A perfect score of 15

Tuesday, July 28, 2009

Imagine driving down the road, minding your own business, when a flying rock explodes your windshield. Now imagine being Formula 1 driver Felippe Massa racing at more than a hundred miles an hour, with no windshield to protect you, when a metal spring from another car flies into the cockpit and explodes into your helmet. The helmet does its job but the force of the blow causes multiple skull fractures and the brain encased in that skull starts to swell.

Eventually, Mr. Massa and a neurosurgeon get together and but an important piece of information that tracks wakefulness helps that surgeon know what Massa was like at the scene, in the helicopter and when he first got to the hospital. The Glasgow Coma Scale is a commonly used assessment tool that allows medical personnel, from the most experienced neurosurgeon to a first responder at the accident scene, to measure the wakefulness or lack thereof. The GCS has three scoring components, eye opening, verbal response and motor response and can be used with little training. The higher the number, the better; the lower the number the deeper the coma. While 15 is fully awake, a dead person still scores a 3.

Head trauma patients are touched by numerous care providers as they wind their way through the emergency care system. A first responder may come upon the scene followed by an ambulance with an EMT or paramedic. Sometimes a helicopter will be summoned. In the ER, there are nurses, paramedics, emergency physicians, general surgeons and neurosurgeons who might be involved. Add operating room burses, anesthesiologists, ICU nurses, intensive cars docs and the number of people touching a patient can be quite amazing.

The Glasgow Coma Scale allows a common language to describe the patient’s status at each one of these handoffs. In addition to the subjective terms that might be used like sleepy or groggy or lethargic, a number score can let people know if the patient is waking up or lapsing into a deeper coma.

The scale is simple to use and easy to teach. Open your eyes spontaneously gets you 4 points, to voice command 3, to pain 2 and no opening gets you a 1.

4 open
3 to pain
2 to voice
1 none

5 alert and oriented
4 confused
3 inappropriate words
2 incomprehensible words
1 none


6 follows commands
5 localizes pain
4 withdraws from pain
3 flexes to pain
2 extends to pain
1 none

Anything below 15 is not normal and that 15 is a magic number. Patients who are fully awake after a head injury ma not need a CT scan and watchful waiting may be appropriate. But if the number starts to fall, suspicion that bad news may be on the horizon grows.

Unfortunately, there are numerous types of brain injuries that are not fixable by surgery or the damage may be so severe that surgery will not alter the outcome. A very low GCS and how long the score has been low gives the neurosurgeon added information to go along with the rest of the physical exam and the imaging studies like CT scans.

Mr. Massa is a classic example of how things change. He was fully awake at the track but gradually became more lethargic and required surgery for a skull fracture and brain swelling. According to reports, the good news is that he is awake and talking with his family. While athletes in some sports strive for the perfect 10, Mr. Massa and his family get to celebrate a routine 15.

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