The first time I had met with P., he was new that day to the rehab unit. The ambulance transferring him to our unit had scarcely left the drive, on the way back to the University Hospital, when I assured myself my plan was on point. No one had taught me this, but I knew I had to imprint on this guy.
I needed to be the first therapist with whom this patient could bond. And now I was here for the initial bonding experience. Through review of P.'s record, I could flesh out his story to decide on a tentative plan with P., his family and support system.
"P. my name is C. I am a speech therapist. It's good to meet you. You are at our rehab center. I'm here to help you anyway I can"...and then I sat back and listened.
P. had been shot in a drive-by assault, some six weeks prior to the day he had entered acute rehab. The trajectory of a single bullet, entering his right forehead, had at high speed dug deep into his midbrain, with a cavity swelling then imploding around that missile. Brain tissue density did indeed change the bullet trajectory, so that the bullet exit wound was found through cerebellar tissue at the lower left cranium.
"P., with what happened to you, I have seen in your chart that you do not talk. You are able to concentrate on a person, when that person touches your arm or shoulder. You don't swallow your own saliva without coughing, so there is a tube in your stomach so that you can be fed".
While the abrupt trauma to P.'s nervous system had brought about his coma and near herniation of his brain stem, - what had been turned off, at the neuropsychological level, were consciousness, alertness, attention, speech, expressive language, and all the higher cortical functions - what make you an adult...they're turned off, for awhile.
P. had been found on an urban street corner by the EMT's, not five minutes after the gunshot had been documented on high- sensitivity audio police surveillance. He was known to the city's police; not having completed high school or a GED, his job had been on the streets. The state had begun to pick up the tab for his highly complex medical care through Medicaid. Acute rehab was intended to get P. more mobile, more independent for ADL, and communicative.
"OK P., it's time now to help you get better. I can't guarantee we will reach a certain goal, but we are going to try to help you swallow better. Here -here is a cotton swab, with some lemon ice coating it....I'm rubbing your lips with it. As the President says, we'll see what happens".
I am always open to pleasant surprises...but after doing this kind of work for over 35 years, the odds for P. having a future in competitive employment is extremely low. P.'s need for long term complex medical care seems to be high intensity and long-term. As of our first day, the social worker says no one had yet been arrested for this shooting. Why did we have to have this case?
Sunday, August 5, 2018
Thursday, August 2, 2018
More guns than there are brains
* US Population Estimate (January 2015): 320,000,000
* Number of guns privately owned in US (January 2015): estimated, 265,000,000
Source: Azrael, Deborah, Lisa Hepburn, David Hemenway, and Matthew Miller. 2017. “The Stock and Flow of U.S. Firearms: Results from the 2015 National Firearms Survey.” RSF: The Russell Sage Foundation Journal of the Social Sciences 3(5): 38–57.
Significant determinants for outcomes after gunshot wounds to the head include:
* Admission Glascow Coma Score (GCS),
* Trajectory of the missile track,
* Pupillary response to light,
* Patency of basal brain cerebrospinal spaces (CSF cisterns) were significant determinants of outcomes in civilian and military gunshot wounds to the head.
Source:"Gunshot Wound Head Trauma", web page managed by the American Association of Neurological Surgeons. http://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Gunshot-Wound-Head-Trauma ; Accessed 8/1/2018.
"Not all bullets are created equal. The energy of a bullet is determined by its mass and speed, and its wounding potential hinges on its ability to transfer its energy to a target; even rounds that are similar in size, or look similar, can cause dramatically different damage."
Source: Meredith Rizzo and Rebecca Hersher, "WATCH: The Science Behind Why Some Bullets Are More Destructive Than Others", SHOTS: Health News from NPR. Washington, DC: National Public Radio. https://youtu.be/UzXsjMDpNq4 Accessed 8/2/2018.
"Gunshot wounds to the head, the most lethal of all firearm injuries, rank among the leading causes of head injury in many United States cities. They carry a fatality rate greater than 90 percent, and at least two-thirds of the victims die before reaching a hospital."
"The bullet trajectory through the brain carries major significance. Bullets that cut through the brainstem, multiple lobes of the brain, or the chambers where spinal fluid is located are particularly lethal.Many initial survivors develop uncontrollable pressure on the brain and subsequently die."
Source: UCLA Neurosurgery, "Cranial Gun Shot Wounds". Los Angeles: UCLA Health. http://neurosurgery.ucla.edu/cranial-gunshot-wounds ; Accessed 8/2/2018.
The first time Reed opened fire on a rival gang member, he says he got hooked on shooting.
“It’s like an adrenaline boost. Like ... I’m da man!” he says. “You know, I enjoyed it.”
