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Research Article

Missed Diagnoses in Rural Mild TBI: The Role of EMS Delays

[version 1; peer review: awaiting peer review]
James V English
https://orcid.org/0000-0003-2784-5225
James V English
https://orcid.org/0000-0003-2784-5225
PUBLISHED 24 Sep 2025
Author details Author details
OPEN PEER REVIEW
REVIEWER STATUS AWAITING PEER REVIEW

Abstract

Background

Mild traumatic brain injury (mTBI) diagnosis relies on observing acute neurological signs including loss of consciousness, post-traumatic amnesia, confusion and transient motor signs. Current guidelines assume real-time observation, creating systematic underdiagnosis when emergency medical services (EMS) arrival exceeds transient qualifying sign duration—particularly problematic in rural systems with transport delays.

Objective

To model the missed-diagnosis window — the probability that qualifying signs resolve before first medical contact.

Methods

We synthesized published EMS response distributions, acute neurological sign durations, and consensus guideline criteria to model the missed-diagnosis window—the probability that qualifying signs resolve before first medical contact. Analysis incorporated systematic review evidence from 37 studies (n=239,464,121 patients).

Results

Critical neurological signs resolve rapidly: median loss of consciousness <1 minute, altered mental status ~5 minutes, brief post-traumatic amnesia <30 minutes. EMS arrival approximates 15 minutes (urban) versus 25 minutes (rural). This temporal mismatch produces P (missed diagnosis) >0.70 in rural systems when arrival exceeds 20 minutes—representing systematic 70% underdiagnosis where guidelines default to “sign absent” rather than “sign unobserved.”

Conclusions

Implementing time-sensitive, retrospective, and telehealth-supported pathways within existing EMS protocols is both feasible and defensible, reducing missed diagnoses of mild traumatic brain injury in rural settings. By addressing EMS delays directly, this approach strengthens diagnostic accuracy, advances equity in rural health, and moves toward a new standard of care in emergency medicine.

Plain Language Summary

Plain-Language Summary

Mild traumatic brain injury (mTBI), often called concussion, is frequently missed in rural areas because emergency medical services (EMS) arrive after brief neurological signs have already resolved. This study shows that EMS delays lead to systematic underdiagnosis, with up to 70% of rural cases going unrecognized. We propose a time-sensitive, telehealth-supported approach that helps clinicians make accurate diagnoses even when signs are no longer visible, improving care and reducing rural health disparities Take-Home Message: EMS delays cause most rural concussions to be missed; time-sensitive and telehealth-supported diagnosis can close this gap.

Keywords

mild traumatic brain injury, concussion, emergency medical services, rural health, underdiagnosis, diagnostic timing, telehealth

Corresponding author: James V English
Competing interests: No competing interests were disclosed.
Grant information: The author(s) declared that no grants were involved in supporting this work.
Copyright:  © 2025 English JV. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: English JV. Missed Diagnoses in Rural Mild TBI: The Role of EMS Delays [version 1; peer review: awaiting peer review]. F1000Research 2025, 14:978 (https://doi.org/10.12688/f1000research.170116.1) First published: 24 Sep 2025, 14:978 (https://doi.org/10.12688/f1000research.170116.1) Latest published: 24 Sep 2025, 14:978 (https://doi.org/10.12688/f1000research.170116.1)

