March 19, 2009

The Delicate Brain

Our guest blogger is colleague Peter Rousmaniere, a columnist for Risk & Insurance magazine and blogger on the immigrant workforce. Beginning with the sudden and unexpected death of actress Natasha Richardson, Peter explores the murky issue of brain injuries, where what appears to be minor may suddenly morph in to a life-threatening - indeed, life ending - catastrophe.

The actress Natasha Richardson's death was emblematic of the frightening uncertainties surrounding brain injury. She died from what appeared at the outset to be a trivial incident on the slopes of Mont Tremblant, Quebec.

The NY Times reported: "Ms. Richardson, who was not wearing a helmet, had fallen during a beginner's skiing lesson, a resort spokeswoman, Lyne Lortie, said Tuesday. "It was a normal fall; she didn't hit anyone or anything," Ms. Lortie said. "She didn't show any signs of injury. She was talking and she seemed all right." Within two days, she was dead. She joins 50,000 others who die in the U.S. each year from brain injury.

Here are some lessons from this tragedy.

First, brain injuries are far more frequent than we assume.

One million athletes a year sustain brain injuries, the vast majority being "mild" traumatic brain injuries, or MTBI in medical jargon. Rand Corporation estimates that 19% of American troops in Iraq and Afghanistan sustain a brain injury, once again mostly MTBIs.

Second, prevention is improving. Sports helmets are less onerous to wear (though Richardson, a novice on the slopes, declined to wear one). In the military, Humvees are better designed to deflect IED blasts. One important step in secondary prevention and in avoiding re-injury is to remove from activity for about a week anyone who sustains a concussion, until subtle imbalance problems from the initial incident resolve. (We are beginning to see a much more cautious approach to managing athletes with concussions.)

Third, is it increasingly evident that the quality of medical and rehab care greatly matters in TBI outcomes. We in workers comp are focused, appropriately, on vocational outcomes, where the variance in return-to work outcomes for TBI survivors is much wider than it is for burn and spinal cord injury survivors.

I recently interviewed TBI experts working for Paradigm Corporation, including its chief medical officer, Nathan Cope, MD. This firm's specialty is taking over the management and financial responsibility for medical care of catastrophic work injuries. The firm's thoughts on TBI treatment is useful because a Milliman study showed that Paradigm's TBI patients return to work 40% of the time versus a workers comp industry average of only 8%. I asked Paradigm to explain this wide variance of outcomes in light of the Richardson tragedy.

According to the company, the immediate initial care can be deemed adequate as long as the TBI is diagnosed upon initial intake. Treatment has to begin very quickly after injury. In Richardson's situation, the symptoms began to occur a couple of hours after the incident, when the actress experienced a headache.

Problems are usually indicated by a combination of two factors: physical complications (such as headaches) and behavioral (such as depression). Supervisors and managers need to look for these symptoms in any worker suffering a head injury.

For the brain injured who survive the immediate aftermath of trauma, there is another layer of risk, involving low expectations for recovery: there is a cultural (and perhaps even medical) tendency to assume that once the brain is damaged, recovery automatically becomes a remote possibility. This is not necessarily the case.

Unfortunately, in workers comp few managed care people really understand TBIs. For them, brain injured workers disappear into a black box, with virtually no prospect for returning to productive employment. Such pessimism is often misplaced and usually results in substantial costs to both the injured worker and the employer.

Peter Rousmaniere

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About this Entry

This page contains a single entry by Jon Coppelman published on March 19, 2009 11:52 AM.

Shift Work and Breast Cancer: A Presumptive Link? was the previous entry in this blog.

Fresh health policy wonkery at HealthBlawg is the next entry in this blog.

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