TRAUMATIC BRAIN INJURY: Part 4

HOW DAMAGE AFFECTS FUNCTION:

When certain areas of the brain are damaged, there will be different functional losses depending on which area or hemisphere it is.

CEREBRUM:

• Left Hemisphere: Will affect the function of the right side of the body and has control over use of language. If left hemisphere is completely damaged a person will have no language ability.

• Right Hemisphere: Will affect the function of the left side

FRONTAL LOBE:

• Back: Weakness or paralysis on left or right

• Middle: Apathy, inattentiveness, unmotivated, slow thinking and processing.

• Middle of back on Left (Broca area): difficulty expressing thoughts-expressive aphasia

• Front: Difficulty retaining information, decreased fluency of speech, apathy, delayed responses, lack of inhibitions-including socially inappropriate behavior

PARIETAL LOBE:

• Front: Numbness, loss of sensation (pain, heat, cold, vibration, touch, and texture)

• Middle: Cannot tell right side from left side, difficulty with calculations and writing

• Non Dominant Lobe: coordination eg. combing hair, not able to understand how objects relate to each other, unable to draw or construct thing, get lost in their own neighborhood

TEMPORAL LOBE:

• Left: Loss of memory for words and ability to understand language-Wernicke aphasia

• Right: Loss of memory for sound and music- may not be able to sing

• Seizures: Temporal lobe seizures may cause the experience of smelling a bad odor, being dazed, unaware of surroundings and make repeated movements, (like repeatedly smacking lips) or personality changes

OCCIPITAL LOBE:

• If both sides are damaged people cannot recognize objects by sight-cortical blindness. They make make up descriptions of things and not realize they are un-real

• Seizures: Seizures involving the occipital lobe may cause hallucinations

Many functions of the brain are by different areas of the brain working together, known as “networks”. When these networks are damaged the following can occur:

• Agnosia: loss of ability to identify objects by one or more senses

• Amnesia: Total or partial loss of ability to recall experiences or events

• Aphasia: Partial or complete loss of ability to express or to understand spoken or written language

• Dysarthria: Loss of ability to articulate words normally

CEREBELLUM:

• Loss of coordination of motor movements- asynergia

• Inability to judge distance and when to stop- dysmetria

• Inability to perform rapid, alternating movements- adiadochokinesia

• Movement tremors-intention tremors

• Staggering, wide-base walking- ataxic gait

• Tending towards falling

• Weak muscles- hypotonia

• Slurred speech- ataxic dysarthria

• Abnormal eye movements- nystagmus

BRAIN STEM:

• Headache

• Confusion

• Temporary loss of consciousness

• Nausea & Vomiting

• Fatigue & dizziness

• Memory loss

• Difficulty with speech

• Sleep disturbances

• Breathing difficulty- may require permanent ventilation

• Locked-in syndrome- fully awake but cannot move or communicate except for eye movement and blinking

• Paralysis

• Coma

• Hemorrhagic stroke

• Death

HYPOTHALAMUS:

• Diabetes Insipidus:- passing large amounts of urine die to vasopressin production interference

• Insomnia- effects wake-sleep cycle

• Fluctuations in body temperature

• Appetite regulation disfunction

• Uncontrolled hormone production

• Sexual dysfunction

• Uncontrolled blood pressure

• Fatigue/weakness

• Headache

• Vision loss

• Lack of interest in activities- anhedonia

• Anxiety & mood swings

TRAUMATIC BRAIN INJURY: Part 3

ANATOMY OF THE BRAIN:

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cerebrum:

• Commonly known as “the brain”

• Lies on top of the brain stem

• Largest area of the brain

• Divided into 2 halves: Right hemisphere that controls left side of the body

  Left hemisphere that controls the right side of the body

• Main FUNCTIONS include: consciousness, thought, reason, memory, vision, hearing, touch, motor control, coordination and emotions.