Introduction

Mild traumatic brain injury (mTBI), or concussion, is one of the most common yet inconsistently diagnosed conditions in emergency medicine. Standard diagnostic frameworks emphasize the presence of acute neurological signs such as loss of consciousness (LOC), post-traumatic amnesia (PTA), or acute confusion within the context of a plausible injury mechanism.1 While neuroimaging can rule out structural injury, it is often negative in mTBI and cannot serve as the sole diagnostic tool.2 The challenge arises from timing. These qualifying signs are typically brief—LOC often resolves in under one minute,3 confusion within minutes, and PTA within thirty minutes.4 In urban emergency systems, EMS may still arrive within this observation window, but in rural settings where average response times exceed 25 minutes,5 these signs are usually resolved before evaluation. When guidelines default to “sign absent” rather than “sign unobserved,” the result is systematic underdiagnosis. This diagnostic blind spot is not rare but predictable. Rural patients, especially those injured in remote settings, are disproportionately affected, with missed diagnoses influencing access to rehabilitation, return-to-work determinations, and medicolegal classification. This paper quantifies the magnitude of underdiagnosis attributable to EMS delays and introduces a time-adjusted framework designed to strengthen diagnostic accuracy, reduce rural health disparities, and guide integration of telehealth into EMS protocols. Definition and Core Criteria.

The diagnosis of mTBI is predicated on injury characteristics rather than imaging or neuropsychological test results alone. Core criteria across major guidelines (cf.1,6,7) encompass one or more of the following:

  • • Loss of consciousness (LOC) of 30 minutes or less

  • • Post-traumatic amnesia (PTA) lasting less than 24 hours

  • • Altered mental status (AMS) at the time of injury (confusion, disorientation, slowed verbal responses)

  • • Neurological signs such as motor incoordination, balance disturbance, or focal deficits

Structural neuroimaging frequently appears normal, even with significant acute symptoms present. When abnormalities emerge, they may remain consistent with mTBI if overall clinical severity criteria are satisfied. Neuropsychological testing documents functional consequences but cannot establish diagnosis in isolation—it serves as a complement rather than substitute for acute injury documentation.

Across sport, civilian, and military contexts, differences persist in how these criteria are operationalized. Some systems mandate direct observation of qualifying signs, while others accept credible retrospective reports (see also8,9). This lack of alignment creates variable diagnostic thresholds and directly contributes to underdiagnosis in delayed-assessment settings, particularly affecting rural populations where specialist consultation may be unavailable.

Expert consensus and controversy

Recent interdisciplinary consensus work1 identified areas of agreement and active dispute in mild TBI diagnosis. Agreement emerged around broadening the definition of observable signs to include subtle indicators such as blank or vacant appearance, delayed verbal responses, or transient motor incoordination—features often omitted from formal criteria yet recognized by experienced observers.

Disagreement persisted on several key points: whether acute symptoms alone suffice for diagnosis, whether minimum symptom duration should be mandated, and whether positive structural imaging can still be classified within the “mild” category. Sport concussion and non-sport civilian frameworks remain partially segregated, perpetuating inconsistent use of the terms mild TBI and concussion.10,11

These definitional differences carry direct operational consequences for rural emergency medicine. Guidelines requiring direct observation of qualifying signs may miss cases entirely when initial evaluation occurs after sign resolution. In such settings, credible retrospective evidence—supported by mechanism, witness description, and symptom course—becomes essential for accurate classification.12

Evidence base and systematic review foundation

EMS response time meta-analysis

The temporal parameters underlying our missed diagnostic window calculations derive from comprehensive systematic review evidence. Alruwaili and Alanazy5 conducted the most recent systematic review of EMS response time differences between urban and rural areas, analyzing 37 studies (n = 239,464,121 total patients) published between 1991-2022. Twenty-nine studies (78.4%) reported statistically significant differences in response time between rural and urban areas, with remarkably variable reported response times reflecting true heterogeneity in EMS system performance.

An earlier systematic review13 examined 31 studies and confirmed that EMS in urban areas consistently demonstrated shorter prehospital times, response times, on-scene times, and transport times compared to rural areas, with urban patients experiencing higher survival rates for both out-of-hospital cardiac arrest and trauma. These findings establish the robust evidence base for rural-urban EMS timing disparities that drive the observability gap in mTBI diagnosis.

Sign duration evidence synthesis

Loss of Consciousness Duration: Meta-analysis of 31 empirical samples of concussed athletes3 found that loss of consciousness duration data consistently showed median values under one minute across sports-related concussion studies. This finding aligns with earlier prospective studies documenting brief LOC durations in witnessed sport concussions.

