We have Dr. Spear next, if you want to go ahead and introduce yourself and let's get started. So trauma 101, A, rehab doctors in terms of being a part of the team don't have much to contribute. And so they don't really want to be consulted in the ICU or acute setting. B, having another cook in the kitchen is liable to complicate an already complicated situation. C, we already have a case manager, so why do we need a doctor that does the same thing? Or D, the lecture is a rehab doc, so I'm not super comfortable with A, B, or C. I feel like there's a younger population, Dr. Maines, because I don't think you would have gone with D. I feel like you would have been very comfortable with A, B, or C. Sort of grew up in a different environment. So how do we use a rehab doc in the acute setting? I think all the questions are correct to a degree. First, I'll go through a little bit of the objectives. I want to kind of go through what a rehab doc does, talk a little bit about media and support issues in terms of this particular case, because it is a little bit more complicated. Go through documentation and thinking about unexpected consequences. I want to talk a little bit about setting expectations, developing a strategy, talk about milder and severe injuries and the kind of mistakes we make at each end, some general rehab considerations, and then kind of go to what I do most of the time and talk just a little bit about neurorehab. So that first question, I think each one of the answers is a little bit true, and it really depends on your setting. And I think that it's important to realize as the traumatologist in that acute setting, you set the stage and the environment, and rehab docs often do like to be in that setting. But we want to make sure that we're useful and that we're a part of a team. We're used to being a part of the team. In the rehab hospital, we have a whole group of people that work in an interdisciplinary way with us. So that's important. And so we want to be helpful. And there are different ways that we can do that, which I will hopefully be able to explain a little bit better, but it also helps to give a little bit of direction and kind of develop that relationship in a way that's helpful in your environment. What we will typically do if we're in the acute setting, and what I do in the ICU is really try to take a deep dive on the family and patient dynamics. And we can really do a lot to reduce reactivity, but we can also get a lot of additional social history and background information that helps to add additional layers to problems that will often emerge, whether there's a lot of reactivity in the family, or if there are pre-morbid medical or psychiatric issues, and then also in planning long-term care, particularly in these patients that are extremely complex, where there's a lot of different types of injuries and there's a lot going on with the dynamics of the family or in a situation like this where multiple family members and people in the community are affected. Another thing that we can often be helpful with is dialing down a specific medication strategy that makes sense for the patient. And there's a saying that we have is it's not just the patient that's injured, but the brain that was injured. The background of that person is important. We wanna give direction to the rehab provider, but we also wanna give them a little bit of space to have some creativity and show you how they can be helpful in ways that you may not be able to anticipate. And hopefully I'll get into that a little bit more. We wanna set a strategy for care. This is important, not just to get them out of the hospital faster and to set them up for good care, making decisions early, but to also decrease the reactivity of the family. I think if we can really kind of get a sense of where they're at and help them put their feet on the ground, it makes a big difference in the longer term. So here's the next question. Media and support structure strategies. A, my hospital has a media department to handle all of this for me with my direction, so it's no problem. B, I use the structure of the hospital environment to help family manage trauma and set priorities. C, this is what social workers are for, keeping patients alive is work enough. Or D, media has no place in this conversation. We need to focus on the patient and the family. And I wanna point out while we're getting the results, Dr. Speer is with Craig Hospital and really one of the premier rehab hospitals in the country and we're fortunate enough to have him around in our ICUs on a frequent basis. We'd like to have him more. And I would say that you're extremely helpful with all of this plus decisions about details of medical care. So we have the results, let's see what they say. So it's interesting that so many people answered one. I think we're lucky to be in settings where we have that kind of support. And I definitely have that at Craig Hospital where we have an entire media division of the hospital. So when we have complex cases or very high profile cases, we have a department that's able to manage the media on the outside and work with the family to address these issues. And so if you have that in your setting, that's pretty fantastic. I've been up here for seven years, but I came up here from El Paso where I worked a lot with the military. I worked a lot on the border and some of the poorest zip codes in the country. And we'd have patients that would exhume themselves after having their throats slit by drug dealers and buried in a shallow grave. And the dirt would clot their arteries and they would exhume themselves and go to the hospital. We had people shot by huge caliber weapons and hit by machetes and the amount of drug violence that we had while I was in El Paso. At one point, we worked with the chief of police from Juarez, most of the police in the police department were paid by the Sinaloa cartel. They walked out of the building one day so the cartel could come in and try to kill the chief of police and they were unable to. He was able to defend everybody else off. The point of that digression is, it can be difficult to anticipate what sort of situations we have where the media can be a real barrier to care and our own safety can sometimes