ISYSEd Packs The House With Orange County Seminar On Spinal Cord Injuries
By Lonce LaMon - January 26, 2011
On Wednesday, January 19th, ISYSEd, based in Brea, California, packed a large convention room during a long lunch hour at the Crowne Plaza Anaheim Hotel to educate workers' compensation claims professionals on the subject of Spinal Cord injuries. Alysha Calderon, the General Manager of ISYSEd, presided over the event.
There wasn't a seat left open in the whole room as Ann Vasile, M.D., Medical Director of Spinal Cord Injury and Rehabilitation at Long Beach Memorial Hospital, Angie Jung, Nurse Case Manager with ISYS, and Kristina Ripatti, a paralyzed former LAPD officer shot in the line of duty in 2006, gave a panel set of lectures to the group which were not only highly educational and informative, but were very entertaining. There was plenty of applause accompanied by repeated cacophonies of laughter as the speakers engaged the audience.
According to Ann Vasile, M.D., there are numerous conditions that manifest themselves as salient side effects to a spinal cord injury. It's not just that the patient gets a spinal cord injury and is subsequently paralyzed to a lesser or greater degree, depending upon the severity of the injury, and that's that. Many other conditions, illnesses, and diseases occur as a direct or indirect result of the spinal injury. Thus, Dr. Vasile lectured clearly to point out all the conditions that could be the responsibility of the workers' compensation payer if the spinal cord injury occurred arising out of or in the course of employment (AOE/COE) and those conditions had not pre-existed the injury.
Early on, Dr. Vasile expressed, the spinal injury patient is vulnerable to pneumonia. Depending on the level of injury, you may have unopposed parasympathetic supply which causes secretions. Here you have somebody who doesn't have good muscle strength they are making secretions, and these things set (the patient) up for early on pneumonia. It may be related to an upper respiratory infection that an able bodied person could handle, but the disabled cannot.â€
Another consequence is restrictive lung disease. Everything shrinks down, Dr. Vasile said. There's less capacity. Everything is shrunk down and there's a smaller space. There's less air.
Officer Kristina Ripatti was patrolling in South Los Angeles around the Exposition Park area with her partner, Officer Joe Meyer, in early June of 2006. Suddenly, a man ran directly in front of their marked car, causing them to have to slow way down to avoid hitting him. Thus, they got out of their vehicle and followed him on foot.
The man they chased was James Fenton McNeal, a career criminal, who had served multiple prison terms for a long list of violent crimes, including armed robbery and murder. Mc Neal reached the front porch of a near-by residence, turned around and pointed a gun at the officers and opened fire. Officer Ripatti was struck by McNeal's gun fire. McNeal was struck in the torso by Kristina's partner's return fire and died at the scene.
Kristina's husband, Tim Pearce, who was also a police officer in her same unit, was the first one to arrive at the scene. Angie Jung, who became Kristina Ripatti's nurse case manager, told the audience she sustained three gun shot wounds to the chest, and two gun shot wounds to her left arm. One of the bullets entered her left arm and went into her left rib. They had to remove part of her left lung. The gun shot caused a complete severing of the T2 and T3 level of her spinal cord.
Dr. Ann Vasile continued by saying she also diagnoses obstructive sleep apnea which is a regular effect of a spinal cord injury. We see it commonly in the higher cervical levels. So that needs to be treated. Untreated obstructive sleep apnea increases risk for just about everything. Stroke. Cardiac disease. So, look for that and treat that.
She discussed bradycardia as a common condition in a spinal injury patient. They get this because they get neurogenic shock. Because you have that lack of the sympathetic supply the blood pressure goes down. You don't get the compensatory sympathetic system to increase the heart rate. Thus, you get bradycardia.
Therefore, often early on, spinal cord injury patients need pace makers. Because there is nothing to bring that heart rate back up to an appropriate level, Dr. Vasile said.
Angie Jung, RN, emphasized the importance of early involvement in the case. It's always best to have someone go out the same day as the injury. So, I went to the hospital that same day.
She also emphasized her goal to attain all the information that is needed for the claims professional. The employer and the claims professional need to know what's going on.
Angie really worried once she found out that Kristina Ripatti had a complete spinal cord injury. This is life changing. She worried about her career, her recovery, and the psychological aspects as well. She knew from day one that she was going to need a very good spinal cord rehab.
Educating the family is very important so they know what to expect. It's important for them to start planning for the rehab phase as soon as possible. It's a very overwhelming time for the patient.
As the nurse case manager, Angie Jung kept in touch with the employer and the insurance claims department not only every day, but sometimes several times a day. We had team conferences with the employer. I informed them as to the extent of Kristina's injury so they could set adequate reserves.
According to Dr. Ann Vasile, Poikilothermia is a persistent condition that spinal cord injury patients have to contend with. Poikilothermia means that one becomes one's ambient temperature. If it's cold, the individual with the spinal injury gets colder than the able bodied. If it's hot, the person with the spinal injury gets hotter than the able bodied. So, the claimant has the challenge of having to dress in layers while being vulnerable to the danger that the temperature fluctuations could set off dysreflexia.
We recommend that patients have heating and air conditioning in their homes, and although this could be considered a luxury, it really is for medical reasons that we are recommending it, Dr. Vasile added. It's dangerous if you're not able to manage your own body temperature. One could have a fever and it could be an infection, but it could just be the poikilothermia and the impaired temperature regulation.