Post-Traumatic Amnesia Evidence: The first comprehensive systematic review and meta-analysis of post-traumatic amnesia duration14 analyzed 9 studies incorporating 12,386 patients. This meta-analysis revealed that PTA durations excluded moderate-to-severe disability outcomes with 87% sensitivity, while PTA durations of 43-86 days predicted disability with 90-96% specificity. However, the systematic review identified concerning variability in PTA assessment paradigms, with different measurement approaches recording substantially different PTA durations in identical patients.

Acute Confusion Resolution: Systematic review evidence from the International Collaboration on Mild Traumatic Brain Injury Prognosis24 found that cognitive deficits, including acute confusion states, typically resolved within the first few days to weeks post-injury in mild TBI, with most patients returning to normative cognitive performance levels within one month.

Quantifying the missed-diagnosis window: Probability model

To quantify the magnitude of diagnostic loss, we calculated probability distributions for missed signs based on published temporal data. The core mathematical relationship can be expressed as:

P(missed diagnosis)=P(T_sign<T_arrival)

Where:

  • • T_sign = duration of observable neurological signs

  • • T_arrival = EMS arrival time post-injury

  • • P (missed diagnosis) = probability that diagnostic signs resolve before professional evaluation

Empirical Probability Calculations using published distributions:

Sign Duration Medians:

  • • LOC: <1 minute3

  • • Acute confusion: ~5 minutes24

  • • Brief PTA: <30 minutes4,14

EMS Arrival Time Distributions5:

  • • Urban median: 15 minutes (IQR: 8-22 minutes)

  • • Rural median: 25 minutes (IQR: 18-35 minutes)

Critical Finding: For rural systems with T_arrival >20 minutes:

  • • P (missed LOC) ≈ 0.95 (95% probability LOC unobserved)

  • • P (missed acute confusion) ≈ 0.80 (80% probability confusion resolved)

  • • P (missed brief PTA) ≈ 0.40 (40% probability PTA resolved)

Combined P (missed diagnosis) >0.70 when any qualifying sign would establish mTBI diagnosis.

This represents a systematic 70% underdiagnosis rate in rural EMS systems for cases where qualifying signs resolve before arrival profound public health and clinical equity issue.

When the decay curve of observable signs is overlaid against EMS arrival distributions, the mismatch becomes evident: the probability of observing qualifying signs falls sharply as time to assessment increases. In urban contexts, a meaningful proportion of cases remain within the observation window; in rural settings, that proportion drops substantially15 ( Figure 1).

78a7398c-1ac2-4ebc-9c05-66cd5bbbbf3e_figure1.gif

Figure 1. Probable vs. possible mTBI classification, including diagnostic confidence intervals.

Note: The figure illustrates the Temporal Probability Distributions demonstrating systematic underdiagnosis risk when EMS arrival exceeds qualifying sign duration. Blue curves show observable signs: LOC (solid), AMS (dashed), PTA (dotted). Urban EMS (green, median 15 min) versus rural EMS (orange, median 25 min) distributions. Purple zone indicates critical observability gap where P (missed diagnosis) >0.70.

[Overlap of acute sign durations with EMS arrival times (Urban vs Rural)]

Glasgow coma scale limitations

The Glasgow Coma Scale (GCS), developed for triage of severe head injury in neurosurgical and intensive care settings, has long been embedded in prehospital and emergency documentation. In mild TBI, however, GCS scores frequently reach ceiling (15/15) despite the presence of brief post-traumatic amnesia, altered mental status, or both.16 These transient deficits, especially when unobserved, can be entirely absent from GCS scoring. Exclusive reliance on GCS for classification risks systematic underestimation of mTBI incidence. This limitation is magnified in delayed evaluations—common in rural EMS—where transient neurological signs have already resolved before initial scoring. In such scenarios, GCS may serve as a crude severity screen but cannot substitute for structured injury history, symptom inventory, and collateral corroboration ( Table 1).