• FUNCTIONAL AREAS are divided into 4 lobes. Frontal, Parietal, Temporal, Occipital

FRONTAL LOBE:

• Regulates the higher intellectual behaviors (executive functions)

• Important role in social functions

• Regulates emotions, cognition, error detection, sense of self, ability to recognize right and wrong, ability to recognize future outcomes from present actions, suppress unacceptable behavior, retain long term memory, moderates emotions to fit socially acceptable standards.

• BROCA’s AREA is in the frontal lobe cortex and is important for the production of written and spoken language. Required for the ability to find appropriate words and grammar.

PARIeTAL LOBE:

• Located above the Temporal, between the Frontal and Occipital lobes

• Movement, touch, vision, hearing, memory, spatial sense of direction

• Motor cortex within the parietal lobe is responsible for movement

• Somatosensory cortex is responsible for touch

• Large portion of the Parietal lobe acts as a coordination center for all the senses allowing us to be aware of people, places and things around us.

TEMPORAL LOBE:

• Located below the Parietal and in front of the Occipital lobes. On both sides of the brain

• Responsible for speech, memory and hearing

• Auditory cortex is responsible for hearing and understanding what is heard

• FUNCTIONS include Long term memory, vision, sexual behavior and personality

• WERNICKE’S AREA is located in the left temporal lobe and is involved in the formation and comprehension of language. Required to form sentences and understand others speech.

OCCIPITAL LOBE:

• Located at the back of the brain, smallest of the 4 lobes

• Visual center is responsible for receiving and coordinating input from the eyes

• Motion, color and other visual inputs are organized and interpreted in this area

CEREBELLUM:

• Means “little brain”, located at the base of the brain

• There are 3 parts to the cerebellum: Cerebrocerebellum, Spinocerebellum and Vestibulorcerebellum

• Responsible for coordination of movement

• Contains 10% of the brains volume but contains at least 50% of the brains neurons

• It is divided into 2 hemispheres that are covered by a thin layer of gray mater called the cortex

• Receives input from other areas of the brain and brain stem

• Receives information on position and movement of the body’s limbs

• Uses this information for equilibrium and coordination

BRAIN STEM:

• Distal part of the brain made up of three parts, Mid Brain, Pons and Medulla Oblongata

• Each part has their own function but together they regulate, breathing, heart rate and blood pressure

• Plays an important role in being awake and alert, attention, arousal and consciousness

• The brain stem houses the reticular activating system which acts as the “on/off” switch, controlling, sleeping, being awake and motivation

• The brain stem as acts as a conduit for messages coming from the body to the brain

• Many of the cranial nerves originate in the brain stem which are responsible for vision, hearing, taste, smell, control of eye movement and coordination and movement of the face

HYPOTHALAMUS:

• Located just above the brain stem

• Links the nervous system to the endocrine system

• Responsible for metabolism

• Controls blood pressure, body temperature, fluid and electrolyte balance and body weight

• It influences, hunger, moods, sex drive, circadian cycles, thirst and release of hormones from the pituitary gland

LEFT HEMISPHERE:

• The left hemisphere of the brain is dominant for language, mathematical skills, and the ability to solve problems in a sequential order. For this reason, the left hemisphere is often considered the logical or analytical brain

RIGHT HEMISPHERE:

• The right hemisphere of the brain seems to be dominant in terms of artistic ability, musical skills, face recognition, and spatial perception. Problems tend to be solved in a more comprehensive, artistic way

MENINGES:

The brain and spinal cord are covered by 3 layers of tissue (meninges) that protect them:

• Pia Mater: Thin, innermost layer which adheres to the brain and spinal cord

• Arachnoid Mater: Delicate, spider web-like, middle layer

• Dura Mater: Outermost, toughest layer

CEREBROSPINAL FLUID:

Helps cushion the brain from sudden jarring and minor injury, also removes waste products from the brain.

TRAUMATIC BRAIN INJURY: Part 2

4 Primary Types of Damage:

1. Hematomas, or bleeding in or around the brain:

• Epidural Hematoma (EDH): When bleeding occurs into the area between the skull and the dura mater.