Dr. Vasile further explained that one of the emergencies she sees with spinal cord injuries is autonomic dysreflexia. It is caused by noxious stimuli, which is anything that is annoying the body. So, the body gets into an overstimulation of the sympathetics and the adrenaline.
There's an overflow of the adrenaline. High blood pressure. Sweating. Head ache. Goose bumps. Flushing. But not everybody gets all that. Someone may just get the goose bumps. And then they start to figure out what their dysreflexia is. One challenge is pregnancy. And dysreflexia became an issue with Kristina.
Kristina Ripatti had a baby less than two years after being shot by the bullet that hit her spine and paralyzed her from the chest down. She expressed her overwhelming gratitude for her healing to her nurse case manager, Angie Jung, her physical therapists, which included Diana Owrey, and to Dr. Ann Vasile.
I couldn't have done half of these things I can now do without the support of this team. It's by no means a one woman show.
She went on to say, "It's totally unexpected and it completely turns your life upsidedown, in an instant and overnight. It fundamentally affects every aspect of your life. I can compare it to visualizing a pie. Each slice of that pie is an aspect of your life. Work. Your life style. Hobbies. Your health. Your relationships. Your intimacy. If any person has to have one of those slices removed from their life, it's devastating. But to take all of them and have all of them affected at one time, is definitely overwhelming. And that's exactly what happens with this injury."
She was married at the time that she was shot; and she and her husband had a 15 month old daughter. Her husband saw her when she was shot and he was greatly affected by it. There were so many issues to deal with: home life, all the health issues, child care.
"It became instantly overwhelming. That's why having a case manager became so important. The first week I was at California Hospital I was in a complete daze. Because of all the wonderful narcotics I was on. But, I kept seeing Angie's face. And I thought, this person must be pretty important. I had no idea at that time just how important she was going to be; and just how valuable of a resource she would be. I was just trying to do some simple things like sitting up."
Kristina further expressed how the service Angie Jung provided was truly invaluable, only one aspect being that she dealt with the insurance process and that was such a huge burden lifted off of her and especially her husband. "We were talking about it last night, and Tim was reminiscing and said, 'You need to express to this crowd about how important it was that she was there.'"
Ann Vasile moved forward through her long list of the conditions that happen to the spinal cord injury patient. She pointed out that there is a decline in the immune system. Then, with the use of steroids, which are used on spinal injury patients, the immune system is further taxed as steroids are immune system repressants. Thus, she regularly recommends a flu vaccine.
Persons with spinal cord injuries get abnormalities in their metabolism. They get high triglycerides. Low vitamin D. A higher risk of osteoporosis.
"Osteoporosis will occur in spinal cord injury. In the first six months, you will see a decline in bone density.
Then, there's the problem of pain. Nociceptive pain is above the level of the injury. Neuropathic pain is below the level of the injury. Pain above the level of the injury is easier to treat because there are more standards.
"Neuropathic pain is harder to treat because it's the injured nerve sending the wrong messages. It's telling you you have pain where you shouldn't be having pain. We treat it not very well. We treat with Lyrica. We use antidepressants. We try topical agents. Acupuncture. Implants. Pumps. None of them have really been the answer. But topical agents and acupuncture are the most usual in conjunction with medications."
Another thing that happens is the spinal injury patient gets bone growth where it shouldn't be: heterotopic ossification. Heterotopic means where it shouldn't be. Ossification means increase of bone.
"It starts with a swollen joint that starts losing range of function. We treat for six months so as to cease that bone growth. But you can't treat for too long as that increases the risk of osteoporosis.
In the hip and knee are the most common places where heterotopic ossification happens with spinal cord injuries. For brain injuries it's in the elbow.
Then there's spasticity. The nerves in the spine are still sending messages to the muscles. And the brain and the spinal cord are not giving the sophisticated information to control that. Thus, it causes an involuntary contraction. Early on, it takes usually 2 to 3 weeks to come out of spinal shock. Those nerves below the brain or spine will have spasticity—an involuntary contracting of muscles. It's not associated with prognosis.
"It is just a reflex action. The patient says, am I moving my leg? It has nothing to do with neurologic recovery. But it does significantly affect function. Because a severe spastic response can throw you out of your wheelchair. We can consider medication. Benzos: valium. Other medications.
Pressure sores are a worrisome and common problem. In referring to Christopher Reeve, the Superman actor who sustained a severe spinal cord injury as a result of a fall from a horse, Ann Vasile pointed out that his ultimate demise was caused by a pressure sore.
Pressure sores can be treated with good bandages, or with a scraping off of the surface, or in some extreme cases with surgery.
Pancreatitis can be seen acutely and chronically. Also ulcers. Hemorrhoids are seen quite frequently.
With respect to sexuality and fertility, in male patients there are more long term impairments. The erection and ejaculation is impaired both acutely and chronically. Sperm tends to be less mobile. In the female menstruation will return within six to twelve months. After 12 months the fertility should be back to the able bodied level."
Kristina Ripatti expressed towards the end of the seminar, as she spoke last, that she was extremely happy to be there.
"The support system is what got me to where I am today. I would like to do whatever I can to be an advocate for spinal injury awareness. If I can just emphasize the point of how important it is to have a knowledgeable team: to have Dr. Vasile and a case manager like Angie.
"Thank you. Educate the workers' compensation community."
lonce@adjustercom.com
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