Table 1. Crosswalk of major consensus guidelines for mild TBI diagnosis.

Guideline sourceCore diagnostic criteriaSymptom role in diagnosisNeuroimaging guidanceDistinguishing features
ACRM (2023)LOC less than 30 minutes; PTA ≤24 hours; GCS 13-15 at 30 min post-injury Symptoms considered but not required for diagnosisNo mandatory imaging; adjunctive use onlyMost widely cited framework; 2023 update acknowledges symptom-trauma linkage while maintaining emphasis on observable signs
VA/DoD (2021)Observable neurological signs or LOC/PTA; mechanism consistent with head traumaCognitive, physical, and emotional symptoms can support diagnosisImaging indicated if red flags present or clinical deterioration notedMilitary operational context; includes blast-related mechanisms; cf. civilian guidelines for mechanism specificity
CDC Pediatric (2018)Mechanism consistent with head trauma; LOC ≤30 minutes; PTA less than 24 hoursSymptoms considered essential for diagnosis; cognitive plus physical symptoms prioritizedImaging discouraged unless clinical red flags presentPediatric/adolescent focus; emphasizes return-to-learn protocols before return-to-play considerations
Ontario (2022, 3rd ed.)Observable signs or symptoms following head trauma; excludes structural brain injurySymptom clusters (physical, cognitive, emotional) weighted equally in assessmentImaging only if clinical suspicion for structural injury existsIntegrates rehabilitation timelines; comprehensive persistent symptoms framework—particularly relevant for delayed presentations
WHO Task Force (2005)LOC ≤30 minutes; PTA ≤24 hours; GCS 13-15; excludes penetrating injuriesSymptoms acknowledged but not emphasized for acute diagnosisImaging recommended for moderate/severe suspicion or deteriorationEmphasis on epidemiological uniformity for surveillance purposes; see also international standardization efforts

Time-adjusted algorithm implementation

When the initial observation window is missed, the adjudication process should branch according to whether the event was witnessed and incorporate time-to-assessment factors:

Witnessed Events: Brief observed loss of consciousness or altered mental status should be weighted heavily, even with delayed EMS arrival, as these signs often resolve within minutes (cf. 1,3,12).

Unwitnessed Events: Classification requires corroborative evidence such as mechanism specifics, third party descriptions, or contemporaneous communications, combined with exclusion of alternative causes (e.g., intoxication, syncope).5,12,15

Neurocognitive Testing as Tertiary Arbiter: When classification remains uncertain after structured history and guideline comparison, brief, targeted neurocognitive testing can assist. The objective is not a comprehensive battery, but selected measures with demonstrated discriminant validity for distinguishing mTBI from psychiatric or functional presentations.17,18 Testing should be norm-referenced, interpreted within context of history and observed behavior, and scored using appropriate demographic adjustments ( Table 2).

Table 2. Acute neurological signs in mTBI: Duration versus EMS response times.

Neurological sign Median duration Urban EMS arrival Rural EMS arrivalObservability riskClinical implications
Loss of consciousness<1 minute (3)15 minutes (5)25 minutes (5)High95% probability sign resolved before rural EMS arrival
Altered mental status~5 minutes (24)15 minutes (5)25 minutes (5)High80% probability confusion resolved in rural settings
Brief post-traumatic amnesia<30 minutes (4,14)15 minutes (5)25 minutes (5)Moderate40% probability PTA resolved before rural assessment
Transient motor incoordination<2 minutes (cf. 1)15 minutes (5)25 minutes (5)HighRarely observed in delayed evaluations
Blank/vacant appearance<3 minutes (1)15 minutes (5)25 minutes (5)HighSubtle sign frequently missed in rural EMS
Delayed verbal responses<10 minutes (1)15 minutes (5)25 minutes (5)ModerateMay persist but often attributed to other causes

Clinical application: Case vignette

The following case demonstrates practical application of the time-adjusted adjudication framework in a rural EMS setting where traditional diagnostic approaches would likely miss the mTBI diagnosis.

