Tag Archives: Concussions

Q&A: Concussion Types

in my story, for plot reasons, my character is in recovery for three weeks from a concussion. there’s no memory loss, but she passes out for 10 seconds and when she wakes up she’s nauseous and has slurred speech + ringing ears. how hard would she have to get hit in the head to have a concussion that is that severe?

This is going to be a bit nitpicky, and it’s not going to give you the answer you’re looking for, so, before we start, sorry about that.

Being knocked unconscious is a Type 3 Concussion (minimum). Nausea, slurred speech, and ringing in the ears are consistent with a concussion. For a Type 3, a recovery time between a week and a month is reasonable.

The rating for types work as follows:

Type 1 Concussions do not result in a loss of consciousness, and symptoms (or, at least, most symptoms) subside within ~15 minutes of the injury.

Type 2 Concussions do not result in a loss of consciousness, and symptoms persist beyond 15 minutes. Recovery usually occurs within 10 days of the injury.

Before we keep going, the symptom list is a bit longer than what you listed above. It can include: Confusion, impaired fine motor control, headache, nausea, vomiting, vertigo, sensitivity to light and/or sound (I think the other senses too, but I’m not 100% certain), difficulty with concentration and thinking, irritability, amnesia. (Also missing a few. This is brain damage we’re talking about, and it can scramble a lot.) (Also note, Type 1 Concussions usually only have mild symptoms, such as headaches and mild nausea. The more severe symptoms will, usually, push it into a Type 2 because they don’t go away.)

Also, before we keep going, worth singling out amnesia for a second. This one gets seriously misrepresented in pop culture. Realistically we’re talking about someone losing some time around the concussion. They may not remember what lead up to the injury, or missing a couple hours after it, and never will. Global, “I can’t remember anything,” amnesia is incredibly rare.

Type 3 Concussions get to pick off the full symptom list above (it won’t have everything, but it’s not limited the way a Type 1 is.) It also comes with less than 60 seconds of unconsciousness. Full recovery usually takes between 10 and 30 days. This is what you’re describing.

Type 4 Concussions involve being unconscious for more than 60 seconds, and recovery time can range from a couple weeks to more than a month.

With all of that said, what you’re asking is, “how hard does she have to be hit in the head?” The answer is, “hard enough.”

Concussions, and most brain injuries, aren’t about how hard you’re hit, it’s about what happens to your brain after you’re struck. A concussion is a bruise on the brain itself. Usually, the head is jostled, and the brain bounces off the interior of the skull, causing injury. This is just like any other bruise except the tissue being damaged is responsible for regulating the rest of your body. A relatively light hit to the head can cause a Type 4 Concussion and kill you. Conversely, you can take some horrific abuse to the head, and not suffer a concussion at all.

If you’ve been digging through medical write ups on websites and trying to figure out how hard someone needs to be hit, the answer is there’s no concrete rule. From a medical standpoint, concussions are about where you ended up, not how you got there.

Finally, recovery times are directly related to how well someone follows medical advice on recovering. There’s a lot of things that are personal to the individual and their concussion. Ex: you may not have trouble watching TV, but others will, and with a future concussion, you might.

Also, further muddying things, multiple concussions are cumulative, even over a long period of time. So, if you’ve suffered a concussion, you’re at greater risk of suffering future concussions from head trauma. Something to keep in mind if your character’s recovering from one.

Concussions are very serious injuries. If you suffer one, even a Type 1, you really should see a doctor, and follow their advice while your brain heals.

-Starke

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Hi I just read the post about knocking a friend out before they did something dangerous I was curious about your thought on a scene that is somewhat related to that but also different. Basically there is a group of bad guys in a burning building and the hero knocks out a fire fighter who enters the building, then brings them outside reasoning that they would safer out of the fight even with the risk of knocking them out.

<Redacted>

So, this
is a follow up to this post, and it’s going to be a bit harsh. Hence, why I’m
answering it as an unattributed quote, instead of the actual ask.

As we’ve
said many times before, knocking someone out is a cheat. It’s an easy out, to
move characters around, without including any of the consequences that you’d
associate with attacking another character. Particularly a friendly character,
or one with plot armor. Also, there’s some other major problems in this
scenario.

