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Thread: Rehab questions for Father with recent SCI (long . . . sorry!)

  1. #1
    Junior Member salinmooch's Avatar
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    Exclamation Rehab questions for Father with recent SCI (long . . . sorry!)

    Hello all,

    I have been snooping here on these forums since my Dad's injury about 2 months ago. It has been a great source of information as well as a source of comfort. Now I find my self with some questions on rehab I need clarification on.

    The brief story:
    A little less than two months ago my father was struck by a car while riding his bike, was thrown from his bike and landed on he head an face. Fortunately he was wearing his helmet which saved his brain, but his neck bore the brunt of the impact. He suffered a type II odontoid (dens) (similar to that of Mr. Reeves) fracture, and the force of the impact drove the dens posteriorly into his spinal cord causing a severe spinal contusion at the C2 level.

    He was placed in a SICU, and his spine initally placed in traction via halo and then surgerically corrected. He was placed on ventilator support.
    He spent a little over 3 weeks in the SICU (which he thankfully does not remember) and has spend about 3 weeks at an LTAC where the team there attempted to wean him off the vent.

    His neurological function as I understand it: incomplete tetra: Intact sensation (light touch, heat cold, pain) thoughout, gross control of his left leg (quads mostly), a little on his right, some emerging control of his left fingers (can barely wiggle). I am uncertain of his chance to be weaned from the vent (his diaphram control, etc), right now he is still vent dependent.

    (so much for breif!)
    So my question concerns the next steps in his rehabilitation. I am in the odd position of possessing enough knowledge to be dangerous and not enough to be useful. I am a fourth year medical student who completed a rotation in rehabilitaion earlier this year (PM&R) and spent some time in a SCI floor (At metro health in cleveland). The main thing I took away from that experience is that nurses, PTs, OTs, and physiatrists that work with a large number of SCI patients make a huge difference in the early rehabilitation experience of patients. Also the peer support from a dedicated SCI floor is helpful too.

    Thus I would like my father to go to one of the model systems for SCI rehab or one of the larger more well known rehab hosptials for his intial rehab. He is currently in an LTAC in a smaller Ohio community. The docotors there want to send him to a a local CARF certified hopsital or to a nursing home.

    The things that seem against my dad in the process:
    1. He is 78. In my opinion when people see that on paper they make certain assumptions. I know my dad as a retired physican, active in mensa, who raised 10 kids, has 28 grandkids, who did the applacain trail after, retiring, and was hit while training for a bike ride that would take him cross the state of Ohio over 2 weeks at 50 to 60 miles a day!

    2. he is still vent dependent which limits him to rehab hospitals that take vent dep. patients.

    3. Metro in Cleveland only has two vent capable rooms - none are available for another two weeks.

    4. I am currently rotating in Boston, and a vent bed in spalding has become available. His case worker in ohio doesn't seem to feel this is an option!?

    Question 1:
    Should we try and wait for the cleveland bed or try and get him to Boston (which is a tenuous option as Spalding hasn't looked at his chart yet)?

    Question 2:
    The LTAC wants him out in about a week - so I'm not sure where he can go for a week if he was to go to cleveland. If he goes to a local rehab hospital can he then transfer to another (i.e. would this be a problem with medicare)?.

    Question 3:
    What is a good way to get a incomplete tetra from Ohio to Boston if that turns out to be an option.

    Question 4:
    If he seems to be headed to vent dependence, how soon should I push for a phrenic nerve stimulator?

    I could go on and on . Any info would help! Thanks!

    Cheers,
    Robert
    Last edited by salinmooch; 07-22-2008 at 11:55 PM.

  2. #2
    Sorry you had to find us, but your dad is lucky to have you as an advocate for him!

    First, is your dad a military veteran by any chance? If so, the VA SCI System of care would be a great option for him. One of the major problems for a patient at 78 is that Medicare provides at most 4 weeks of rehab for a SCI, and that is rarely enough, esp. for someone of his age and degree of disability.

    Personally, if you can manage the wait for MetroHealth, and they are willing to provide information to you and his current setting about continuing with appropriate SCI vent weaning (which is different from non-SCI vent weaning), I would stay with that plan. See if there is a Kindred facility in his area. While I am not a Kindred fan in general as they lack SCI experience, they are used to vent weaning in the subacute setting. Downside is that he probably would not get any PT or OT there.

    The only way to get him from Cleveland to Boston would be to private pay for an air ambulance. Very expensive, and not covered by Medicare or most other insurances. They really cannot force him out of where he is now, so if you firm up the bed at MetroHealth I would negotiate with them to extend his stay until that bed is available.

    Generally 12 months is the wait to consider any type of phrenic or diaphragmatic pacing, but Cleveland is the hub of that research, so you should be able to get good advice there.

    Is he in a halo?

    Does he have shoulder shrug?

    (KLD)

  3. #3
    Senior Member fishin'guy's Avatar
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    First, sorry about your dad Salin, this is a great spot for answers. Great Dr.s, Nurses, and other "straight from the horses mouths" so to speak.
    Nurse thank you and everyone for their astute knowledge of sci, and taking the time to be on here to help us all.

  4. #4
    Junior Member salinmooch's Avatar
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    Thanks for the quick reply.

    I am to talk with Metrohealth tomorrow via conference call with some family there present in person. I will see if I can get something firm from them to take back to the LTAC to see if he can stay longer.

    He is unfortunately not a eligible for the VA. He did have the foresight to provide himself and my mom with good insurance, and he has a substantial umbrella, although I do not know the details and SCI rehab and care is not cheap as you know! There is a future possibility that the at fault driver who stuck him's insurance will assist as well, though that is another ugly part of this situation (that insurance is currently stonewalling):

    He had a halo for about 1 week, but his fracture was quite unstable, so it was fixed with a screw.

    He does have a nice strong shoulder shrug.

    Frankly I think a challenging rehab would just the thing - he says he is ready for more challenge than the small amount of PT he gets now (pass on by lip reading siblings of course).

  5. #5
    I forgot to tell you to download the clinical practice guideline on Respiratory Management in SCI from the site you can find linked from the "sticky" topic at the top of the Care forum. You can also find several other helpful CPGs related to SCI, all written and published by the Consortium for Spinal Cord Medicine (and funded by the PVA) at the same site.

    When you say he is not eligible for VA care, does that mean he is or is not a veteran??

    (KLD)

  6. #6
    Senior Member dizzal's Avatar
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    Keep asking questions and you are doing a great job advocating for your Dad

  7. #7
    Junior Member salinmooch's Avatar
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    Thanks for the kind comments!

    Thank you for the info as well - I will check out the clinical practice guidelines and disseminate to my family. Knowledge is power!

    I should have been clearer - My dad is not a veteran.

    I spoke with MetroHealth today and they did give him a place starting August 8th. Now to negotiate with the LTAC. I looked up Kindred as well.

    Since his insurance situation is not completely clear to me currently, I am trying to think of coices based on medicare.

    Do I assume correctly that Medicare will only pay for a limited number of transports?

  8. #8
    Transports? You mean critical care ambulance rides (required due to the vent)? Yes, but generally if they are going to a different level of care that is not a problem. They will not pay for air ambulance though.

    (KLD)

  9. #9
    Junior Member salinmooch's Avatar
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    Yes I meant critical care ambulance rides. Apparently the LTAC wants to send him to the local Rehab hosp. and then to Metro health. That does not make a whole lot of sense to me.

  10. #10
    Like I said, fight them on this. They can't actually send him anyplace against his will/consent.

    (KLD)

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