be at risk when we're looking at other problems associated with some of our cases and it's difficult to, you can't make this stuff up. And so it is helpful to be ready and prepared for anything. It sounds sort of pithy for me to say that to a bunch of traumatologists, but I think it helps to kind of have some of these ideas anticipated so that you are ready for everything. And if you don't have a media department, one of the things that I do in working with families, because a lot of times I'll be working with large groups of people, is I really sit down with the entire family and I identify a couple of things. One, an alliance with a social worker and to figure out how we're going to, let's see, I'm having trouble getting to the next slide. Here we go. In terms of working with the media, but also really setting expectations with the family and sitting down with the family to spend some time with them. A lot of times family members are on wildly different pages about what kind of care to give, how aggressive to be, what treatment should be done. And a lot of times just putting them all in the same room and letting the meekest, most introverted people talk first and slowly going around the table so everyone can be heard can really create a lot of consensus without us really having to direct care a whole lot. It's also really helpful to identify what members of the family are going to be the key people so that we're not having the same conversation with lots of people over the course of the time that we're working with them. We wanna identify the medical issues that can be issues downstream. A lot of times in the acute setting, there are things that we don't think about like, you know, we can just keep them non-weight bearing and we can take care of an ORIF downstream or we don't really have to worry about the spasticity because that issue can be addressed in the future. The problem is, is that for a lot of these patients, it can be a huge barrier to their rehabilitative care. It can affect getting to downstream settings that are gonna be more appropriate for their care. And then it can also end up in problems emerging downstream that could have been addressed earlier. For example, patients who have a lot of spasticity, it's inconceivable how often I have to get tendon lengthens, lengthening surgeries to the calcaneal tendons in patients in rehab just to begin working on transfers and walking. It's also inconceivable how often severe spasticity could have been completely averted with a intrathecal baclofen pump or some targeted Botox treatment very early in their care or reassessment of their medications to avoid dyskinesias that ended up being more of an issue secondary to medications that we wouldn't have been able to anticipate. So we help them to survive long enough to deal with issues that become far more problematic that could be avoided earlier on if we were able to have the specialist that ended up dealing with those issues earlier on. It's also surprising how often I'm not able to get spinal cord patients or more severe brain injury patients into rehab because they have large wounds to their skin that should never have happened in the acute setting. No matter how good the setting is, it's something that needs to be really vigilantly watched. And then one of the other things that I think is helpful to think about is funding. We think that funding is something that we shouldn't worry about because we need to provide care, but the kind of care someone gets downstream of the acute setting is really impactful into their long-term ability to recover. And a lot of times we'll have patients that actually have funding and we don't know it. And so they end up in settings they shouldn't, or we have the ability to get them on a plan or get them access to care if we have someone advocating for them early on or get them access to things like workman's compensation resources. And so these are one of the things that we're heavily involved in in the acute setting. And if you wait too long, oftentimes these opportunities pass you by. And then last is this concept of stress inoculation. We have families that are gripped and just terrified. And we all do a pretty good job of placing them at ease, but if you could have someone like a rehab provider that can sit down with them and help them anticipate possible futures and really talk about how they're doing, not just the patient, then they can be better advocates. They can be less reactive. They can be more supportive of the interventions that we need to give. And sometimes it's simple as just a little bit of stress inoculation about what they need to prepare for and then understanding the kinds of grief they're experiencing. You know, there's anticipatory grief about the future. There's disenfranchised grief about how sometimes people look like milder injuries are really good, but nobody seems to understand what they're going through. And there's something called frozen grief where a patient doesn't seem to be getting better and they're just living terrified and unable to get out of that stress state and move into the future in a meaningful way. And these are things that can be treated. So documentation and unexpected consequences. This is the next little section. I don't sweat the documentation. My focus is only on patient care and documenting for reimbursement. B, notes set the bias for downstream providers. So document what you find or can quote directly. C, I document what will be helpful to me if I were in cross-examination or in a deposition. Or D, I write my notes as though I reading them to a patient and their families and I had to explain them. I think everyone sort of has their priorities. It's nice to see that it's answered the way it is. I think number four, D sort of encapsulates the first three and I think it is the sort of most empathic way of representing all four of them, but they're all important, right? And I think it's not just our need to really communicate effectively with our patients because ultimately they in this day and age do read our notes. But I think it's also important that we only document what we can effectively document and what really does help the people that are going to continue to care for that patient downstream