Collage Rehabilitation Partners Appoints Shannon Swick to Chief Executive Officer

When A Case Slips Through the Cracks

“Have you had individuals that are admitted to an inpatient facility 5-6 months post injury? I just took on a brain injury case that has slipped through cracks – he is refusing to go to outpatient therapy, is very irritable and is becoming aggressive.”

Calls like this come in regularly from case managers who don’t know where to start. The short answer to the question is yes. In the early days of a brain injury, behavioral challenges might be considered a “normal” phase of recovery. Injured workers who seem to be recovering well physically, are sent home with instructions to see their physician and go to outpatient therapy -slowly things can begin to unravel. Mood swings, irritability, change in personality, outbursts, refusing treatment, failed attempts at return to work, verbal and physical aggression can become are just a short list of what can go wrong. Often, the injured worker doesn’t recognize these changes which can be extremely stressful for their family members and can impact the individual’s safety. Behavioral challenges vary from person to person and require a specialty inpatient or residential program to identify the cause of the behavior and move toward stability by developing effective strategies to move forward toward a productive life.

Bob was a truck driver who rolled his truck a year prior to admission to one of our neurobehavioral programs. He doesn’t remember the accident or his group of his co-workers who pulled him through the front window and transported him to meet an EMS team where he reportedly lost consciousness and experienced several episodes of apnea. He was intubated and airlifted to a trauma center where he was diagnosed with a concussion.  He was extubated, complaining of pain and extremely combative with the hospital staff. The following day, he was discharged to his rural home with instructions to follow up with a physician.

A year later, chronic pain in his head and neck, visual disturbances ringing in his ears, weakness, irritability and tingling in his hands were just a few of the many symptoms he was experiencing. The decision to seek residential treatment was not easy for Bob. He considered himself the provider and head of his family which included not only his wife but his granddaughter and her child who was the center of his life.  He took great pride in his work and earned awards for safety on the job more than once – the implications of this accident affected every part of the life that he had led up until that day. His wife, daughter and grandchild began to avoid him; where he once enjoyed being busy, making and fixing things, traveling and providing for his family, he became angry, difficult and moody.  Visits to medical providers yielded very little in the way of help and his symptoms worsened over time.  At the request of his workers compensation insurance case manager, Bob was evaluated for a post-acute rehabilitation program.  As hard as it was for him, Bob admitted that he was in pain, weak, fatigued and dizzy – always.  Our evaluator and Bob’s Worker’s Compensation Case Manager knew that Bob had suffered much more than a concussion.  It took him several more months to finally agree to short term admission for post-acute rehabilitation.

Rural living situations often mean that there is very little in the way of an available integrated treatment program to pull together a cohesive plan to address symptoms and equally as important, allow injured workers to rehabilitate and gain back a meaningful life. Visits to medical providers often are frustrating and yield little in the way of help for symptoms which can worsen over time. Cases like these require a comprehensive evaluation and a specialized brain injury program to uncover the underlying issues that are the cause of the behavior and execute an individualized plan that works toward behavioral and medical stability, cognitive improvement and the establishment of a successful path.

Key features of this success include:

  • Establishing trust with the injured worker from day one and making sure they know that we were here to help
  • Treating symptoms and recognizing their origin
  • Teaching self-monitoring and self-regulation
  • Encouraging the injured worker to remind themself of what needs to be done to stay asymptomatic
  • Helping to gain an understanding that traumatic brain injury is a chronic condition that doesn’t have to be as debilitating as long as strategies learned in treatment continue to be utilized
  • Educating family on the specifics of the injury and their role in helping their family member stay healthy

The morning after his admission, Bob’s agitation and anger got to the point of being dangerous.  He was demanding to go home. He became aggressive, making numerous threats toward ReMed staff as well as his family members.  His behavior continued to escalate but interventions including a change in medication and a consistent presence of skilled staff helped Bob understand why he was admitted to the program and became the key to moving forward.  Additionally, he was told if he wanted to leave, he could, but there was a right way and a wrong way to do that. Four days later he was expressing hopefulness and a willingness to engage in treatment. Team members began to establish a basis of building trust and Bob was able to reconcile that our team was there to help him.

Week One provided greater insight into Bob’s personality.  According to him he stated that the “new medication seemed to be curing everything.” But his symptoms were observably there and he was struggling.  Week Two he told the team he was struggling with holding it all together and was ready to work hard and get better. And the team got to work and Bob got to work.

The team went to work assessing and treating his symptoms – while Bob presented symptoms common to a severe vestibular disorder, it was determined he did not have a vestibular disorder but instead a profound visual disturbance (optic neuralgia). A consult with a visual specialist in conjunction with our occupational therapist provided him with the right glasses which helped significantly with his dizziness, headaches and sensory overload.  Improvement of  this issue significantly contributed to his ability and wherewithal to work on his treatment goals which included decreasing pain, improving function and cognition, identifying triggers and developing coping skills, maintaining medical stability, improving psychological health and adhering to a stable activity pattern. Throughout the course of treatment, the team began to see who Bob truly was.  As time went on, he continually stated that he felt better, that he “was not that guy” referring to the Bob initially seen and he made significant improvements and understood the importance of self-monitoring and self-regulation which would keep him asymptomatic. The team worked from a distance with his family to educate them and help them understand his symptoms better and what they needed to do over the long term to keep him on course and healthy.

At just under 90 days, Bob was discharged in time to be home for the holidays. The dynamics of his admission and treatment were something that our experienced team understands and is experienced with – initially a failure to engage until trust is built and the realization that we are there to help him get better and function at a level that is meaningful to Bob and his family, so that he can get back home

He left with a binder full of key strategies and his medical summary which will go everywhere with him.  Providers in his local community were identified, including a local case manager who understood brain injury. Prior to discharge he asked if he could do something special for the team who helped him make so much progress. He prepared a recipe – one that his family enjoyed for generations at the holidays – to share with his rehabilitation family.