Traumatic Brain Injuries: All Your Eye Cannot See

traumatic brain injuries
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The impact of a traumatic brain injury (TBI) may be less than what meets the eye. X-rays, MRIs or bloodwork may not determine the full extent of the injury. In preparing a life care plan, I am often looking for all the eye cannot see.

Typically, a TBI case will be referred to me a year or two after the accident. By then, the individual has received medical and rehabilitation services to determine their “new normal” of functioning and generally is considered to be at maximum medical improvement.


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Life Care Plan Process

In reviewing the medical records, it is important to have a comprehensive evaluation from a neuropsychologist. These evaluations provide me with a framework of the individual’s strengths, weaknesses, and the impact on daily functioning. The goal of the life care plan is to maximize one’s independence as much as possible.

As part of the evaluation, I determine what types of support are available (or needed) and the cost. I assess if the evaluee can prepare basic meals and if they can be left alone for extended periods. Other areas may include whether they need help with transportation to medical appointments or someone to attend and advocate on their behalf. Do they need help with creating a grocery list and going to the store? Do they need help organizing their day, such as structuring their time, engaging in an exercise program, participating in hobbies, budgeting, organizing/cleaning their home, and paying bills?

Another critical component involves an individual’s vocation and their ability to return to work. They may be able to return to work without any difficulties or modifications to the environment. On the other hand, they may require a vocational evaluation (testing), accommodations, job restructuring, and/or additional training if they are unable to return to work with their previous employer.


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Above and beyond the daily support, the evaluee may need a case manager to help with long-term planning, medical appointments, referrals to specialists, paperwork, etc.

Mild TBI Cases

Mild TBI cases are the most challenging. These patients outwardly may not have a noticeable impairment. When having a general conversation, one may not recognize that there are any issues. But it’s not until you dive a little deeper that you discover areas of impact. For example, they may be delinquent on paying bills, missing doctor’s appointments, or forgetting to attend an important family event. Therefore, it makes it very challenging to estimate damages to present to a jury because they’re not going to have a true understanding of all the areas of impact.

Establishing a Baseline

In reviewing the medical records, it is helpful to have records prior to the date of the injury as a comparison point. A comprehensive neuropsychological evaluation can provide predictors of what their pre-level functioning was like. Additionally, these professionals are an important part of my analysis, and I will often consult with them as part of the evaluation process.

During the clinical intake interview, I will obtain information regarding their educational level, degrees, certifications/specialized training, and a detail of their past relevant work. I will typically request high school transcripts (if available) and review college and/or technical school records as well. Review of these records will assist in determining any pre-existing learning issues or difficulties present prior to the injury. If it’s a younger person who doesn’t have a well-defined vocational history or hasn’t determined their career goals and aspirations, I will take a deeper dive into the family background.


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Caregiver Fatigue

There is a level of caregiver fatigue with all head injury cases that is often very challenging and taxing. If it’s a child, or a spouse, suddenly they’re living in a home with someone who’s different than they were before. Many times, this results in a change of roles and can negatively impact the relationship(s). Consideration of whether the family requires additional support becomes an important element to address in the life care plan. Examples of support may include additional cognitive therapy, counseling, adaptive equipment/memory aids, or companion support. The life care plan for the individual may also include counseling sessions for the spouse (or parents).

The key to writing a good life care plan for a TBI patient is knowing where to look for what you cannot see.

Julie Sawyer-Little

Julie Sawyer-Little, owner of Sawyer Consulting LLC has provided life-care planning and vocational forensic consulting since 1998. She received her Master of Science in rehabilitation counseling and vocational evaluation from East Carolina University. She is also a licensed occupational therapist. She has provided vocational forensic consultation, long-term disability evaluation and life-care planning services in the area of personal injury, workers’ compensation, medical malpractice and family law. Sawyer-Little is a fellow of the American Board of Vocational Experts and experienced in evaluating level of work capacity, lost wages, benefit of training, and labor market analysis. For more information call (919) 772-1486 or visit

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