because our notes are written for everybody. So rehab providers in general and really any setting downstream struggles with how to put the pieces together. Documentation, especially from the acute stage where everyone's really focused on the patient care is often thin and incomplete. And so there are a few things that we look for in that documentation. One of the things that I often have to go back through multiple notes or contact providers about or weight bearing issues. Another is follow-up. In getting patients into clinic after they've gone into the outpatient setting or the rehab setting, identifying appropriate bracing, how long they need to be in certain bracing, the strategy behind certain seizure medications, or if they had seizures at all. A lot of times medications that patients are discharged on are not always an accurate representation of what we want. And then the strategy for anti-coagulation. It's unusual for most rehab providers to really redo assessment or look upstream and look where things could be improved upon and focus on and make sure that the ball doesn't get dropped. But it ultimately is our responsibility to make sure that we plug back in with what happened upstream and make sure that now that we've got a little bit of time and a good retrospective scope, that we take the time to make sure that everything was done well. In patients where weight-bearing is an issue, if I've got a patient that I need to do rehab on and they're non-weight-bearing to three extremities, then I can't bring them into an inpatient setting. But if they go to a skilled nursing setting, there's only a fraction of a chance that they'll make it back into rehab. And so the opportunity for a rehab doctor in the acute setting to be coordinating with the orthopedic surgeon to make good decisions about where to provide care and how to strategize that care so that patients don't lose opportunity becomes very important. And then when we follow up, it's more often than you would expect. I'll have a patient who is seen by an orthopedic surgeon who expects to see them, and we'll call that surgeon's office and we'll be told, well, we don't take that insurance, we're not gonna see him. And we'll say, well, you got to follow up at least once, this was their patient. And they'll say, well, we were told by the insurance, we're not even allowed to see them. And so multiple issues become barriers to making sure that there's continuity of care. And while we will advocate for that and fight all we can to make sure that that happens, a lot of these things can be averted with a little bit of communication on the front end A, and then nothing can really replace a willingness to have a conversation with the rehab providers downstream. So anytime I can get the numbers in my phone of the neurosurgeons and trauma surgeons and upstream providers that I work with on a daily basis in my phone, the better because there's nothing that can replace just a fast conversation about a patient's care. Okay, next polling question. This is something that I think about a lot, mainly because I do brain injury and it's really how we care for patients on the milder end and on the more severe end. So A, range of motion, skincare and other rehab considerations are not short-term concerns and so they are not a priority. B, getting palliative care and donor alliance involved in less than 24 hours is important in all very severe brain injuries. C, mild TBIs who can communicate and say they are ready to go home usually are. And then D, where I discharge a patient too is not critical because things tend to sort themselves out in the end. Yeah. You know, this is roughly what I would expect. It's nice to see that very few people answered that there was only 6% on one. While it's true, the cost of care downstream goes up astronomically when we don't prevent skin issues or something as simple as range of motion from occurring. I mentioned a little bit before the tendon lengthening surgeries that I've had to do and prolonged patient's cares for weeks at a time. Inpatient rehab, a place like Craig is about $3,600 a day. So if I have to go back and do a surgery or I have to discharge the patient to an LTAC or do a skin flap surgery and treat them for osteomyelitis for two months prior to doing a skin flap surgery, you can see how fast the bill will go up on a patient who has a coccygeal wound or a trochanter wound that didn't need to be there if we were turning the patient and keeping an eye on those things. So it is helpful to have a specialty that works with nursing and the therapist to prevent those things from happening. In terms of getting Palliative Care Donor Alliance involved early on, it is important when you're dealing with patients that have been shown to be brain dead. But we also got to make sure that those patients have been completely taken off of all sedating medications. I have a patient from last year who's back at home and completely taking care of herself, who was about to be taken to have her organs harvested, but didn't have the sedating medications removed completely. While she remained in a minimally conscious state for the early weeks in which she was receiving care, because there wasn't someone who was a brain injury specialist involved early on, that almost didn't happen. Now, she's completely independent at home, so the consequences of a mistake there can be catastrophic. Then on the milder end of injuries, one of the concerns that we often deal with, I'm trying to click to the next slide at the same time, are issues with awareness. To go back to the beginning, we talked a little bit about contractures, wounds, sleep, and then post-op infections. Having an entire service that will keep an eye on those things and be your peripheral vision so that you don't have to worry about them, and that they not only get out of the acute setting rapidly, but they get good care downstream, can really overall protect the long-term outcome of these patients. I've had a few patients that I've taken care of with a lot of limb salvage surgery that took a year or two of their lives to really get a limb back that was partially functional. The amount of debility and depression and financial impact that it had on those patients was far more