You have
characters burning a building. Okay, fine. You have your hero on the scene.
Again, that’s fine. If your character’s goal is to stop the antagonists, that
means they go where they’re needed. You have firefighters on the scene. Note
the plural. These guys travel in packs. They’re not the lone wolf type who will
rush into burning buildings alone. In most modern environments, this also means
the other first responders are going to be on the scene. That’s police and Emergency
Medical Services (EMS). So, the bad guys are here, the cops are here, the firefighters
and paramedics have arrived, and your character is bouncing around in the
middle. Still, this is fine, mostly.

But, this
is where problems start to catch up.

First,
it may be different for firefighters (though, I doubt it), but with EMS, if the
situation you’ve been called into isn’t secure, you do not go in.

EMT certification
quizzes include questions like, “you arrive at a bar, the bartender tells you
someone was shot out back. The police aren’t here yet. What do you do?” If you
answer with anything other than, “wait
for the police to arrive and secure the scene,” you’re done. Out. You failed
the test with one question.

In the
hypothetical and in real life, you are to sit there and let someone die, rather
than run into a situation you don’t have control over and risk getting yourself killed. That’s a job for the police. They go in, secure the place, then you get to go in and do your job.
Not the other way round.

Your bad
guys are still torching the place. Firefighters will not go in until the police have stopped them. The only way
around this is if your bad guys are hiding. Which is possible, but it’s very
likely the 911 call that got them on their way mentioned psychos torching the
place. That means it’s a police problem first, theirs as a distant second.
Evacuate nearby buildings, help contain the blaze, and keep it from spreading?
Sure. Stumbling into a combat zone? Not so much. Stumbling into a combat zone
is more SWAT’s purview.

Second, firefighters
are a team, not loners. (Really, this is true of all emergency services.) If
you’ve got one going into a building to search for survivors trapped by the flames,
they’re not going to be doing that alone.

Because
they’re looking for people, they’ll find your bad guys, and then pull out. Again,
people actively torching the place is an issue for the police. As soon as they
realize they’re dealing with people trying to kill them, their place is
outside.

Third,
the moment your character attacks an emergency responder, they’re signing on
with the bad guys. Okay, the bad guys might not accept the job offer, but it’s
the thought that counts. Remember when I said emergency responders were a team?
Yeah, in attacking one, your character is not only committing a crime, in the moment,
they’re also making themselves an enemy of the police and the other responders
on scene. In the moment, the larger context doesn’t really matter.

Fourth,
there’s a couple practical consideration to knocking out a firefighter, they’re
wearing 75lbs of armor. Granted, their turnout gear might not do much against
gunfire, but it will do wonders against idealistic fools who attempt to
incapacitate them. (Actually, given that turnout gear is made from a Kevlar
variant, it might be bullet resistant; I’m not certain.) They also have the
least to worry about, in there, since they’re protected against the flames, and your firebugs will go
after anyone, anyway.

This is,
of course, entirely ignoring the issues associated with knocking someone out (which
is to say, you can’t really do that.) For those of you who haven’t read our Concussions tag, here’s a very short recap: Getting knocked out is a life
threatening injury. It involves inflicting a severe concussion on the victim. If
unconsciousness lasts for more than a few seconds (30 is the rule of thumb),
the victim will have, almost certainly, suffered severe, and irreparable, brain
damage. We also have a Knocked Out tag, if you started thinking about chloroform
or tranq guns.
(There’s also a “Concussion” tag. Oops.)

Clocking
someone upside the head, and having them rendered instantly, and harmlessly,
insentient until the power of plot compels them to rise is a fantasy. As a
writer, it may seem to be a convenient one, but it’s just cheap.

It’s a
buyout, to allow your character to freely remove characters from the current
scene, without facing the normal consequences of attacking them. In this case,
in an act of, “heroism,” that wouldn’t work.

So, you
have your bad guys torching the place. You have your hero, there to stop them.
Again, that’s all fine. You have your, “hero,” attack an armored bystander,
rather than, telling them that the people
responsible for the blaze are still there?