• Subdural Hematoma (SDH): When bleeding occurs between the dura mater and the arachnoid mater.

• Subarachnoid Hemorrhage (SAH): When the bleeding is beneath the arachnoid mater

• Intra-cerebral Hematoma (ICH): Bleeding into the brain tissue its self.

Bleeding into the brain or between the layers will cause swelling which will then lead to an increase in Intracranial Pressure. This is a very serious condition

2. Focal Contusion:

• Bruising of the brain tissue as a result of the brain tissue being in direct contact with the skull.

3. Diffuse Axonal Injury (DAI):

• When the brain rapidly moves and rotates inside the skull at the time of injury. The long connecting fibers in the brain, which are called axons, are sheared as the brain is rapidly accelerating or decelerating inside the hard bone of the skull.

• DAI usually causes injury to multiple parts of the brain, therefore people who suffer DAI are usually in a coma.

• The changes in the brain may be minute and can be difficult to detect using CT or MRI scans.

• It is one of the most common types of Traumatic Brain Injury but also one of the most devastating.

• e.g. Car accidents, violent attacks, falling, sports injuries and child abuse (shaken baby syndrome)

4. Ischemic:

• When an insufficient blood supply to the brain is a result of the Traumatic Brain Injury.

Traumatic Brain Injuries are usually classified as FOCAL or DIFFUSE injuries.

• FOCAL injuries are usually caused by direct contact:

• Scalp injury

• skull fracture

• surface contusion

• DIFFUSE injuries are usually caused by acceleration-deceleration events:

• DAI

• Hypoxic-ischemic damage

• Meningitis

• Vascular injury

Focal and diffuse injuries frequently present at the same time in Traumatic Brain Injury.

TRAUMATIC BRAIN INJURY: Part 1

WHAT IS TRAUMATIC BRAIN INJURY?:

Traumatic Brain Injury (TBI) is when there is damage or injury to the brain causing some or all of the following:

• Loss of consciousness

• Alteration in consciousness or mental status

• Temporary loss of memory, also known as Post Traumatic Amnesia or PTA

• Structural damage seen on CT scan or MRI

  Severity of TBI can be classified as:

• Mild

• Moderate

• Severe

4 PRIMARY MECHANISMS OF DAMAGE:

• Direct Impact: When something directly strikes the head.

e.g. Windshield

The Ground

A human using an implement to hit someone e.g. a hammer

Golf ball

• Sudden or rapid acceleration/deceleration: When nothing externally directly strikes the head but when the brain inside the skull experiences violent movement.

e.g. Whiplash

Shaken baby syndrome

• Penetration Injury: When an object is driven into the brain.

e.g. High Velocity- bullets or shrapnel

Low Velocity- knives or bone fragments from skull fractures

• Blast Injury: Caused by the impact of pressure waves created by an explosion or direct injury to the head from the blast.

THE VALUE OF RESEARCH

Research is an under utilized service that Legal Nurse Consultants can provide

Whether it’s to educate the Attorney, the Jury, the Judge or to bolster the opinion of your clients Law suit it’s an invaluable asset.

• Only provide research that is relevant to the incident or issue within your case.

• It can be time consuming and it’s easy to end up down rabbit holes you cannot get out of. So be logical in your approach and searches.

• Start with a simple topic sentence, then pick out your key words.

• Use “and” in-between words to include articles that include both keywords only.

• Use “or” between words to get articles that include either word.

• Use “not” if there is a word you do not want included.

• Use “near” if you are looking for anything similar.

• For standards of care issues search the date of the issue, 2 years before and 1 year after.

• For causation issues use up to date information.

The best way to get more efficient is to practice, practice, practice and create your own logical system for key words and getting to where you want to be in the mine field of research.

Remember to save your research so that you can use it for further cases and become more efficient.

POST TRAUMATIC STRESS DISORDER (PTSD) RELATED TO INTENSIVE CARE ADMISSION

It’s becoming well known that there is another major cause of PTSD out there that is not related to traumatic times in Afghanistan. The ICU stay

When you mention PTSD most people will automatically think of our brave men and women in the armed forces. They come back from war haunted by the extreme violence and loss that they experienced and cannot get these visions, feelings and memories out of their minds. This is causing a huge negative effect on their quality of life.

