Eight months now I have been treating a worker injured on the job. Currently she is at risk of losing workers compensation benefits related to her recent cognitive decline. Losing the benefits would be a devastating blow to this mother of four*. Her husband is unable to work full time due to caring for their six children and now his wife.
She suffered her injuries when a large stack of wooden pallets fell on her causing immediate neck and arm pain. She was admitted to the hospital and discharged shortly thereafter. Subsequently her symptoms became worse, she was re-hospitalized and fell into a coma for several days. Unfortunately diagnostic work-up focused mostly on her neck and shoulder and neglected her brain. She was discharged from the hospital after awaking from her coma. She was able to live at home with her husband and family, but unable to work due to pain.
Approximately four months after her injury the patient's husband noticed a rapid change in her behavior: drowsiness, paranoia, memory loss, inappropriate speech. A neurologist was consulted and he recommended physical and occupational therapy. My evaluation revealed marked deficits in the patient's neck and shoulder function and acute onset of vertigo with neck motion. Interestingly I found the patient's cognitive deficits to be more profound than her orthopaedic deficits. Those deficits matched those of a brain injured patient: poor attention span, short-term memory loss, decreased executive function. Apparently no MRI was performed on her brain and so I was unable to understand what was the underlying cause for this patient's decline.
She has made excellent progress with her shoulder and neck function. Sadly, though, her cognitive status prevents her from being safe when unattended and will possibly prevent her from ever being able to work again. Workers compensation is looking to deny any coverage for cognitive related disabilities claiming that her cognitive decline is not associated with the accident, but is rather a combination of the patient's diabetes and her poor diet since the injury. Neuropsychiatric evaluation revealed that the patient does have profound cognitive deficits in the realms of attention span, short term memory, safety judgement. In their conclusion, the psychiatrists stopped short of directly implicating her work injury for this patient's cognitive decline. I plan on advocating for workers compensation coverage for this patient. Below is the beginning of my line of argument.
Rational for explaining my patient's cognitive decline boil down to two: 1) traumatic brain injury with chronic cognitive sequela; 2) diet induced diabetic encephalopathy. I will develop the former rational as workers compensation is developing the later.
Traumatic brain injury typically results in an immediate and significant cognitive loss followed by a steady but small cognitive decline over the life of the patient. Given that my patient experienced a coma after her injury she likely suffered at least mild brain injury if not moderate or severe. Unfortunately no MRI is available from that time period and no MRI has been performed since. Consequently brain damage cannot be assessed. The lack of an MRI is very surprising in a case such as this one. A brain MRI has not been performed either due to medical mismanagement or due to the patient's haste to exit the hospital (she has expressed a strong phobia of dying in the hospital due to past family experience). Because no MRI is available certain brain injury diagnoses can not be ruled out and therefore should be considered as possible causes.
My patient experienced significantly increased appetite after her work injury. Increased appettite is associated with injury to the ventro-medial aspect of the hypothalamus. In such a case the patient's increased appetite (and subsequent diabetic encephalopathy) would then be a direct result from the work related injury. Magnetic resonance imaging of the brain would reveal the status of my patients hypothalamus. Damage in the hypothalamus means that the patient's increased appetite is a symptom as well as a cause. Increased food consumption would lead to diabetic encephalopathy. This entire process would then be a work related injury. Workers compensation would then be warranted for her cognitive issues.
Should the MRI demonstrate no damage to the hypothalamus I would argue that the patient's appetite changes are at the least an indirect symptom of depression related to her injury. Depression, unless treated, leads to increased appetite and hence the diabetic encephalopathy. Additionally, brain damage from the accident would predispose the patient toward onset of encephalopathy due to uncontrolled glucose levels. In other words, had she not had a brain injury, diabetic encephalopathy would be no where near as pronounced as it is now.
*I have changed various non-medical details about this patient to ensure privacy.
2 comments:
So she is losing her worker's compensation because physically she is making progress, and otherwise her ailments fall beyond the boundaries of what her employer is responsible for (i.e. cognitive functioning)? Also, how long typically would an individual receive worker's comp after being injured on the job?
She has plateaued with her physical progress at the current time. Her physical functioning level would prevent her from returning to manual labor, but is at the level of sedentary desk work. Her former employer is attempting to draw bounds around cognitive issues claiming they are not a work related injury. In this way they can refuse cover the cost of any cognitive training.
It is the employers responsibility to cover the cost of any work site injury until the fullest possible outcome is achieved. In this case my patients employer allowed an unsafe environment and is now responsible for my patients ruined abilities until they have satisfactorily restored the damage done to her.
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