Today, Shepherd Center access case manager Dorea Fowler discusses treatments for people with spinal cord injury in the first 72 hours after injury.
This podcast describes the way spinal cord injury affects the body, including the levels of injury and muscles that coordinate with those injuries, and how people with spinal cord injury differ from other patients in an intensive care unit.
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SCI in the First 72 Hours
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Learn more about Dorea Fowler, RN
Dorea Fowler, RN
Dorea Fowler, RN began working at Shepherd Center in 1991 as a nurse in the Spinal Cord Injury Unit, including several years as program nurse for Shepherd Center's Spinal Cord Injury Day Program. Dorea has also taught training courses on spinal cord injury for patients, families and staff members at Shepherd Center.Learn more about Dorea Fowler, RN
Transcription:
SCI in the First 72 Hours
Melanie Cole (Host): For people with spinal cord injury, the first 72 hours after injury are crucial to diagnose and manage ongoing treatment. My guest today is Dorea Fowler. She’s an Access Case Manager at Shepherd Center. Welcome to the show, Dorea. Tell us what happens in the first 72 hours after spinal cord injury. What goes on in the Emergency Room?
Dorea Fowler (Guest): Well, there’s a lot going on. First, the trauma team has to activate – typically it’s going to be Neurosurgery, or in some facilities, it’s going to be an Ortho-Spine Surgeon because they’re going to try to stabilize the neck or the back as soon as possible to try to prevent any more damage. Usually, the family has gotten word of the devastatingly serious injury and the potential for changes for the rest of their lives as far as paralysis. The family is usually reeling pretty good at this point also.
Once the neurosurgery team or the ortho-spine team is involved, then they’re going to go to surgery as quickly as possible to stabilize the spine. Then there’s all the hopefulness that happens in the family that hopefully after the surgery their spine will be able to recover, or at least their body parts will, and then hopefully the neurologic injury of the spinal cord will recover.
Melanie: So that was going to be my next question was, does the family quite often say to you and to the doctors, “But there’s still hope, right? This is not a permanent condition,” or “The surgery will fix this,” or “Will it continue to get better?” How do you answer them when they ask these questions?
Dorea: Absolutely, the families are very optimistic and very hopeful in our modern age of medicine. We’ve become so much faster and so much more efficient within the trauma system, so they are hopeful, and they do say, “Well, you fixed Johnny’s neck, does that mean he’s going to walk again or use his arms again?” Nobody really has that answer. No one can tell you for sure what kind of recovery they’re going to have and as a medical profession we can fix the broken pieces, we can fix the bones, but again, we can’t repair the spinal cord, so it’s a wait and see and no one really knows what kind of recovery they’re going to have. It can take up to two years for you to actually have any recovery.
Melanie: Explain just a little bit, in a short period of time, about some of the types and levels of spinal cord injury so that family members can get a general working idea of what a cervical spinal cord injury might do to the patient or what a sacral spinal cord injury might do to a patient -- what they can expect?
Dorea: Yeah, well the higher the injury is in the body, the less control your brain has. If you have a cervical injury that’s in the neck, then that’s going to affect your ability to move your arms and your legs and then lower in your neck obviously you do have some arm function, but it’s not 100% -- it’s not normal. And then you go lower into the back, and you have an upper back, your thoracic area, your middle back is your lumbar area, and then your lower back, which is Sarum. Depending on where the injury is it’s going to affect what you can use, so the higher in the back, the higher up your torso your injury level is, and that means your injury level is above that you’re normal, below that you’re not normal. So again, with the back injuries, which can be thoracic, lumbar, or sacral, you have normal arm and hand function, but you don’t have control from your chest down or your abdominal area down.
The sacrum is kind of tricky because it’s one bone and five pairs of nerves, but it’s actually below where you would normally walk. Your lumbar nerves talk to your walking muscles so if you have an injury to your sacrum you’re usually still able to walk, but you don’t have any control over your genital area, like your bowel, your bladder, and your sexual function. We’ve had people, like a painter who fell off a scaffold and cracked his tailbone – his sacrum, so he could walk, but he had no control over his bowel and bladder.