Wait, what?

Your character’s
first response, when presented with someone who is doing their job, is to
resort to serious violence to, “protect,” them?

I
understand the impulse, but this, really,
is one of those times where heroism is about not resorting to violence to achieve your character’s goals.

You cannot
safely knock someone out.

Your
character’s best option is to tell the firefighters that the guys responsible
are still in there, let the firefighters evacuate them, and send in SWAT. Even
failing that, immediately attacking a firefighter is, quite possibly, the worst
available option.

-Starke

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Last year, I fainted from dehydration. Not that I was doing anything strenous, I just barely drank water that day and my brain went “NOPE” that evening. I fell backwards, somehow turning myself around as I fell and landed on my hardwood floor. But the thing is, I didn’t come to until my head hit the floor and woke me up. The ER said no concussion, but how is it that, when you could probably get a concussion from bonking your skull on the hard floor, that the blow woke me up?

A concussion is when you suffer physical trauma to the brain. That is to say, bouncing your skull off the wall hard enough that your brain hits the inside of your skull, and is injured in the process.

This is characterized by cognitive impairment. Difficulty tracking moving objects. Difficulty processing information. In some cases difficulty speaking, or remembering stray trivia, like who the president is, what year it is, or your name.

So, it sounds like the ER was right, you probably didn’t suffer a concussion. You fainted, bounced your skull off the floor, but your brain wasn’t actually injured in the process. It was there to tell you, “well, that sucked. Get up, let’s not do that again.” And, here we are. Blow to the head, no concussion. It happens. It’s unpleasant, but it does happen.

-Starke

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Given that you’d have to inflict serious damage to the CNS to achieve decisive incapacitation (assuming the person doesn’t stop attacking you, for fear of their life, the second they get badly injured) by bashing someone’s skull in, I feel like saying choking someone into unconsciousness is “not any safer than pounding their skull into a wall until they stop twitching” might be pretty hyperbolic. I get the point you’re making, but it seems like you might be over-reaching with this comparison.

Sorry, this ended up in the drafts pile before the holidays and got lost. It’s in reference to this post. Which is in turn a follow up to this post.

It’s mild hyperbole. Strictly speaking, pounding the skull into the wall until they stop twitching would probably mean completely dead.

Blood chokes, that work to cut off the flow of blood to the brain instead of restricting the victim’s breathing are incredibly dangerous, to the point that brain damage or death are likely, to not completely guaranteed. So, without any hyperbole, it would be more accurate to say, “these are both very dangerous and can result in death.”

It also gets into the entire discussion about human beings as a whole. We are remarkably easy to break, but hard to kill. There are mountains of medical cases where someone suffered what should have been a fatal injury, only to survive. Grievous head wounds are an example of that.

-Starke

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How many times do you have to have a minor concussion to really need to see a doctor?

Once. I’ll keep saying this, but: concussions are one of those injuries you really should not screw around with. When you’re talking about your characters, things are a bit more flexible, but it’s still an injury that would need to get checked out as soon as possible.

-Starke

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If getting knocked out is so dangerous, how do boxers do it? Most of them seem to have minimal brain damage.

Ronda Rousey just did an interview with ESPN that basically said her career is over from her fight with Holly Holm. That’s not what she said, what she said is got a concussion that left her hospitalized and she’s going to need at least six months of recovery before she can even think about getting hit again. She can’t even eat an apple because some of her teeth are still loose and will be for the next three months.

She may come back, but it’s going to take a long damn time.

She’s probably looking at at least a year before she gets in the ring again.

If she ever does, which she might not if any injuries persist.

We all remember Muhammad Ali lighting the torch at the Olympics when his hands were literally shaking from the degree of damage he’d suffered. He has Parkinson’s. There’s an article in LA Times about his brain damage being the result of his boxing career.

Greatest boxer of a generation. It’s tragic.

And it’s not uncommon.

This happens to many professional fighters later in life. It happens to football players too, all the time. There are so many stories across the country of high school football players dropping dead on the field because they had a concussion or bleeding in their brain that no one caught. They do get concussed fairly often. You can get the data on this through the American Journal of Sports Medicine and other sources, the average is 1 per every 100,000. Roughly 12 high school students every year will die directly from playing football.

