A year ago this month, actress Natasha Richardson died after sustaining what was thought to be a mild brain injury after she slipped on a beginner's ski slope in Canada. By contrast, 43-year-old Thomas Eckel drove into a head-on collision in St. Lucie, Florida, in 2005, resulting in massive blood loss, multiple broken bones, cardiac arrest and a brain injury so severe that doctors feared he would not survive. Instead, he is mobile, energized and productive, and has returned to his job as a truck driver with his previous employer.
These cases not only underscore the unpredictability of brain injury but demonstrate that with proper medical care and ambitious recovery targets, cases that were once considered lost causes can turn into success stories. In the past, many adults with work-related traumatic brain injury were simply warehoused. But with advances in treatment and care strategies, including an employer that is ready and willing to help in gradual return to work, many survivors of severe brain injury can regain most of their former way of life.
Understanding the Problem
More than half of all work fatalities result from transportation accidents and falls, many of which involve head trauma. The number of nonfatal brain work injuries cannot be reliably estimated, however, because brain injuries are often poorly documented or mild enough to be shrugged off by the injured person. Even an emergency room doctor or nurse may disregard a mild brain injury of an injured worker, especially if the patient has broken bones or bleeding that requires immediate care.
Brain injuries typically (but not always) involve a concussion, and even a minor concussion can have severe consequences. Internal damage increases pressure within the brain that builds over time and can ultimately cause severe debilitation and even death. Fortunately, the great majority of concussive injuries heal without treatment and even without doctors being aware that the worker incurred an injury.
A person who suffers a moderate or severe brain injury, on the other hand, typically has to spend weeks in an acute case hospital before transferring to an inpatient rehab hospital. Such cases can often cost more than $1 million to treat.
Even after treatment, a person's condition can change up to 10 years after his or her injury. Continued access to professional care and family support is important to prevent the deterioration of the patient's memory, cognition and physical condition.
Many case managers, including Marilyn Spivack, neurotrauma outreach coordinator at Boston's Spaulding Rehabilitation Hospital, praise the workers compensation insurer community for their efforts in brain injury treatment. "We had so many brain injury programs in the 1980s and 90s," said Spivack. "Then the HMOs came along and they lost their enthusiasm for treatment because they didn't see the return-to-work outcomes as quickly as they wanted-or at all."
Today, the situation has improved. Spivack believes that workers compensation insurers, in particular, now understand the importance of intensive, albeit expensive, rehabilitation. She appreciates that they take the long view and consider themselves financially responsible for the disabled worker throughout his or her lifetime.
Other catastrophic injury case managers have had similar experiences. "You have a workers compensation brain injured patient who is in the same hospital room as a nonworkers compensation patient, and the difference in resources is like night and day," said one worker.
But practices vary among insurers and between insurers and third party administrators that work with self-insured employers. The best insurers aggressively search out expert treatment of brain injury but may pay more in medical costs in the first year. This level of care reduces the risk of complications and puts the injured worker on track to a better recovery. The long-term medical costs of care and the total lifetime claims costs are contained.
In Eckel's case, as with all catastrophic brain injuries, his care involved several independent teams of medical providers. In addition to the surgical team in the first hospital to which he was taken, Eckel was also treated in an acute rehabilitation facility and an outpatient facility.
Dr. Nathan Cope, founder and chief medical officer of Paradigm Management Services, a provider of complex and catastrophic medical management services, has advised on hundreds of brain injury cases. He has found that several factors can significantly affect how a patient recovers from brain injury, including the lack of systematic coordination, gaps in evidence-based medical guidelines and lag times in getting innovations from the laboratories and specialized care facilities into mainstream medical practice.
"The reality is that our health care system, while generally of high quality, is marked by inconsistent, inappropriate, redundant and fragmented delivery," said Dr. Cope. "These factors cause significant rates of medical errors, lower medical outcomes and add unnecessary medical costs. I've seen this in hundreds of cases and believe that the best way to avoid these downfalls is with the medical management oversight of experts.
Dr. Cope led the team that coordinated Eckel's care. "Part of what made the difference for Mr. Eckel was the systematic coordination of his case," he said. "This coordination started with a comprehensive recovery plan. We outlined all aspects of his treatment, recovery and ultimate return to work."
Involving the Employer
In 2001, a line drive off a baseball bat struck the head of Gary Weinstein while he was on the field with a youth baseball team in Maryland. The baseball fractured his skull in 18 places. During a 10-day coma, he underwent two high-risk brain surgeries. He then overcame several medical setbacks before being transferred to a series of rehabilitation programs. Eventually, however, Weinstein was able to recover and return to full-time employment as a manager of a youth baseball league and coach of a baseball team. His degree of recovery was extraordinary given the extent of his injury.
Dr. Michael Weiss, who advised on the case, explained that family, community and employer support for the patient reinforced Weinstein's personal strengths. In addition, Dr. Weiss helped set a recovery goal that was higher than many treatment teams would have selected. But Weinstein's employer bought into this goal and along with the outpatient rehabilitation team was able to help structure a program of gradual return to work.
For the brain-injured worker, employer involvement is important-the ability to relearn skills at work will greatly influence how far his or her recovery progresses. For example, the brain injured worker needs to learn his limitations and devise compensatory tactics. For many patients this includes learning how to cope at work with stressful situations. Over time, their confusion declines and may even completely disappear.
As with all successful brain injury recoveries, job coaching is a critical phase that demands employer participation. Rehab counselors often make the trip with the worker back to her or his workplace. Memory failure, a signature feature of brain injury, is sometimes best treated, in part, at the physical site of the employer. So for several months, the vocational specialist helps the worker find ways to organize the day, reinforce memory and work with others. In this way, the patient's prospects for recovery are greatly improved.
Each year, 50,000 Americans die of a traumatic brain injury and 235,000 are hospitalized. At least 5.3 million Americans currently have a long-term or lifelong need for help to perform daily living activities as a result of a traumatic brain injury. But with proper support and commitment from medical experts, family and employers, many more patients can recover from this frightening injury.
BRAIN INJURY AND WAR
According to the global policy think tank RAND, up to 320,000 of the 1.6 million troops deployed in Iraq and Afghanistan have suffered a traumatic brain injury, most commonly due to roadside bombs, or improvised explosive devices (IEDs). An IED sends a severe jolt along with a violent blast of air pressure and heat through the vehicle in which troops are riding. Passengers can strike their heads against internal walls or equipment and the blast alone can damage the brain, even without a concussion.
Brain injury is emerging as the signature wound of today's wars. The Department of Defense has invested more and more resources to prevent and treat these injuries, and advances in detection and treatment will have long-term benefits for the military, workers compensation and contact sports.
For instance, neurosurgeons in military hospitals in Iraq and Afghanistan are learning how the effects of the injury can be mitigated by shaving minutes off delays in treating survivors of IED detonations. The Department of Defense has taken extraordinary steps to streamline treatment of brain-injured soldiers. It can begin to operate on survivors within a half hour of the blast and fly the patient to Landstuhl Regional Medical Center in Germany within hours, then to Walter Reed Army Medical Center in Washington or the National Naval Medical Center in Bethesda, Maryland, within days.
Its surgeons have also advanced the art of opening up the skull to relieve pressure on the brain, such as they did with ABC News reporter Bob Woodruff after he was seriously injured by an IED in Iraq in 2006.
Meanwhile, advances in screening of athletes are being introduced into the military. For example, to screen its members before and after deployment, the Maine National Guard is using a tool developed initially for professional sports teams.
Gray Matters: The Employer's Role in Brain Injury Recovery
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