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Thread: Could Dr. Young answer the questions about C2-C3 injury

  1. #1

    Could Dr. Young answer the questions about C2-C3 injury

    My father got an car accident two months ago. The doctor's diagnosis is C2/C3 complete spinal cord injury and vent-dependent. Because he is just a visitor here with no health insurance, he has been in ICU for two months.

    Right now, my father can shrug his shoulders and breath on his own with the small vent support. His neurosurgeonthe said shoulder-shrugging was only controled by C2. Only if he can raise his back arms aside (which he can't do right now), that means he has no problem in C4. So my father still has difficulty to wean the ventilator although he already has some weak diaphragm function. Do you think his explanation is correct?

    You mentioned that as you know, in China there is no vent-depent patient like my father because of the respirator. Could you give me some explanation on the difference between the ventilator the SCI patient need and the ventilator used in the common surgery in China?

    Because the Hospital has been considering discharging my father, if possible, could you give me some advice on the condition for safe discharge or safe transportation to China? We just want to help my father stay in the right place to give him a chance to wean the ventilator before going back home.

    Thank you very much!

  2. #2
    Where is your father visiting from? Have you talked to the embassy of his country?

    Shoulder shrug is much more controlled by C4 than C2, and shoulder abduction by C5, so I am not sure if you are understanding the neurosurgeon.

    Where do they propose discharging your father to? They cannot just dump him on the street. They would need to find a safe discharge location for him. The problem of couse is his lack of insurance, and unless your family is wealthy, private pay is prohibitive in an inpatient facility. Rehabilitation and a vent weaning program without insurance, and not being eligible for Medicaid is a major problem.

    Ventilator and respirator are terms used interchangably by many people. Many third world countries have few ventilator dependent people with SCI because they don't survive the initial injury without CPR, or because the emergency care system and ICU system is poor.

    Air ambulance would be the only way to transport your father at this point, and this would cost many thousands of dollars to get him anywhere in the USA, much less China.

    I would suggest calling the help line at both www.spinalcord.org and www.paralysis.org to see if they can come up with any ideas for you to help get your father some appropriate care.

    (KLD)

  3. #3
    Thank you very much for your reply!

    My father came from China and the hosptial is planning to discharge my father back to China. We are eager to let my father wean the ventilator first because he should have a good chance to do that and we are very concerned about the condition, the rehabilitation program, and expense in China for long term acute care of vent-dependent SCI patient.

  4. #4
    Quote Originally Posted by sharming
    Thank you very much for your reply!

    My father came from China and the hosptial is planning to discharge my father back to China. We are eager to let my father wean the ventilator first because he should have a good chance to do that and we are very concerned about the condition, the rehabilitation program, and expense in China for long term acute care of vent-dependent SCI patient.
    Hi, sorry about not answering earlier. First, the doctor is correct is saying that the shoulder shrug is not C4. I gave you the wrong impression. C4 is controls the deltoid muscle which is the muscle on the corner of the shoulder and is what allows the arm to be lifted.

    Second, you had described your father's sensory line as being a cm or more below the clavicle (the bone that runs from the throat to the shoulder) and that he also has a sensory line that stops several cm on the arm below the shoulder tip. The following is a dermatome map:


    I believe that every effort should be made to get your father off the respirator. The most desirable of course would be if he could be weaned and were able to breathe on his own. If that is not possible, he needs to have a phrenic nerve stimulation test to see if it will activate the diaphragm. If it causes diaphragm movement, he should have a phrenic nerve pacer placed. If it does not, he should consider a diaphragm stimulator.

    Wise.

  5. #5
    Wise, considering the expense of these tests and of the surgery and device for a phrenic or diaphragmatic stimulator, I would find it extremely unlikely that an uninsured, unfunded patient would be even remotely considered a candidate for this in a hospital in the USA.

    Can you address the issue of respirator use in China?

    Sharming, how are they proposing to get your father back to China?

    (KLD)
    Last edited by SCI-Nurse; 01-10-2006 at 07:21 PM.

  6. #6
    The hospital will meet us this Thursday to discuss my father's long-term plan, especially the discharge issues which makes us very nervous now. I will see what their plan is. Thank you!

  7. #7
    Quote Originally Posted by SCI-Nurse
    Wise, considering the expense of these tests and of the surgery and device for a phrenic or diaphragmatic stimulator, I would find it extremely unlikely that an uninsured, unfunded patient would be even remotely considered a candidate for this in a hospital in the USA.

    Can you address the issue of respirator use in China?

    Sharming, how are they proposing to get your father back to China?

    (KLD)
    KLD,

    I spoke to the family about this, gave them some names of doctors in Beijing and Shanghai, the places most likely to have facilities that can take care of patients on respirators. Unfortunately, in all my visits to spinal cord injury centers in China (over 15 centers), I have not yet seen a place that has any respirator-dependent patient in China. Hong Kong does have facilities for respirator dependent people but I am not sure that they would be able to get into Queen Mary Hospital in Hong Kong.

    The family asked me what is the difference between hospital respirators and ones for individual home use. I think that perhaps you would be better able to answer that question than me.

    Wise.

  8. #8
    Thanks, Wise.

    A hospital ventilator is a large complex machine that has the ability to have many sophisticated modes and patterns of breathing often needed for problems such as ARDS or other serious acute lung problems. Here is a typical ICU type ventilator.

    For someone who is newly injured, these settings may be needed, but once they are medically stable, most people can be easily moved to a ventilator that has essentially three settings: volume, rate and pressure. This allows the ventilator to be much smaller, battery powered, and mounted on a wheelchair. These have gotten much smaller over the years, and now there is more than one company making them. Respironics bought out Lifecare, which was the original company still makes the PVL line of ventilators, but some other companies (such as below) are even smaller.

    (KLD)

  9. #9
    Dr. Young and KLD,

    Your information is really helpful for us!

    The hospital here is trying to find a hospital in China to accept my father. And actually that is the only choice we have right now. If my father didn't need respiratior, we really want him to go back home as early as possible. So right now we can only wish that my father can wean the ventilator before discharge.

    KLD,

    With the portable ventilator, can the patient still have chance to breathe on his own finally? Or only a hospital ventilator can help the patient to wean the respirator because of its sophisticated modes and patterns of breathing ?

  10. #10
    Usually if weaning is possible, it is done with the hospital ventilator, but it is still possible if done properly with the portable ventilator. Often those who have limited SCI experience in the ICU really don't do SCI ventilator weaning properly anyway. The best way is to take the patient off the ventilator for short frequent periods so they don't fatigue (called spontaneous breathing trials or SBT). This works better than partial support modes which can be set on a hospital ventilator.

    Here is a good professional journal article about this:

    http://www.vard.org/jour/03/40/5Sup2/Gutierrez.html

    I would encourage you to download the clinical practice guideline on respiratory management in SCI (written for professionals) and share it with his current health care team. You can get a copy here:

    http://www.pva.org/cgi-bin/pvastore/products.cgi?id=1

    There will be a patient version soon, but it is not yet available.

    You may also want to look at resources on home ventilation at this site:

    http://www.post-polio.org/ivun/index.html

    (KLD)

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