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By MICHAEL SAMOGALA RN, CRRN, CBIS
An individual experiencing both a traumatic brain injury (TBI) and a spinal cord injury (SCI) at the same time, often described as a dual diagnosis, can present significant challenges and complexities compared to sustaining these injuries during separate occurrences. The incidents of spinal cord injury noted by the World Health Organization (WHO) in 2013 were between 250,000 and 500,000 worldwide annually. Many publications state that greater than 60% of those individuals presenting to the trauma center with a spinal cord injury are later identified with a dual diagnosis. Further complicating the dual diagnosis is that in many cases spinal cord injuries that also involve a TBI are not being readily identified in the acute phase of treatment. In relation to initial acute care, and then again in the post-acute rehabilitation phases of recovery, an occult TBI diagnosis is often first identified by behavior and may be perceived as non-compliance, inability to learn, or a negative emotional reaction to the spinal cord injury, along with a decreased motivation and poor initiation of tasks as well as participation in the rehabilitation process.
As health care professionals in both the acute and post-acute arenas, we must become aware that the common causes for not initially identifying a TBI include the concentrated efforts regarding the stabilization of the spinal cord injury as well as the consistent monitoring of its subsequent sequelae in determining the diagnosis, severity and confirming the level of injury. The TBI that at times cannot be fully evaluated during the immediate triage process often is not given consistent consideration beginning with the emergency medical services observation and description regarding cognitive deficiencies or loss of consciousness (client cannot remember what they don't remember) followed by incomplete documentation or lack of direct observance regarding cognitive deficiency and the lack of access to specific in-depth neuropsychological examination and testing within the treatment protocol of some health care facilities.
Dual diagnosis which most often involves cervical injuries at the C1-C4 level commonly occur in motor vehicle accidents or falls (velocity to motion). In consideration of this injury level, attention must be given to the many medical complications that accompany both the TBI and SCI and how a dual diagnosis further impedes their identification and treatment. Dual diagnosis indicates recorded statistics refer to a 67 percent rehospitalization rate. One of the most detrimental challenges for the individual with a dual diagnosis relating to the safety and effectiveness of the rehabilitation process is the inability to learn and retain information associated with these injuries and their complications. A perfect example would be the information that is required for the client and significant other to retain in both identifying and managing autonomic dysreflexia as experienced in a spinal cord injury above the thoracic 6 level. As we understand, this is a true medical emergency which can lead to seizure, stroke or even death.
Within a true CARF accredited program, the dual diagnosis and the specific needs related to these individuals are addressed in a formal repetitive education program by all disciplines including medicine, nursing, physical therapy, occupational therapy, speech language pathology/cognitive specialists, neuropsychology and psychiatry staff and evaluated in a consistent manner. The appropriate documentation and communication of the identified needs and barriers to effective education/retention are shared with all those individuals involved in the client's care and discharge services.
Behaviors are apparent in various forms dependent on the area of the injury and the severity of the TBI. Of course, the frontal and occipital areas relating to the common coup contrecoup injury is always a consideration. Impulsivity, is defined as "without regard to consequence." In observing, assessing and identifying cognitive/behavioral deficits and/or impulsivity the safety of the client and those in his/her environment is of paramount concern. The post-acute transition of care provides for a continuous progressive and conclusive evaluation relating to a safe and appropriate discharge location with adequate supervision and services to ensure the progress of the individual in obtaining their highest level of function and independence. In addition to the behavioral issues discussed above, general procurement of consistent supervision and reassessment by post-acute rehabilitation professionals within the client's community is an absolute necessity. As we now understand due to secondary cascade of injury, TBI individuals often experience significant deficits/barriers far beyond their original date of injury. The responsibility to these individuals often does not end once they are discharged from any facility in that traumatic brain injury is most often a life changing event. Catastrophic injuries in the mildest form demand frequent reassessment, intervention, planning and evaluation.
In final analysis of the affect and consequences of dual diagnosis in the post-acute setting, behavioral incidents, length of stay, medical/nursing/therapy hours and economic resources are all negatively affected, mostly due to the occult cognitive and learning deficiencies that so often go unrecognized and/or addressed within the rehabilitation program. Early identification and specialized post-acute intervention within a CARF accredited post-acute program such as NeuLife Rehab may assist in meeting the very unique and complex demands of this population improving their quality of life, level of independence and reducing the negative impact on the health care system within the community and ensuring the most successful outcome.
Michael Samogala RN, CRRN CBIS has been directly involved in providing professional nursing and education services to the healthcare community for over 40 years. Most notably receiving board certification in rehabilitation nursing and as a brain injury specialist, he continues to provide professional credited continuing education programs to multiple professionals across the country and remains in the position of Director of Corporate Education, NeuLife Neurological Services. Michael continues as an active member of The American Nurses Association, The American Association of Rehabilitation Nurses, The Academy of Spinal Cord Injury Professionals, The Academy of Brain Injury Specialists.
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