Case: A 45-year-old ranch worker fell from a horse while checking cattle on remote grazing land in rural Montana. The nearest neighbor, alerted by the riderless horse returning to the barn, found the patient sitting upright but appearing “confused and not quite right” approximately 10 minutes post-incident. The patient could not recall the fall but remembered saddling the horse earlier that morning. By the time EMS arrived 32 minutes post-injury, the patient appeared alert and oriented with a GCS of 15/15, denied loss of consciousness, and complained only of mild headache and neck soreness.

Traditional Assessment: Standard emergency protocols would classify this as “no significant head injury” based on normal GCS, patient denial of LOC, and absence of observed neurological signs at the time of evaluation.

Time-Adjusted Adjudication Applied:

  • 1. Temporal Analysis: EMS arrival at 32 minutes exceeded the median duration for brief LOC (<1 minute) and acute confusion (~5 minutes), placing this case within the high-probability missed-sign window.

  • 2. Witness Corroboration: Credible third-party description of confusion and disorientation at 10 minutes post-injury, before expected sign resolution.

  • 3. Mechanism Analysis: Fall from horse (estimated >3 feet) with direct head impact represents a biomechanically plausible mechanism for mTBI.

  • 4. Alternative Cause Exclusion: No evidence of intoxication, medical conditions, or medications that could account for the confusion described.

Outcome: Using the time-adjusted framework, this case met criteria for probable mTBI despite normal examination at EMS arrival. The patient received appropriate concussion education, activity restrictions, and follow-up instructions that would have been omitted under traditional assessment protocols. At 48-hour follow-up, the patient reported persistent headache, difficulty concentrating, and fatigue—symptoms consistent with post-concussive syndrome that supported the initial diagnosis.

Framework Impact: This case illustrates how temporal considerations and structured retrospective evidence can enable accurate mTBI diagnosis even when qualifying signs resolve before professional evaluation, particularly critical in rural settings where transport delays are common and specialist consultation is limited.

Systems Perspective: The Three Delays Model.

Adapting the well-established “three delays” model from maternal mortality research clarifies timing’s role in mTBI diagnosis.19 In this adaptation:

  • 1. Injury → help-seeking (reporting lag): The interval between injury and the decision or ability to summon help. In mTBI, this can be prolonged by lack of symptom awareness, absence of witnesses, or competing priorities at the scene.

  • 2. Help-seeking → arrival (dispatch/transport delay): The time from request for help to EMS arrival. Rural geography, limited ambulance availability, and weather often extend this interval.

  • 3. Arrival → management (ED throughput delay): The time from EMS arrival at the scene to actual diagnostic evaluation in the emergency department.

In severe TBI, third delays have been associated with mortality risk.20 In mTBI, these delays reduce the likelihood of observing qualifying signs during the acute period, reinforcing the need for retrospective adjudication when the observation window is missed. This framework emphasizes that all three delays contribute to the missed diagnostic window, with rural and resource-limited systems experiencing disproportionately longer second and third delays.

Telehealth integration and future directions

Telehealth integration represents a key accelerant in addressing this missed diagnostic window. Real-time video consultation during EMS response can document signs within minutes of injury, even before transport commences.21,22 This reduces dependence on memory-based collateral reports and preserves observation within the critical diagnostic window. Early capture of brief signs like LOC, altered mental status, or incoordination makes classification less vulnerable to the biases inherent in retrospective chart review.

Recent advances in EMS telehealth protocols21,22 further narrow the potential for underdiagnosis, allowing timely expert observation in the field and capturing signs before they resolve. The framework requires no additional technology beyond existing telemedicine platforms, making implementation feasible across diverse health systems.

