First-Ever Consensus Guidelines Set New Standard for Brain Injury Care in First Responders

More than 50 clinicians, researchers, policymakers, first responders and agency representatives have reached consensus on the first-ever recommendations for the recognition, diagnosis and management of traumatic brain injury in first responders, publishing today in The Journal of Head Trauma Rehabilitation. The 52 authors agreed to 28 recommendations designed to help first responders, healthcare professionals and agencies work toward five primary goals: timely recognition of traumatic brain injury (TBI), safe recovery, operational readiness, reduced stigma and first responder-centered care. The guidelines apply to law enforcement officers, corrections personnel, firefighters and emergency medical technicians (EMTs), a group of professionals at high risk for violent interactions, falls and car crashes who work in a demanding culture that makes it tough to seek help.

Researchers and clinicians at The Ohio State University assembled the team that developed the guidelines. While addressing injury prevention, treatment and return to duty, the recommendations also recognize that better outcomes will require education, supportive reporting practices and organizational cultures that enable first responders to identify injuries and access appropriate care. The authors wrote in the paper that management of traumatic brain injuries in first responders must shift from an individual burden to an organizational responsibility.

The first step is recognizing that TBI is a problem in first responders, said lead author Jaclyn Caccese, associate professor in the School of Health and Rehabilitation Sciences at Ohio State. She noted that many people think of TBI as a sports problem, but there are a lot of other populations that TBI impacts, and clearly first responders is one of them. There is a lot to learn from sports and the military, she said, but those approaches have to be adapted with first responders to reflect the realities of their work, and that partnership is really important if the recommendations are to be practical, trusted and ultimately useful.

The authors convened at Ohio State last spring to pursue consensus on protocols surrounding six frameworks that they had been discussing in smaller groups for months before they met: workplace policies, injury prevention measures, challenges of recognizing injuries, diagnosis and treatment of the injury, mental health monitoring, and steps needed to get a concussed first responder back to work.

Though concussion research on athletes and military personnel has informed this work, the complex nature of first responders’ responsibilities brings a different set of challenges after a TBI. Symptoms can interfere with duties that require making split-second decisions, while driving at high speed with lights and sirens can provoke symptoms. Shift work disrupts sleep, which is essential to repairing the brain, and an additional strike to the head could set back the recovery process. The recommendations emphasize shared organizational responsibility, supportive and non-punitive reporting and referral processes, clinician-guided care, occupation-specific return to duty progression and continued research partnerships with first responder communities.

Two recently published studies led by Caccese and colleagues provided new details on the size of the problem of TBIs in first responders. In a statewide survey of Ohio law enforcement and corrections officers, 64.1% of respondents reported at least one lifetime TBI, and 28.3% reported duty-related TBI. Nearly three-quarters of the duty-related injuries had never been diagnosed or treated. A review of 23 studies of TBI occurrence in first responders showed the prevalence of a lifetime TBI in this population was 58.8%. The research also showed there is a high risk for TBI in firefighters and revealed that head injuries in EMTs have barely been studied at all.

New federal funding will support an investigation into symptoms and recovery timing in first responders. The National Institute for Occupational Safety and Health awarded Ohio State $1.9 million to fund a project adapting the sideline assessment and repeated testing of injured athletes as closely as possible to the law enforcement environment. Personnel with a head injury will be compared to uninjured controls on a range of symptoms 72 hours after the TBI, once symptoms have resolved, when they are cleared for unrestricted work and six months later. The idea is to look at the common mechanisms of injury, how long it takes officers on average to hit those milestones, and what their trajectories look like, said Caccese, who is the principal investigator on the grant. The team will also examine risk factors for persisting symptoms, seeking to understand why officers who take longer to recover do so.

Many other consensus statement authors are working to shrink the gap of research on TBI in first responders and helping spread the word about the recommendations and the collaborative process that led to them. A major next step is working with first responder organizations to determine how the recommendations can be implemented across different agencies and occupational settings. Caccese and colleagues are presenting the consensus statement at the International Association of Chiefs of Police in late October.

Though there is a lot more work to be done, Caccese said publication of the recommendations is a significant milestone in the effort to build more consistent, evidence-informed systems of TBI care with and for first responders, whose workplace safety and well-being really affects everyone. A first responder should not have to recognize a TBI alone, decide whether reporting it could threaten a career, find a clinician who understands the demands of the job, negotiate appropriate work restrictions, and determine when it is safe to resume a high-risk duty, she and colleagues wrote in a preface to the topical issue of the journal. Yet in many settings, there is no clear system to guide that process, and the consensus statement offers a framework for beginning to build one.

This work was supported by the Assistant Secretary of Defense for Health Affairs endorsed by the Department of Defense through the Traumatic Brain Injury and Psychological Health Research Program, and by Ohio State’s School of Health and Rehabilitation Sciences and Center for Brain Injury Recovery & Discovery.

Subject of Research: Consensus recommendations for recognition, diagnosis and management of traumatic brain injury in first responders

Article Title: A ‘huge leap forward’ for brain injury care in first responders

Article References: A ‘huge leap forward’ for brain injury care in first responders. Original publication (Bibliographic details unavailable.)

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Keywords: traumatic brain injury, first responders, concussion, consensus statement, law enforcement, firefighters, EMTs, return to duty, occupational health, Ohio State University, Journal of Head Trauma Rehabilitation, NIOSH