Melanie: So how important are that first 72 hours to maintaining some of that, or possibly being able to adjust, or get the patient to adjust to what has just happened?
Dorea: Oh, it’s absolutely critical. So again, the trauma systems are so much faster now, and they talk about something called the golden hour. That’s why at the accident scene or when you fall getting the EMS team there as quickly as possible because they’re going to stabilize your spine, and then they’re going to get you to that trauma center to try to get potential surgery if that’s recommended as soon as possible because that’s going to reduce any kind of stricture or narrowing of the spinal canal which is going to cause pressure on the cord. There's a secondary injury where you can have that cellular death because of that swelling or pressure on the cord, and it doesn’t get the right blood flow to oxygenate the cord. Getting to that trauma system as quickly as possible is going to reduce those complications and then you would have, hopefully, a less severe injury. I think you mentioned before, complete versus incomplete types of injuries, and that can determine – how quickly you get that trauma care – whether you’re a complete injury or you convert to an incomplete injury.
Melanie: How is it different once they go to the ICU versus other patients that might be in there, for someone with a spinal cord injury?
Dorea: Oh, it’s very different. When you have a spinal cord injury, depending on where your level of injury is on your spinal cord, your brain is not in control below that point. Say you have a T1 level of injury, which most people think, “Oh, T1, that’s great, you’re paraplegic. You still have all this arm function. You’re going to be easy to manage,” but at a T1 level of injury, the line that you draw on their body basically is their armpits. From their armpits down, their brain is not in control, so that’s going to affect your blood pressure, it’s going to affect your breathing, it’s going to affect your bowel and bladder. Those are things that aren’t usually a problem with a different type of patient in that ICU because maybe they had a fall and they had a fractured hip, or they had a heart attack, or they even had a stroke, their brain is basically in control of their body, but after a spinal cord injury, below your level of injury, the communication has been cut off between your brain and your body.
Melanie: So then bring this all around and wrap it up for us, in that first 72 hours, the importance of getting that diagnosis and getting to the family to get them to understand and cope with what’s happening -- what do you do every single day Dorea and how do you deal with the families about that coping? Just tell us about that first 72 hours and wrap it up for us.
Dorea: Well, there’s a lot involved. Again, getting to that trauma system as quickly as possible to stabilize the injury that’s causing damage to the spinal cord injury is going to hopefully preserve function, so it may minimize damage to the spinal cord. A lot of the research studies nowadays are actually trying to fix the damaged part of the spinal cord. By getting the help as quickly as possible, reducing the injury, then that’s going to help you regain function down the road hopefully, but again, nobody really knows for sure. It’s a wide range for the family. They are hearing their family member may never walk again, may never use their arms again, and then once they have surgery and the healing begins then they might get small increments of function back. It could be movement, it could be feeling, it could be a little bit of both, it could be a lot of both, it could be neither. They have a huge range of emotions that they’re going to go through because they don’t know what their family member’s going to be able to do and generally, I say two days from now, two weeks from now two years from now. Part of the healing, I think, is in the beginning once we talk to the families, is we’re all hopeful for the return of function, but we don’t know what’s going to happen in time, so what we do is prepare for right now. What if nothing changed right now because this is probably the worst it’s going to be? And then as he gets better, hopefully he gets function back and then it gets easier on the family.
Melanie: What do you do, Dorea, as an Access Case Manager? Speak about your role at Shepherd Center.
Dorea: Yeah, so I have, to be honest, never in my nursing career did I think I would be a case manager, but I’m one of the nurse evaluators. Our old title was nurse liaison. I go to the trauma centers and evaluate patients that need our rehab and because spinal cord injury is so specialized, not every patient meets our criteria. I go to the trauma centers, evaluate the patients, and make sure that we can give them the rehab that they need. If they don’t need us, I recommend other facilities, so in that realm, I’m starting the case management, but if they do need us, then I start the process with helping the family figure out what their family member is going to need down the road and what the next level is going to look like after that trauma center, so rehab and potentially home after rehab. I’m actually starting case management the first day I see the patient, so that’s when our title changed to access case manager.