Growing up on the Northwest Side of Chicago, Reed says gang members kept guns in a Crown Royal bag under his front porch. He says after he committed his first shooting, at about the age of 13, he was always chasing that rush — and would often volunteer to go with his fellow gang members when they went out looking to shoot rivals.
“It’s like a drug. You get addicted to living the lifestyle, living the gangster lifestyle,” Reed says. “Since I was a kid I always was infatuated with that type of lifestyle. Always.”
Source: Robert Wildeboer, "When Shooting Feels Like a Drug". Chicago: WBEZ 91.5 Radio. http://interactive.wbez.org/everyotherhour/like-a-drug/ Accessed 8/2/2018.
* Number of guns privately owned in US (January 2015): estimated, 265,000,000
Source: Azrael, Deborah, Lisa Hepburn, David Hemenway, and Matthew Miller. 2017. “The Stock and Flow of U.S. Firearms: Results from the 2015 National Firearms Survey.” RSF: The Russell Sage Foundation Journal of the Social Sciences 3(5): 38–57.
Significant determinants for outcomes after gunshot wounds to the head include:
* Admission Glascow Coma Score (GCS),
* Trajectory of the missile track,
* Pupillary response to light,
* Patency of basal brain cerebrospinal spaces (CSF cisterns) were significant determinants of outcomes in civilian and military gunshot wounds to the head.
Source:"Gunshot Wound Head Trauma", web page managed by the American Association of Neurological Surgeons. http://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Gunshot-Wound-Head-Trauma ; Accessed 8/1/2018.
"Not all bullets are created equal. The energy of a bullet is determined by its mass and speed, and its wounding potential hinges on its ability to transfer its energy to a target; even rounds that are similar in size, or look similar, can cause dramatically different damage."
Source: Meredith Rizzo and Rebecca Hersher, "WATCH: The Science Behind Why Some Bullets Are More Destructive Than Others", SHOTS: Health News from NPR. Washington, DC: National Public Radio. https://youtu.be/UzXsjMDpNq4 Accessed 8/2/2018.
"Gunshot wounds to the head, the most lethal of all firearm injuries, rank among the leading causes of head injury in many United States cities. They carry a fatality rate greater than 90 percent, and at least two-thirds of the victims die before reaching a hospital."
"The bullet trajectory through the brain carries major significance. Bullets that cut through the brainstem, multiple lobes of the brain, or the chambers where spinal fluid is located are particularly lethal.Many initial survivors develop uncontrollable pressure on the brain and subsequently die."
Source: UCLA Neurosurgery, "Cranial Gun Shot Wounds". Los Angeles: UCLA Health. http://neurosurgery.ucla.edu/cranial-gunshot-wounds ; Accessed 8/2/2018.
The first time Reed opened fire on a rival gang member, he says he got hooked on shooting.
“It’s like an adrenaline boost. Like ... I’m da man!” he says. “You know, I enjoyed it.”
Growing up on the Northwest Side of Chicago, Reed says gang members kept guns in a Crown Royal bag under his front porch. He says after he committed his first shooting, at about the age of 13, he was always chasing that rush — and would often volunteer to go with his fellow gang members when they went out looking to shoot rivals.
“It’s like a drug. You get addicted to living the lifestyle, living the gangster lifestyle,” Reed says. “Since I was a kid I always was infatuated with that type of lifestyle. Always.”
Source: Robert Wildeboer, "When Shooting Feels Like a Drug". Chicago: WBEZ 91.5 Radio. http://interactive.wbez.org/everyotherhour/like-a-drug/ Accessed 8/2/2018.
"My identity as a gun violence survivor
is a paradox. On one hand, it's a reminder that life can change fast, in
unimaginable ways — in my case, a gunman opened fire on me and my
constituents at a community event seven years ago, killing six, injuring
12 others, leaving me partially paralyzed and reducing my ability to
speak. On the other hand, tragedy has given me agency, courage and
historic purpose in the movement to save lives from gun violence.
As
a survivor, I’m often sought out to comfort those in distress. People
send emails, write letters, leave messages on Facebook, but usually,
they just stop me on the street. Many times, they have their own
experiences with pain and trauma — often left unmentioned — but their
survivorship is marked by a recognizable resilience."
Source: Gabrielle Giffords, "Getting shot seven years ago gave me courage to fight gun violence: Gabby Giffords", USA Today. Washington: Gannett Corporation. https://www.usatoday.com/story/opinion/2018/01/08/seven-years-after-being-shot-were-still-standing-up-gun-lobby-gabby-giffords-column/1011400001/ Accessed 8/2/2018.
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