainees into clinical or academic work after concussion. We have, therefore, developed a postconcussion recovery protocol to guide successful reintegration into clinical and academic activities after concussion. We report a case of successful use of this postconcussion recovery protocol in a fellow training in Anesthesiology Critical Care Medicine. The trainee has provided written consent to publish this case report.

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CASE REPORT

Five months into Anesthesiology Critical Care Medicine fellowship training, a 40-year-old man suffered a mild concussion during scheduled vacation leave. He did not have loss of consciousness, visual changes, nausea, or vomiting. However, he developed an immediate, severe headache with light-headedness and unsteady gait, lasting approximately 5 minutes. Over the next 2 days, he continued to have a headache, although with decreasing severity. After awakening very early in the morning of postconcussive day 2, he developed vertigo with light-headedness and loss of consciousness. After he regained consciousness, he was taken to the hospital.

In the emergency department, he reported headache but no additional signs or symptoms of his recent concussion. A computed tomography scan of his head demonstrated a nondisplaced left zygomatic arch fracture but no significant intracranial pathology (Figures 1 and 2). He was discharged from the emergency department with the diagnosis of mild concussion, told to return to work at his discretion, and a follow-up appointment was scheduled for the trauma clinic 2 weeks later. Later that day, he contacted his program director expressing concern about his ability to safely return to patient care duties so soon after his concussion. Because there were no published, hospital, or departmental guidelines or policies in place to address academic and clinical reintegration after concussion, the program director developed a postconcussion recovery plan based on the athlete-focused “Heads Up” initiative developed by the Centers for Disease Control and Prevention5,6 (Table 1).

Table 1.

Table 1.

Figure 1.

Figure 1.

Table 2.

Table 2.

Based on the postconcussion recovery protocol, the fellow returned to work on postconcussive day 5 with a limited patient contact half-day (Table 2). That day, the fellow developed mild headache symptoms that resolved after additional rest at home. He returned to work 24 hours later on the afternoon of postconcussive day 6 for another half-day limited-work experience. On postconcussive day 7, the fellow completed a full workday with limited patient contact. On postconcussive day 8, the fellow returned to full clinical work. On postconcussive day 14, he had his initial appointment with the trauma clinic and was discharged without need for scheduled follow-up. After 9 months, the fellow has had no additional symptoms, has required no special treatment or accommodations for his clinical or academic work, and has satisfactorily completed his Anesthesiology Critical Care Medicine fellowship.

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DISCUSSION

This report describes the use of a novel postconcussion recovery protocol to reintegrate an Anesthesiology Critical Care Medicine fellowship trainee into full academic and clinical responsibilities after mild concussion. This postconcussion recovery protocol promotes a gradual reentry to academic and clinical responsibilities, allows trainees to monitor their own symptoms, and provides guidance for recovery when symptoms do occur after concussion.

Concussion is a form of mild traumatic brain injury affecting memory, orientation, and level of consciousness.7 Additional symptoms include headache, vertigo, nausea, vomiting, photophobia, phonophobia, tinnitus, postural lightheadedness, memory difficulty, concentration difficulty, mood lability, irritability, hypersomnia, insomnia, anxiety, and depression.8 Postconcussive syndrome is a severe, sometimes disabling, chronic syndrome of concussion-like symptoms, including somatic, cognitive, and behavioral abnormalities, that occurs for prolonged periods in some patients with concussion.9 To reduce the risk of postconcussive syndrome, concussion has traditionally been managed with complete physical and cognitive rest, including avoidance of television, telephone, reading, texting, and video games, for up to 7 days to promote brain recovery.8,10 Recent data suggest that mild cognitive activity and light, noncontact, physical activity 1–2 days after concussion may reduce the risk of postconcussive syndrome.11 In athletes, a stepwise return-to-play protocol has integrated these new findings and has been promoted for athlete safety and long-term neurocognitive recovery.12

The neurocognitive, behavioral, and somatic effects of concussion may have specific consequences for medical trainees. Concussion and postconcussive syndrome may lead to decreased performance from short-term memory impairment, from difficulty understanding complex physiological, pharmacological, and pathological concepts, and from interfering with mental and visual focus when reading or visualizing patterns, figures, or graphs, especially on electronic screens. Concussion and postconcussive syndrome may also interfere with trainee clinical performance and decision making, especially in complex or emergency situations, where loud noises and blinking lights are routine, rapid integration of multiple data points is necessary, and cohesive interactions with coworkers, patients, and families are important to ensure good patient outcomes. Trainees in anesthesiology, surgery, critical care, cardiology, and emergency medicine may be exposed to these types of situations more than other graduate medical trainees.

