Transcript Impact of Traumatic Brain Injury Among Recently Returned

Polytrauma Rehabilitation:
A New Model of Care
Rose Collins, Ph.D.
Minneapolis VA Medical Center
VA Psychology Leadership Conference/ APA
April 28, 2006
Objectives

Polytrauma: Definition and patterns

Paradigm of Care

Psychology in Polytrauma Care

Treatment Issues and Considerations

Future Concerns and Directions
TBI, Blast Injury & Polytrauma



TBI in peacetime: civilian vs. military

Mechanism: MVA, falls

Incidence
TBI in combat:

Mechanism: Blast

Incidence
Blast injury sequelae: Polytrauma
Common Sequelae of
Blast Injury








Brain injury
Amputation
Fractures
Wounds
PsychologicalPTSD
Crush injuries
Burns
Auditory/vestibular

Eye, orbit, face,

Dental

Renal

Respiratory

Cardiac and
vascular

Gastrointestinal

Pain

Peripheral nerve
Polytrauma: Definition

Trauma to several body areas or
organ systems

Occur at the same time

One or more is life threatening
TBI in Combat Settings

New mechanism of injury

New constellation of injuries

Challenges to TBI rehabilitation

New expertise and new model of
care
Polytrauma Rehabilitation Centers
(PRC) Level I

New patterns of injurynew paradigm of care

“Brain Injury Plus”

Brain injury drives the care process

Integrate care for complex polytrauma in single
location—simultaneous tx of mult injuries

Higher level of medical acuity

Sequence and integrate treatment to meet
patient need

Coordinated team effort with expanded team of
consultants
Extensive Team of Consultants













Anesthesiology
Audiology
Chaplin Services
Dentistry
Driver Rehabilitation
Gastroenterology
General Surgery
Infectious Disease
Medicine
Neurology
Neuro-ophthalmology
Neurosurgery
Nutritionist












Optometry
Oral and Maxillofacial
Surgery
Orthopedics
Orthotics
Otolaryngology
Pharmacy
Plastic Surgery
Prosthetics
Psychiatry
Pulmonology
Radiology
Urology
Care Across the Continuum:
Coma to Community









Multi-level national network of care
Delivery of specialized care close to home
Comprehensive interdisciplinary assessment of
previously unidentified TBI patients
Proactive Case Management
Continued management of existing and
emerging sequalae
Care for the patient who can’t return home
Telehealth
Identification of community resources
Collaboration with VBA
VA Polytrauma System of Care
Department of
Veterans Affairs
VHA
VBA
State &
Community
Resources
Seamless Transition
Department of Defense
VHA Continuum
of Rehab Care
DOD Healthcare Sys
Polytrauma Rehab
Centers (Level 1)
Polytrauma Network
Sites (Level 2)
Polytrauma Teams
(Level 3)
Local VA Polytrauma
Case Mgrs (Level 4)
Informed,
Empowered
Patient &
Family
Dynamic Links
The Right Care, At
the Right Time, In
the Right Place
Better Functional and
Clinical Outcomes, Higher
Satisfaction, Lower Costs
DVBIC
Specialized
Rehabilitatio
n Services
Case Management Challenges






Family
DoD/VA Liaison
Military Treatment
Facility
Military Transport
Military Command
TRICARE





Medical Holding
Company
“Home” VA Medical
Center (Level II, III)
Civilian Hospital
State/Local Services
Veterans Benefits
Psychology in Polytrauma
Rehabilitation








Integrated, active, interdisciplinary team
member
Combat Stress and PTSD
Complex Pain syndromes
Behavioral management, adherence
Depression, Suicide
Intimacy
Provider stress
Education to mental health staff, nursing,
and all hospital staff, Level II sites
Family Issues

Multiple stressors
Away from home, support systems
 Care of other children, aging parents
 Job loss, financial strain




Adjusting to VA and rehab environment
Duration, intensity & fluctuation of medical
course
Expectations: Advocacy vs entitlement
Family Issues








Role strain and change
Stress, trauma
Political context
Anger, grief and loss
Guilt
“Ambiguous loss” (Boss, 1999; 2006)
Depression, anxiety
Stress increases at transfer to Level 2
Treatment Considerations








Pathologizing family vs family stress theory
Psychodynamic interpretations, motivated
forgetting
Group size, duration
Directive, active, concrete, metaphor
Multi-modal education and treatment
Adjusting “to” and “with” cognitive impairments
Acceptance vs status quo
Assistance: increasing dependency vs support for
 independence
Future Issues & Directions






(Complicated) Mild TBI
Vocational rehab & supports
Community reintegration
Increase substance abuse
Increase suicide
Life span, aging, secondary
condidtions