Thursday, April 07, 2005

You'll be back to normal in no time!

I'm taking a class outside regular medical school on cognitive interventions (focusing on improving outcomes for stroke and TBI for students in the speech pathology and occupational therapy programs here.) One reason I wanted to take this class is to get a perspective on how other health professionals are involved in the types of patients I might encounter as a doctor. This week, we had a moderate TBI survivor come in and talk a little about her experiences.

She highlighted one of the effects of improved emergency medical care that I hadn't really thought much of. Because people are surviving injuries and illnesses that once would have been fatal, there are more people walking around with brain injuries. The firefighters who pulled her from her car never thought she would make it out of the hospital. But, three years later, she was talking to a classroom full of students, with no apparent physical problems about how she learned to function in day to day life again. She likened herself to "that crazy old aunt everyone has, who is just a little bit off." She had developed such effective coping mechanisms that if she hadn't been talking about her brain injury, I may not have even noticed that anything was wrong.

A few things struck me. After her accident, she was told by her doctors that she'd be "back to her normal self" after 6 months or so of a rehab program. But of course, most TBI patients never really return to the same person they were before the accident. She had a hard time believing her therapists that she may not be able to go back to everything she did before the accident (including being a nurse who also taught in the college of nursing.) Three years after the accident, she still attends occupational therapy sessions, still attends the support group, and still has to adjusts her coping mechanisms to fit in with society. She was lucky in that her family has the resources to pay for extended rehab, and that she was very quickly identified as a brain injury patient in the hospital. But because a doctor told her once that she'd be "back to her old self" it took her a long time to accept that it was ok to try a new activity rather than spending all her energy trying to develop her skills to a level where she could go back to the type of volunteer work she did before the accident.

After she left, we had a great discussion on what the goals of speech and occupational therapy should be. Obviously, one goal is to get the patient to a point where they are relatively independent and functional in their environment. But even for those with more mild injuries, trying to get the patient back to the level of functioning that they had before the insult is a double edged sword. Every patient and family will have different goals for themselves that we need to work with when assessing function and developing a rehab program. As doctors, we need to be careful about our wording when dealing with brain injuries. While being able to walk, dress and feed oneself again is a great accomplishment for many patients, simply being able to do these things does not make them "normal" again.