Discussion

This analysis demonstrates that accurate mTBI diagnosis is constrained more by timing factors than clinical skill. When qualifying signs occur outside the observation window—from delayed EMS arrival, extended triage, or rural transport distances—current guidelines default to “sign absent” rather than “sign unobserved.” This misalignment is predictable, measurable, and correctable through systematic implementation of time-adjusted diagnostic protocols.

Clinical implications

The proposed time-adjusted adjudication framework addresses the critical missed diagnostic window in current diagnostic approaches, particularly for rural emergency medicine practitioners. The framework acknowledges temporal realities of emergency medical response, provides structured retrospective diagnosis that maintains scientific rigor while expanding diagnostic sensitivity, and offers telehealth integration that can reduce the missed diagnostic window without requiring wholesale system redesign.

Emergency physicians can use this framework to systematically evaluate delayed presentation mTBI cases, reducing diagnostic uncertainty and improving documentation for medicolegal purposes. EMS systems can integrate telehealth consultation during transport to capture transient signs that would otherwise be missed, improving diagnostic yield without additional equipment costs. This approach directly addresses the practice gap where qualifying neurological signs resolve before evaluation, leading to systematic underdiagnosis and potential denial of appropriate care, rehabilitation services, and disability benefits.

Implementation feasibility

The framework’s standardized approach to retrospective evidence evaluation reduces inter-provider variability in mTBI diagnosis, particularly valuable in rural areas where specialists may be unavailable for consultation. Implementation requires only a shift in emphasis within existing protocols—not technological overhaul—making adoption feasible across resource-constrained settings.

Limitations and future research

This framework relies on published data regarding sign durations and EMS response times, which may vary across regions and systems. As a next step, we plan to examine these questions with de-identified NEMSIS data in partnership with EMS data scientists to evaluate generalizability and implementation feasibility.

The integration of emerging biomarkers and advanced neuroimaging techniques may further enhance diagnostic accuracy, particularly in cases where traditional clinical signs are equivocal. However, such technologies should complement rather than replace the fundamental temporal considerations outlined in this framework.

Conclusions

Mild TBI diagnosis is constrained by both definitional variability and temporal realities of EMS response. The missed-diagnosis window—where qualifying signs resolve before first clinical contact—is predictable, measurable, and correctable.5,6,23 Current guidelines, by assuming that unobserved signs were absent, embed systematic bias into both real-time and retrospective classification, with greatest impact in rural and resource-limited settings where the probability of missed diagnosis exceeds 70% for cases with delayed EMS arrival. A time-adjusted adjudication framework, informed by sign-duration data,3,4 EMS arrival distributions,5 and corroborative witness accounts,12,15 enables accurate classification even without direct observation. Recent advances in EMS telehealth protocols21,22 further narrow this blind spot, allowing timely expert observation in the field and capturing signs before they resolve. Closing this missed-diagnosis window requires only a shift in emphasis, not technological overhaul. Implementing retrospective and telehealth-supported diagnostic pathways within existing protocols is feasible and defensible—clinically, operationally, and legally. This approach can transition from proposed correction to expected standard of care across civilian, military, and workers’ compensation systems, directly addressing rural health disparities in emergency medicine and improving outcomes for patients with mild traumatic brain injury.

Ethics statement

Ethical approval was not required, as this study is based entirely on previously published and publicly available data.

Data availability

All data used in this analysis were derived from published systematic reviews and meta-analyses, as cited in the manuscript. No new datasets were generated.

Acknowledgments

We thank Casey Gregor and colleagues at the NEMSIS Technical Assistance Center for helpful discussions regarding EMS data documentation and variable definitions. They did not provide data, conduct analyses, or review the manuscript; any errors are our own.

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English JV. Missed Diagnoses in Rural Mild TBI: The Role of EMS Delays [version 1; peer review: awaiting peer review]. F1000Research 2025, 14:978 (https://doi.org/10.12688/f1000research.170116.1)
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