Melanie: Wow that is really great information. Thank you, so much, for being with us today. You’re listening to Shepherd Center Radio, and for more information you can go to Shepherd.org, that’s Shepherd.org. This is Melanie Cole. Thanks, so much, for listening.
SCI in the First 72 Hours
Melanie Cole (Host): For people with spinal cord injury, the first 72 hours after injury are crucial to diagnose and manage ongoing treatment. My guest today is Dorea Fowler. She’s an Access Case Manager at Shepherd Center. Welcome to the show, Dorea. Tell us what happens in the first 72 hours after spinal cord injury. What goes on in the Emergency Room?
Dorea Fowler (Guest): Well, there’s a lot going on. First, the trauma team has to activate – typically it’s going to be Neurosurgery, or in some facilities, it’s going to be an Ortho-Spine Surgeon because they’re going to try to stabilize the neck or the back as soon as possible to try to prevent any more damage. Usually, the family has gotten word of the devastatingly serious injury and the potential for changes for the rest of their lives as far as paralysis. The family is usually reeling pretty good at this point also.
Once the neurosurgery team or the ortho-spine team is involved, then they’re going to go to surgery as quickly as possible to stabilize the spine. Then there’s all the hopefulness that happens in the family that hopefully after the surgery their spine will be able to recover, or at least their body parts will, and then hopefully the neurologic injury of the spinal cord will recover.
Melanie: So that was going to be my next question was, does the family quite often say to you and to the doctors, “But there’s still hope, right? This is not a permanent condition,” or “The surgery will fix this,” or “Will it continue to get better?” How do you answer them when they ask these questions?
Dorea: Absolutely, the families are very optimistic and very hopeful in our modern age of medicine. We’ve become so much faster and so much more efficient within the trauma system, so they are hopeful, and they do say, “Well, you fixed Johnny’s neck, does that mean he’s going to walk again or use his arms again?” Nobody really has that answer. No one can tell you for sure what kind of recovery they’re going to have and as a medical profession we can fix the broken pieces, we can fix the bones, but again, we can’t repair the spinal cord, so it’s a wait and see and no one really knows what kind of recovery they’re going to have. It can take up to two years for you to actually have any recovery.
Melanie: Explain just a little bit, in a short period of time, about some of the types and levels of spinal cord injury so that family members can get a general working idea of what a cervical spinal cord injury might do to the patient or what a sacral spinal cord injury might do to a patient -- what they can expect?
Dorea: Yeah, well the higher the injury is in the body, the less control your brain has. If you have a cervical injury that’s in the neck, then that’s going to affect your ability to move your arms and your legs and then lower in your neck obviously you do have some arm function, but it’s not 100% -- it’s not normal. And then you go lower into the back, and you have an upper back, your thoracic area, your middle back is your lumbar area, and then your lower back, which is Sarum. Depending on where the injury is it’s going to affect what you can use, so the higher in the back, the higher up your torso your injury level is, and that means your injury level is above that you’re normal, below that you’re not normal. So again, with the back injuries, which can be thoracic, lumbar, or sacral, you have normal arm and hand function, but you don’t have control from your chest down or your abdominal area down.
The sacrum is kind of tricky because it’s one bone and five pairs of nerves, but it’s actually below where you would normally walk. Your lumbar nerves talk to your walking muscles so if you have an injury to your sacrum you’re usually still able to walk, but you don’t have any control over your genital area, like your bowel, your bladder, and your sexual function. We’ve had people, like a painter who fell off a scaffold and cracked his tailbone – his sacrum, so he could walk, but he had no control over his bowel and bladder.
Melanie: So how important are that first 72 hours to maintaining some of that, or possibly being able to adjust, or get the patient to adjust to what has just happened?
