Concussion. Kester J Nedd DO

or understand the problems that I am having, and she expects me to do things that I cannot do.” Getting to really know this patient after several visits and meeting and understanding his wife’s perspective, I soon realized that the patient did have real symptoms, which were proved through clinical exams. Most of his complaints were rooted in the fact that his wife gave him little attention and made it a rule in the house that if he did not perform certain tasks, she would not allow him certain privileges. These included not receiving an allowance, having sexual intercourse, and not being permitted to drive his car. The patient soon realized that being sick at least got him sex because his wife paid more attention to him when he complained of feeling sick. Given that the patient was in a workers’ compensation situation, he had been seen by a neuropsychologist on the request of the insurance company. The neuropsychologist noted that he had various inconsistencies on the neuropsychological test, like what was noted the case of Mr. Dalbert. Various neurologists who saw Alfonzo had similar conclusions. Therefore, he was diagnosed as “malingering”. With this diagnosis given by his neuropsychologist, Alfonzo was forced to go back to work under the threat of his workers’ compensation financial benefits provided by the insurance carrier being cut off. The patient had important “drivers” that made him continue the sick role, and in my opinion, he utilized them well. Clearly, the clinicians came to this patient with a lot of biases and failed to understand the drivers of his pain, emotional state, and physical limitations. It took me some time spent with the patient’s attorneys, the workers’ compensation carrier, the patient, his wife, and employer to address the issue. At the end of the day, everyone agreed that the patient had a real condition and had suffered a real injury. The patient had regressed to a stage earlier than his stated age, causing him to emulate immature and childish coping behavior driven by his emotional needs. Today, the patient is working as a productive individual providing for his family. Saving this patient involved bringing all the parties together to eliminate the biases that we all have. Having put aside our biases, we were able to develop a treatment plan that made sense while addressing the patient’s situation. This patient had a real problem that was easily treated with medications and input from another neuropsychologist skilled in the management of such situations. We must realize that many patients who are considered to be malingering or exaggerating their symptoms do so but sometimes actually have real conditions. We, as clinicians, do a disservice when we fail to look for the real conditions that can be treated and introduce our personal biases because we believe that the patient has been untruthful in their symptoms or exaggerate their clinical exam situation for various reasons. It takes special skills as a clinician to distinguish fact from fiction and to even talk to patients and their families when such situations of malingering exist. If at the end of such a discussion, you have a satisfied patient or they are willing to have you follow up on them, you can be really impressed with yourself as a clinician. You will surely not win every case, as some patients’ beliefs about their condition are so ingrained that it may not be possible to assist them out of a situation in which they are malingering or exaggerating their symptoms. However, there are some tools we can employ to help determine the validity of the patient’s reporting and our findings on clinical assessment. The following tools are helpful in this situation:

      Table # 7 – Establishing validity in patient reporting

Consistency on neurocognitive and neurological exam; perform tests of malingering that can be useful	The field of neuroscience utilizes testing tools that are generally consistent across patient population and disease conditions based on our classification of diseases. Any significant variation on what is expected often introduces concerns of legitimacy that should not be ignored. It takes a knowledgeable and experienced clinician to be able to administer and interpret these exams/tests.
Evaluation of the incentive and drivers of playing the sick role, if any	This can be driven by a parent, spouse, family members, friends and issues of obligation, fear of a particular outcome or a reward.
Purging yourself from biases as a clinician	Assuming that the patient is guilty until proven otherwise is not the best approach to the patient’s situation.
Listening to all sides before drawing conclusions	Information provided by all parties can be misleading. A smart clinician knows the right questions to ask to get the information needed and utilizes such information to analyze a patient’s situation.
Clinicians’ knowledge of what they treat	Before attempting treatment, a clinician must be certain as to what they are treating. As a rule of thumb, it is not a good idea to treat something you do not know or understand.

      In the USA, the entire system of jurisprudence is strictly polarized down the middle; physicians and neuropsychologists are defined as either supporting the plaintiff or the defense side. We must realize that at times money/economics are the major drivers at play here.

      Beyond workers’ compensations and personal injury, the US has been through one of the largest settlements seen between the National Football League and the retired players only to be matched by the tobacco settlement. Irrespective of where you find yourself, perplexing questions central to this issue of compensation for the retired injured player are as follows: Who is injured and who is not? Who is healed and who is not? The National Football League (NFL) world has been rocked by controversy on this question when an injury occurs, defining the post-concussion sequelae of such injury and finally determining if the symptoms persist. Even after a billion-dollar settlement with the former players, setting up a way of objectively making those determinations with the former players has been challenging. While there have been consorted efforts by all parties, professional biases by specialty physician groups, neuropsychologists, and the legal community and pressure from the players, their advocates, and NFL representation can limit clinicians’ ability to objectively answer the fundamental question as to who should qualify for the settlements.

      For soldiers returning from recent military conflicts, the question as to who is injured and who remains with symptoms and signs have been at the forefront. During my training years, I spent time in a Veterans Hospital and had the opportunity to see and evaluate veterans of war from the Vietnam War. Sure enough, I was looking at brain injuries and concussions that went untreated. For all practical purposes, this is a generation of persons with TBI/concussion, who have been lost in the community with little attention from the medical system. Returning soldiers and their families, as in the case of football players, have been living in the shadow, as they have largely gone undiagnosed and untreated.

      Another issue where there is a clash of cultures is that of post-traumatic stress disorder, otherwise known as PTSD. PTSD is commonly seen in soldiers and following traumatic events, such as accidents (Morissette 2011). Most persons with this condition have knowledge of the accident and often re-live the experience in many ways. In PTSD, the key feature of the condition is heralded by what is known as “anniversary reaction.” Individuals are often reminded of the experience (anniversary) consciously and unconsciously where they re-live the experience of the accident when they are exposed to days that seem like the day of the event, anniversary periods such as the time and circumstance of the accident, or in seeing others with similar fate. These experiences can be anxiety-producing and can create fear and apprehension. For years, soldiers were not taken seriously about having this condition until the military realized that these individuals became highly dependent due to crippling symptoms. Today, the US military has developed an entire system to deal with patients who have witnessed horrifying experiences, including trauma from blast incidents and direct blow to the head (Morissette 2011).

      A group of patients who develop PTSD that we often forget are patients in intensive care units (ICUs), who experience the terror of certain procedures and experiences. They may vividly recollect those experiences and feel trapped. Nurses and doctors are often insensitive about the issue of pain-producing procedures carried out without enough anesthesia or sedation or the terrifying hallucinations or nightmares that patients may experience in the ICU. Sideris (2019) presented a paper on the case of a patient who developed PTSD due to terrifying hallucinations and nightmares in the ICU. Like the cases seen in the returning soldiers, these cases of PTSD in trauma and ICU settings may be more common than we previously recognized.

       CHAPTER 9

       Скачать книгу