The Anesthesiology Critical Care Medicine fellow in this report was assigned to a cardiothoracic critical care rotation at the time of injury, an environment where fellows are responsible for patient assessments and interventions, use complex protocols and algorithms, incorporate data from the patient’s electronic medical record and bedside monitors, and interact with the bedside nurse, family, and other physicians with frequent interruptions by alarms and pagers. The development and utilization of this postconcussion recovery protocol encouraged him to monitor his own symptoms and to proactively create a safe environment for his structured return to work.

Unfortunately, some limitations to the use of the postconcussion recovery protocol do exist. First, the constellation of symptoms after concussion may impede the ability of concussed trainees to accurately monitor their own symptoms and progress. Decision making may be impaired and emotional lability may be excessive, yet trainees may not perceive these changes and may not recognize their own limitations. For some trainees (and athletes), it may be necessary to use a formal concussion assessment tool, such as the Sports Concussion Assessment Tool 2 that objectively assesses perceived symptoms, cognitive abilities, and physical examination to define concussion severity and recovery.13 Current recommendations for concussed athletes are to use neuropsychological testing like the Sports Concussion Assessment Tool 2 for severe injuries as part of a multimodal treatment and monitoring plan.14

While this trainee had only headache symptoms during his postconcussion recovery protocol, other trainees may have different symptoms of concussion and postconcussive syndrome. Careful monitoring and observation by the program director may be needed, with additional involvement of supervising faculty, peers, and other health care professionals who interact with affected trainees. Increased supervision of concussed trainees may also be necessary to maintain patient safety. If trainees’ symptoms do not improve or have significant recurrence, referral to a sports medicine specialist or neurologist may be warranted.

Another consideration is the applicability of this postconcussion recovery protocol to overnight call shifts. At the time of his injury, this fellow had just completed his monthly in-house night float requirement and was not assigned this shift again for 4 weeks. While the stated postconcussion recovery protocol does not specifically include instructions for overnight shifts, trainees should not attempt overnight shifts until they have completed the postconcussion recovery protocol to phase 4, although individual programs and trainees should consider how best to incorporate this important clinical activity into trainee concussion recovery.

In this case, with the approval of the fellow, the postconcussion recovery protocol was disclosed only to the supervising faculty, his peer fellows, and the intensive care unit nurse manager. It is unclear whether patients and their families should be notified that a member of the health care team is recovering from a concussion or that increased medicolegal risk is incurred by supervising faculty and/or health care systems for care provided by concussed trainees. Future research may provide valuable information about the impact and treatment of concussion in medical professions. In addition, simulation may be considered as a tool to monitor trainee recovery and responses in stressful-simulated patient care situations. Despite these limitations, the use of the proposed postconcussion recovery protocol is an important step in providing a framework for clinical and academic reintegration after concussion.

Trainees, program director, and administrators should not use this postconcussion recovery protocol as a replacement for medical evaluation after concussion. This protocol is not intended to replace evaluation, diagnosis, and treatment from qualified concussion experts. Treatment guidelines and protocols should always be individualized and be based on the affected provider’s clinical, educational, and job-related situation.

Figure 2.

Figure 2.

In summary, this report describes the successful use of a novel postconcussion recovery protocol for an Anesthesiology Critical Care Medicine fellowship trainee after mild concussion. This protocol provides guidelines for trainees, program director, and administrators for the progression of increasing physical and cognitive intensity after concussion. This postconcussion recovery protocol should be considered for anesthesiology trainees and clinicians who sustain concussion.

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DISCLOSURES

Name: Kevin W. Hatton, MD, FCCM.

Contribution: This author helped acquire the data, and write and revise the manuscript.

Name: J. David Bacon, MD.

Contribution: This author helped acquire the data, and write and revise the manuscript.

Name: Katherine McKinney, MD, MS.

Contribution: This author helped revise the manuscript.

Name: Randall M. Schell, MD, MACM.

Contribution: This author helped revise the manuscript.

This manuscript was handled by: BobbieJean Sweitzer, MD, FACP.

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