Much research has gone into looking at the long lasting effects of an ICU stay greater than 48 hours. Resulting in a similar negative effect on quality of life. Patient’s with experiences of delirium, hallucinations, dreams or the sensation of being hurt during their ICU admission are more likely to experience post ICU PTSD.

More than half of ICU patients experience anxiety, depression and/or PTSD after discharge. Delirium recall has been shown to increase the risk of PTSD in these patients. Symptoms are often triggered by loud noises, bells and alarms, blood draws, therapies and treatments and the need for subsequent monitors. At the end of life the need for quiet and calm has never been more important for many patients.

Patients that have had traumatic ICU stays have an increased risk of uncontrolled pain issues, difficulty returning to an acceptable quality of life and death is more likely than non ICU patients.

Will we be seeing and increase in post ICU PTSD related to COVID 19? Not just those patients who were treated in ICU for the virus but all ICU patients. For the last year patients haven’t been able to have many, if any, visitors at their bedside. Having loved one’s around you during illness or difficult times is vitally important to keep you calm, keep you orientated and give you the peace of a familiar face. These things have been taken away and then add in the loneliness and we may have a recipe for increased levels of PTSD in ICU’s.

When looking at medical records, we Legal Nurse Consultants should always consider the effects of ICU stays on the outcomes and future needs of our clients.

THERE'S A DIFFERENCE

There is often confusion between Legal Nurse Consultants and Nurse Paralegals. As Consultants we are experts in the Medical records and NOT experts in the Law. Legal Nurse Consultants are often actively practicing clinical staff, so are up to date on Health Care and ever changing Policies and Procedures. Just because you have an in house Nurse Paralegal does not mean you do not need a Legal Nurse Consultant. Maybe you are swamped with cases and need extra help. Maybe a case is not your paralegals area of expertise or maybe you have had a good working relationship with a Legal Nurse Consultant in the past who will do a better job for you. Just remember we are not experts in the Law we are experts in Medical Records, organizing, analyzing and producing an amazing report that will undoubtedly help your next case. Call today you won’t regret it.

I'M BACK

Everyone is talking about “how bad” 2020 was and believe me I hear them loud and clear. I cannot say those words exactly, 2020 was not a “bad year” it was a year full of challenges, unexpected happenings and great accomplishments.

My year started with a break-in at our cabin up in the mountains of Eastern Washington. They smashed our doors, took our stuff and violated our privacy. My Husband was more affected than I was, probably because they took his rifle, his special knives, his tools, his booze and his clothes. Apparently they just wanted my socks and ski gear, it can be cold up here. It was a traumatic event and very time consuming, reporting to the Police, insurance companies, replacing items and writing lists and lists of what was taken. To this day we still come across things that were taken that we had not remembered. The only saving grace was that they did not trash the place, spray paint the walls or shred up the furniture, thank you burglars.

Off we went to a conference, where we had planned to ski but oh, we have no gear, that’s right it was taken.

As we drove home across the mountains and snow covered plains we started to hear about the infamous Covid 19 virus. Little did we know how that those few words were going to control every inch of our lives for the next year.

We were fortunate that our everyday lives were not really affected. My husband worked his 60 hours a week as usual but the stress of every day wearing masks, gowns, goggles, carrying hand sanitizer in every pocket and not knowing what was really going on soon became very tiring. Everyone did what they needed to do to keep themselves and their patients safe.

Along came April and we knew a little more about this virus but it was digging its heels in and taking hold. A bittersweet phone call landed in my living room one night announcing that my Mum, living in the UK, had contracted the virus and died a few days later. I was relieved that she had finally been able to let go after suffering with dementia for so long and I wasn’t upset that she died of Covid 19, she was very peaceful. What I struggled with was that having been a Hospice Nurse for so long I could not be at my own mother’s side. I have been with 100’s of other people’s mothers but not my own, that was tough. I know she got excellent care and my brother was allowed in to say goodbye but it gave me a whole new perspective for all those families whom I call to notify them of their loved one’s death and they were not able to be there for whatever reason. I definitely do not take it lightly. For her Funeral we sat on the Family room couch at 7am, listening to her 6 person service over the phone. Ironically they only place they could get reception was to put the phone on her coffin, love you Mum.

