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EMSWORLD.com | AUGUST 2017 31 Gene Gandy: Every EMT, AEMT and para- medic has been taught the Glasgow Coma Scale (GCS). It is described variously as a tool to objectively assess the degree to which a person is conscious or unconscious, a way to track changes in level of consciousness and a way to establish a baseline for awareness. It was developed in 1974 by Drs. Graham Teas- dale and Bryan J. Jennett at the University of Glasgow in Scotland. Teasdale and Jennett were neurosurgery professors working in the field of head traumas. Their paper outlining the GCS was published in 1981 and since has become the gold standard for evaluation of responses from patients with traumatic brain injury (TBI). Kelly, can you describe the GCS, how it's supposed to work and any problems you see with it? Kelly Grayson: The Glasgow Coma Scale relies on numeric rating of three parameters: eye opening, verbal response and motor response (Figure 1). Generally, the higher the score, the greater the level of consciousness. But over the years the Glasgow Coma Scale has succumbed to that old military malady known as "mission creep." We use it for too many things it was never designed for. Teasdale and Jennett intended it solely as a bedside scoring system for comatose head- injury patients. It was never intended as a catch-all descriptor of level of consciousness for patients without head injuries, nor was it intended to have each parameter assigned a number and tabulated into a cumulative score. Yet that's how we use it, and it fails in those tasks to varying degrees. One argument against the GCS is its vari- ability between individual raters. Simply put, one medic's "purposeful movement" may be another's "localizes pain." There is even vari- ability in the verbal parameter. For instance, a patient with mild dementia may score as "confused" on the verbal component even though that's been her baseline for years, while a confused patient with a traumatic brain injury is a different kettle of fish entirely. Prognostically it's far too variable. I shud- der to think of how many mildly sick bed- bound patients I intubated back in the day under the doctrine of "GCS less than 8, intubate" when there was an entire wing of patients in the same nursing home with iden- tical scores who had been that way for years. Gandy: Jason, as an emergency physician, what importance do you give a GCS score from the medic during their first report to you when you receive a patient? Jason Kodat: Absolutely none, and I don't recall having ever dictated a GCS into a patient record, either. I've just submitted a proposal to speak at our regional EMS con- ference I titled "GCS and Other Wastes of Your Time." It's so confusing that a survey discovered that one-fourth of British hospi- tals were using the original form of the GCS— rather than the modern 15-point form, which has one additional item—in 2003, when the GCS was 29 years old. 1 Gandy: Steve, there's a new coma score, called FOUR (for full outline of unresponsive- ness) Score, now being touted as a better tool than the GCS. Can you describe it for us? Steve Cole: The idea was to produce an assessment scale that was more sensitive for predicting severity and mortality than the GCS. As discussed, the GCS was originally developed as a simple assessment tool in 1974 and expanded to detect mortality in TBI in the '80s. Since then it's come to be used in a wider variety of conditions and now almost every patient record in EMS and emergency medicine. Despite this widespread accep- tance, it has had a few problems: It doesn't always predict mortality well, and despite its simplistic design, many providers assess it incorrectly. Attempts to modify or improve the GCS (e.g., the SMS) have been varied and troubled too. In 2005 several physicians from the Mayo Clinic scrapped the GCS entirely and developed a new scale. While at first glance it seems more complicated (it has four categories instead of three), it also seems more intuitive and easier to use. This results in a net positive, especially for paramedics and EMTs. It also has been vali- dated extensively in multiple languages and settings and seems to be a better predictor of severity and mortality than the GCS or Simplified Motor Score (SMS) are. Each category is graded on a scale of 0–4, and unlike the GCS, on which dead people have a GCS score of 3, they will now get a score of 0. The four categories are eye, motor, brain stem reflexes and respira- tion (Figure 2). You will note that the "ver- bal response" of the GCS is not included, Figure 1: Glasgow Coma Scale Response Score Eye opening Opens eyes spontaneously 4 Opens eyes in response to speech 3 Opens eyes in response to painful stimulation 2 Does not open eyes in response to any stimulation 1 Motor response Follows commands 6 Makes localized movement in response to painful stimulation 5 Makes nonpurposeful movement in response to noxious stimulation 4 Flexes upper extremities/extends lower extremities to pain 3 Extends all extremities to pain 2 No response to pain 1 Verbal response Oriented to time, place and person; responds appropriately 5 Converses but is confused 4 Replies with inappropriate words 3 Makes incomprehensible sounds 2 Makes no verbal response 1