This is kids, this is not the higher levels where they have better medical care but push them harder. This is high school. And that’s just death, that’s not counting injury or long term damage.

Brain injuries are very common on the boxing circuit, in professional fighting, and many other sports. They can be and often are career enders. This is a risk that every professional fighter takes when they enter the ring.

Many professional fighters in the United States only fight 3 to 4 times per year. When my brother was doing collegiate boxing, he fought about every three to four months. This is due to the amount of stress that kind of physical combat puts the body under.

They do take medical precautions. They do as much as they can. They’re choosing to take the risks. And it’s not always enough to save them.

If you don’t think that professional boxers or any other kind of fighter doesn’t suffer long term damage from their career choice or are somehow immune, then you just haven’t been paying attention.

I’ve been in seminars with UFC fighters where they were talking about the ring and their advice was essentially, “they get you in a hold, just tap out, don’t even wait. You’re not proving anything. Don’t risk your career over one fight.”

You fight. You get hurt. You hope you don’t get hurt so bad that it ends your career, that you can recover. And if you can’t, well, there’s always someone out there to take your place. Another young idiot who think they’re immortal or invincible.

Though, honestly, where did you think all those jokes about boxers being meatheads or thick-skulled come from?

Reality.

Brain damage.

There are so many jokes about boxers being idiots because brain damage. It’s become a cliche. People make fun of this. You might have made fun of this, at least once. I know I’ve told the Rocky jokes.This truth is such an embedded part of our culture and been with us for so long that you don’t even think about it. It’s literally become a joke. The injured while fighting plot is one of the most common in boxing movies.

There is an entire character stereotype built around this concept.

The Big Dumb Bruiser.

For the longest time, (and you still see it), there was an assumption in media that if you were European and a fighter then you had to be an idiot. D&D has an entire class built on this concept.

Why?

Boxing.

You can only take so many hits to the face before your brain stops working.

How many times have you heard that, by the way?

“Don’t mind him. He’s taken one too many to the face.”

That’s a boxing joke. Or a fighting joke. Boxing is like alcohol, everyone knows that it kills brain cells and they forget because that knowledge is so common.

-Michi

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In continuation to your last answer: Are there are ways to incapacitate someone to the point where tying them up isn’t the more efficient option?

Break them. Their arms. Their legs. Their hands. Whatever else they’re using that you don’t want them to use, like their jaw to keep them from talking. Their spine. Paralyze them.

It will probably do more permanent damage and will be difficult to move them if you have to, but you can cripple them for life.

Break them.

That is an option.

The guy with the fractured or snapped knee cannot chase you. The guy with the broken jaw can’t yell for his buddies. They may be able to swing their arm, but they can’t use it if it’s broken. You damage them to the point where they are no longer capable of fighting back.

Or… drug them.

However, this isn’t as simple as it sounds. Drugs affect people in different ways, the amount you need is based on their height, their weight, their body, and their susceptibility to it in the first place which is very difficult to judge if you don’t have access to their medical history. You gas a room and even if it takes out like 90% of them, you still have to stay alert for that 10% where it didn’t quite take.

Drugs are the other cheat which end up in fiction a lot as the easy way out. They don’t work as advertised. They are not any more consistent than anything else. It’s a situation where the amount you need to put one of the guys to sleep is just going to flat out kill the one next to him. There is no one size fits all dosage.

And you have to keep dosing them consistently at regular intervals or it will wear off. You have to come back and check to make sure they didn’t come to. And you should probably tie them up anyway, just in case.

Just to be clear, your choices are:

Cripple them for life.

Kill them.

Tie them up.

Run away.

Find a way to deescalate the situation.

Using your own body as the lock up point like in a hold or a throw or just sitting on them still counts as tying them up. The downside to that is you have to keep holding onto them or let them go. This is why breaking them is better if you need to exit a situation because they cannot pursue.

Lastly: superpowers. (Which will technically count toward “tying them up” 9/10.)