Dorea: Oh, it’s absolutely critical. So again, the trauma systems are so much faster now, and they talk about something called the golden hour. That’s why at the accident scene or when you fall getting the EMS team there as quickly as possible because they’re going to stabilize your spine, and then they’re going to get you to that trauma center to try to get potential surgery if that’s recommended as soon as possible because that’s going to reduce any kind of stricture or narrowing of the spinal canal which is going to cause pressure on the cord. There's a secondary injury where you can have that cellular death because of that swelling or pressure on the cord, and it doesn’t get the right blood flow to oxygenate the cord. Getting to that trauma system as quickly as possible is going to reduce those complications and then you would have, hopefully, a less severe injury. I think you mentioned before, complete versus incomplete types of injuries, and that can determine – how quickly you get that trauma care – whether you’re a complete injury or you convert to an incomplete injury.
Melanie: How is it different once they go to the ICU versus other patients that might be in there, for someone with a spinal cord injury?
Dorea: Oh, it’s very different. When you have a spinal cord injury, depending on where your level of injury is on your spinal cord, your brain is not in control below that point. Say you have a T1 level of injury, which most people think, “Oh, T1, that’s great, you’re paraplegic. You still have all this arm function. You’re going to be easy to manage,” but at a T1 level of injury, the line that you draw on their body basically is their armpits. From their armpits down, their brain is not in control, so that’s going to affect your blood pressure, it’s going to affect your breathing, it’s going to affect your bowel and bladder. Those are things that aren’t usually a problem with a different type of patient in that ICU because maybe they had a fall and they had a fractured hip, or they had a heart attack, or they even had a stroke, their brain is basically in control of their body, but after a spinal cord injury, below your level of injury, the communication has been cut off between your brain and your body.
Melanie: So then bring this all around and wrap it up for us, in that first 72 hours, the importance of getting that diagnosis and getting to the family to get them to understand and cope with what’s happening -- what do you do every single day Dorea and how do you deal with the families about that coping? Just tell us about that first 72 hours and wrap it up for us.
Dorea: Well, there’s a lot involved. Again, getting to that trauma system as quickly as possible to stabilize the injury that’s causing damage to the spinal cord injury is going to hopefully preserve function, so it may minimize damage to the spinal cord. A lot of the research studies nowadays are actually trying to fix the damaged part of the spinal cord. By getting the help as quickly as possible, reducing the injury, then that’s going to help you regain function down the road hopefully, but again, nobody really knows for sure. It’s a wide range for the family. They are hearing their family member may never walk again, may never use their arms again, and then once they have surgery and the healing begins then they might get small increments of function back. It could be movement, it could be feeling, it could be a little bit of both, it could be a lot of both, it could be neither. They have a huge range of emotions that they’re going to go through because they don’t know what their family member’s going to be able to do and generally, I say two days from now, two weeks from now two years from now. Part of the healing, I think, is in the beginning once we talk to the families, is we’re all hopeful for the return of function, but we don’t know what’s going to happen in time, so what we do is prepare for right now. What if nothing changed right now because this is probably the worst it’s going to be? And then as he gets better, hopefully he gets function back and then it gets easier on the family.
Melanie: What do you do, Dorea, as an Access Case Manager? Speak about your role at Shepherd Center.
Dorea: Yeah, so I have, to be honest, never in my nursing career did I think I would be a case manager, but I’m one of the nurse evaluators. Our old title was nurse liaison. I go to the trauma centers and evaluate patients that need our rehab and because spinal cord injury is so specialized, not every patient meets our criteria. I go to the trauma centers, evaluate the patients, and make sure that we can give them the rehab that they need. If they don’t need us, I recommend other facilities, so in that realm, I’m starting the case management, but if they do need us, then I start the process with helping the family figure out what their family member is going to need down the road and what the next level is going to look like after that trauma center, so rehab and potentially home after rehab. I’m actually starting case management the first day I see the patient, so that’s when our title changed to access case manager.
Melanie: Wow that is really great information. Thank you, so much, for being with us today. You’re listening to Shepherd Center Radio, and for more information you can go to Shepherd.org, that’s Shepherd.org. This is Melanie Cole. Thanks, so much, for listening.