impactful than if the patient had had an AKA or a BKA earlier in their treatment and had more comprehensive rehab. It's helpful to have a rehab physician make these decisions along with the limb salvage team as an example of some of those implications. Another thing that will happen is we'll have patients that are non-weight-bearing as I had mentioned earlier, but they're more mild injuries, and they seem like they're doing okay, but they have a complete lack of awareness of their deficit and they will keep getting up and trying to walk on that non-weight-bearing extremity. Unless you're paying someone to constantly hold them down and prevent them from getting out of bed, they will constantly bear weight and refracture, reinjure the non-weight-bearing extremity. More aggressive management or erring towards an ORIF, or being more aggressive with medication or neuropsychiatric workup becomes very important on the front end. Having a little bit more decision on the front end with trachs and pegs. There's a lot of good guidance on when to do a trach and a peg, but one of the things that we don't always think about is the amount of time that we're going to spend working on swallow and trying to prevent them from aspirating downstream, and erring towards a trach and peg earlier. Or in a patient that may be able to eat, but is very likely to be getting ill multiple times, or going to have a lot of trouble with dysphagia, even if they're able to meet basic needs when their nutritional needs are so high. Our brain is only two percent of our body weight, but it's 20 percent of our metabolic need, and after an injury, it's even higher. The amount of calories we need to get into these patients and rehabs really does make us want to err towards getting trachs and pegs much earlier if possible. Then the last thing is about the more mild injuries. We see people who on CT look relatively normal, and a lot of times we don't move on to get an MRI, and we don't see the amount of frontotemporal shearing or the effects of those contusions impacting their awareness. Really, it's not what they don't know that's the problem, it's what they know for sure that is just flat out wrong. These patients and their families oftentimes don't realize how impaired they are, and when they go home, they can't get plugged back into care, and they don't have the opportunity to get the treatment that they often need to become more independent. Nose agnosia, that lack of awareness of their deficits that we see in those milder injuries end up being much more impactful in their ability to return to work or driving, or in the impact that it has on family that need to stay out of work and provide additional supervision and support. I spend a lot of my time having conversations about patients that have already gone home that are at a loss and terrified about what to do with loved ones because they chose not to go to inpatient rehab. It ends up being a common mistake. We do make an attempt to get filters out, but good documentation about what the filters are and when they were placed so that they can be removed in rehab or downstream. A lot of times, we'll send patients home with aspirin, with a recommendation to follow up for a CTA, but they won't know who to follow up with, and they won't get contacted about how to do that. Making sure that if we're going to recommend someone get a CTA and stay on aspirin, that we've done good education with the family, and that we have a mechanism in place to follow that up, or that it's well-documented in the notes so that the rehab providers can make sure to follow up on those things themselves. Eighteen is setting expectations and developing a strategy. First, A, focus on patient care. We're looking at a patient's funding is tantamount to a wallet biopsy. B, it is important to set expectations that extend into the next setting of care and I have a strategy. C, evidence shows that doctors are horrible at prognosticating, especially in neurotrauma, so I don't try. Then D, I've been doing this a long time and I'm a splendid prognosticator. I got this. This is as much a personality test as it is a care test. It is. I'm also hoping to just get, wow, okay. I bet that hasn't happened the rest of this day. Wow. That's nice to see. That's very nice to see. There is a tiny bit of truth in the others. The other three were traps, but I think the wallet biopsy idea is something that often, now that I work at a place that does provide care and can't get everybody in, everybody thinks, okay, well, when Dr. Spear is looking at patients, you actually don't hear this as much as I used to, but in the first couple of years I got here, I would hear a lot that Craig cherry picks. The facilities downstream are all just trying to get the easiest to care for patients that have the most money. But in the acute setting, there's a real opportunity to set someone up for a funding structure that will behoove better long-term treatment. For example, and it's very different in some states than others. Where I came from in Texas, if you had Medicare, then you were not going to get rehab and it became very difficult to provide care. Whereas in Colorado, if you have Medicaid, I can actually in some ways give you better care than anyone else because I can do what I think is right and no one's watching the amount of days that you're in rehab. But to that end, there are patients that may be able to use their primary insurance for some things but still qualify for Medicaid as a secondary. Or patients whose work compensation is not wanting to take ownership for their situation, and it becomes important to advocate for these patients so that they don't get dropped by their employer. I see this in a lot of full-time workers in construction work where some companies will drop them. I see this in elite athletes where companies will sponsor athletes, but then they will sneak in a dangerous activity exemption clause in their Olympic snowboarder. I've seen Monster do that. Red Bull tends to take very good care of their people. But these are things that are important to look at so that we can set them up on the front to make sure they get good care. That's where looking at the funding piece becomes very important. Then setting those expectations