Like everyone else our vacations were cancelled, we moved them to later dates and then moved them again. I’m still trying to get to the UK to see my dad but I don’t think it will be anytime soon.

In the midst of all this we decided towards the end of the Summer that we would sell our house on the West side of Washington, that my husband would retire at the end of the year and we would move full time to Eastern Washington. So off I went at full throttle, did 9 months of work on our house and gardens in 6 weeks, negotiated contracts, packed up 6000 sq ft of living space and drove it across the State. Trip after trip after trip. Put over 10,000 miles on our truck, got my coffee card punched more than I knew possible and developed box hauling biceps that shocked even me. I drove through rain, hail, snow, fog, ice and wind, I would never recommend moving in November when a mountain pass is involved.

It was a great relief to have sold our house, for my Husband to have retired and to be headed for the next phase of his life. Great things are to come we will be building our forever home, taking time to enjoy the world and friends around us, I will be concentrating on full time Legal Nurse Consulting and we are expecting our first Grandchild in May.

So as I look back at 2020, I feel stronger, bolder, relieved and grateful. Our House is sold, my Mum is at peace, my Husband retired and I am looking forward to a great year of Legal Nurse Consulting. See you there.

KUDOS

It seems that employees of today need constant compliments, prizes and special recognition to be able to keep their jobs and perform well. As the last of the Baby Boomers retire and the Millennials take over Generation X, now being 80% of the workforce, times have changed.

My Husband, a Trauma Surgeon, got a wonderful letter form the “Higher Up’s” at his Hospital because he did something that he has done his entire working career, he helped out a Peer. The Emergency Room Attending was having difficulty getting a central line in a very sick, septic patient. My husband was just finishing his call shift and saw someone in need of help. So he did the obvious thing, he helped them out; he placed the line and thought nothing of it.

He was flabbergasted when he received a letter this week, signed by all of Administration, thanking him for going out of his way to help a colleague. He now has a shiny “Kudos” pin on his white coat. Sure it made him feel good and he was glad that his boss had to give it to him but he was “just doing his job” as far as he was concerned.

I’m the last of the Baby Boomers, having been a nurse for 37 years, where team work is just part of every day, every shift and every patient load.

Isn’t this what we have done all our Nursing careers:

• ·         Helped each other out

• ·         Worked together as team players.

• ·         Supported one another

• ·         Taught one another

• ·         Learnt from one another

We didn’t expect to be gushed with “Kudos” and certificates or have our name on some recognition wall for all to see. We were rewarded when our patients did well, when our team mates overcame hurdles in caring for sick patients and when at the end of the day you could smile and feel accomplished in giving your best care.

It’s a different world out there I’m just hoping I can still fit in.

FLU SEASON HAS BEGUN

It seems the Flu season of 2019-2020 has started a little early, mostly in the Southern States. The emergence of Influenza B is mostly to blame for this.

We usually see Influenza A at the beginning of the season but some reason we are seeing Influenza B in these early months.

Preliminary CDC estimates for 2019-2020 Flu season are out:

• 17 million illnesses

• 800,00 medical visits

• 16,000 hospitalizations

• 910 deaths

For comparison the 2017-2018 season:

• 79,000 deaths

• CDC estimated that the vaccine prevented 7 million cases of the flu.

INFLUENZA B

• Only affects humans and seals

• Usually passed human to human

• Very little influenza B in 2018-2019 season

• Affects mostly children and young adults

• Flu shot covers both Influenza A and B

PREVENTION:

• Wash your hands whenever going to eat or touch your face.

• Stay home if you have a fever

• Get a Flu shot