Introducing fantasy elements will change the game some, but doesn’t change the fact that a violent altercation between two people or more is about deciding “me or them”.

Any mook your character leaves alive is one that can come back at them later, even if they’ve tied them up. They can pass on information about them to their friends. They can holler for the guards. They can come after you while your back is turned because you thought they were incapacitated, but they really weren’t or only passed out for three seconds. Or your characters will run into them again later with more of their friends. Thought two mooks were bad? Try eight? Try fourteen and they turned on the gun turrets.

Depending on what they have access to they can really ruin your day.

It’s an interesting character choice.

Do they leave these guys alive knowing that they can screw them over later? Are they in a position where they can afford that possibility? What are their feelings on this subject? How does that conflict with other characters in the narrative?

This is the problem. Your characters choices actually have consequences outside of the fight, outside of their relationship with these very specific characters. While that can go on to become “a moral lesson” about the importance of kindness and pacifism, it can easy go the other direction.

Which is the chance you take.

Media tries to use the K.O. as a substitute for death. There is no substitute for death. Only dead men tell no tales. (And even then, they still do. It just takes longer.)

Fighting to subdue takes longer and it is more difficult that fighting to kill.

There is actually nothing more efficient in a fight than killing.

The question is not what is “most efficient”. It’s is killing really the best solution to this problem? Is it something your character or characters can stomach? Where do they draw the line? Is there a line? Does it line up with their goal?

Death can be just as detrimental to the overall goal as leaving the mook tied up.

You live in the uncertainty of the right choice. All your characters can do is make choices in accordance with what they believe and then live with the consequences. There will always be consequences. However, the question is: did they achieve their goals along the way?

Once your character chooses to engage in violent action, they are closing off alternate options and are signing up for not only the possibility of death but the likelihood. Violence is about hurting people, once your character chooses to engage then they’ve moved away from the options that lead to no one getting hurt or the vast majority of people surviving. If you don’t want to hurt anyone, then don’t fight. Really. There are always other options, even in your fiction and they are actually worth considering. The presentation that death is the worst thing that can happen to someone in regards to violence and that anything else that happens, so long as they remain alive, is… really screwed up, frankly.

Remember, knee capping some poor asshole is crueler than just flat out killing them. There are a lot of ways to inflict violence on someone that actually makes death the kinder option.

Plus, violence often creates as many problems as it solves.

Avoidance and death are both more efficient than subdual. Even if you incapacitate someone with a taser, you still have to tie them up.

That’s the problem.

They will become a problem. You have to eventually let them go. Or someone else will. (Or kill them.)

Hard choices.

-Michi

Q&A: Kockouts

How plausible is it to knock someone unconscious without killing them? I have a monster character that, when people annoy him, picks them up and slams to either knock them out or kill them. One of my characters has to have this happen to them and they survive it, but I’ve heard it’s actually really rare to knock someone out and not kill them. Is it true that this isn’t plausible, and if it’s not is there anything else, like smothering, that they *could* survive? I love your blog by the way.

I know we’ve answered this one in the past, but it doesn’t seem to be properly tagged, so I can’t find it. The very short version is, “It’s entirely plausible, but your character will probably end up a vegetable after the fact.”

Being knocked unconscious is actually a concussion. It’s a life threatening injury. Being knocked out for more than a few seconds (of the top of my head, the number is somewhere around 30) will result in permanent brain damage for the victim. Being unconscious for more than a few minutes will result in either a coma or death. (For what it’s worth: I’m phrasing it like the symptom is the cause. The concussion’s severity determines both how long the victim is out, and the extent of other neurological damage.)

So, while it’s entirely possible to be knocked out by being body slammed into a wall, freeway support column or ‘57 Chevy, undertaking complex tasks like walking, talking, or remembering your own name, will probably be out of reach afterwards. Depending on the severity of the concussion these symptoms could last for minutes to permanent.

It’s also worth pointing out that concussions are cumulative. They’re literally bruising on the brain itself, from bouncing against the inside of the skull. These do stack up, meaning future concussions occur more easily, and are more severe. Knocking characters out repeatedly will kill them, quickly.

-Starke

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