and the next set of care, I've been trying to get that point across in the last three slides. But C is absolutely true. We are horrible at prognosticating. There's actually good evidence that shows that we're bad at prognosticating. But the wrong part of that answer is that we should try and that it's actually important for us to try. I wrote down two quotes that I thought that guide me in my decision-making and how I think about these cases. Then I was going to share a little bit of information about how I think about severe traumatic brain injuries. There's the funding piece and making sure that they get appropriate care. We really need to think about this on the front end. The other thing that I've also talked about a little bit before, but is setting out a game plan with the stakeholders. I talked about sitting down with the family and the support structure, patient when possible, and talking about care with everyone present. Everyone feels like they're a part of that stakeholding decision-making group. Then putting together a set of options that really fit with the patients and families ethos. Then I like to talk a little bit about prognosis. I start by saying that this is something that we're not good at. Something that I've taken to saying a lot more recently is I'm going to tell you what my experience is. I'm going to give you what information I can from a threshold standpoint. I'm going to tell you a little bit about the silver linings of this particular situation. Then I'm going to let you know if I have a negative prognosis to give or something that really sounds alarming to you as a family, I want you to also know that I'm going to roll up my sleeves and do everything I can to prove myself wrong and fight with you to get the best possible outcome. Because I don't want you to think that I've set a certain expectation, and that I'm going to fulfill it and not try to exceed it. With more severe shearing injuries, there are a few things that we can say that speak to the level of injury. One is that we should never, except in the case of a brain dead patient, make any decisions in less than 72 hours. There are consensus statements around how to care for patients with disorders of consciousness and minimally conscious states. One of the poor prognostic thresholds that we have is that a good recovery is unlikely if post-traumatic amnesia lasts longer than three months, or time to follow commands, aka coma, lasts longer than one month. I've seen patients that are inside that threshold have very good outcomes. What I mean by unlikely good recovery is on a Glasgow outcome scale. The Glasgow outcome scale is one is dead, two is unresponsive, wakeful, three is they're unlikely to be independent for more than 24 hours at a time after their recovery, four is that they could be completely independent, but they will need structure and support and some supervision beyond 24 hours, and five is they're completely independent. It's pretty remarkable that while a good recovery is unlikely, that people could still have a moderate outcome even if they remain in a post-traumatic amnesia for more than three months, or they're in a coma for more than a month. Now, the converse is that a good prognosis is likely, meaning they're unlikely to have a severe disability, aka they're likely to be completely independent or largely independent, if they're in a coma less than two weeks, their time to follow commands is less than two weeks, or they're in a post-traumatic amnesia for less than two months. This is most of the severe brain injury patients that people in trauma settings deal with. You have to ask yourself, when you see a patient with a severe injury, you really can't say that they're not going to have a fantastic outcome until they're in a coma for longer than two weeks. There's two quotes that I often use with families and staff that I'm educating about this. One is, medicine is a science of uncertainty and an art of probability. It's William Osler. Then the other favorite quote is a guy named Wade Marshall, who was one of the advisors of Eric Candle in Search of Memory. We were confused and they were confused, but we were more accustomed to being confused. I share the good with the bad when I talk about patient's care. I want to make sure that they understand the bad prognostic factors, bilateral brain stem injuries, age greater than 65 years of age, other comorbidities, underlying infarcts, hypoxic ischemic injury. Then I also want them to know when there is a silver line. If I have a patient who's been in a coma for longer than two weeks and they have a severe injury, but they're a young woman, they're much more likely to have a good outcome. The example that I gave earlier of that lady who almost ended up on the donor table and is now completely independent was a 23-year-old woman. All of the people who've exceeded even my Pollyannish expectations have all been young women. I have a good understanding of what CMS expects from LTAC IRF sniff settings, as well as the best facilities in my community. B, in out-of-town patients, I know how to help vet care around the country. C, I know how to advocate for care in patients across the funding spectrum and look forward to every doc-to-doc I get. D, getting a family together and home ASAP is always the priority. It's also why I think the punchline of this whole talk is that it's helpful to get a rehab doctor into the acute setting to do some of this work for you, to make sure that we get the best outcomes. Understanding what these other settings are is important. The difference between an LTAC and an inpatient rehab facility is significant, but they're both very expensive settings of care. If you go to an IRF, you won't be able to get to an LTAC, but if you have a more severely impaired patient, going to an LTAC first to buy some time for a longer care plan makes sense, and then getting them to the IRF afterwards. There are model systems for brain injury and spinal cord injury, and if you have any in your region that it's important to know about them for the more severe cases. Especially for patients with disorders of consciousness, we're having them in a supported setting that's appropriate, makes sense. Then knowing that in disorders of consciousness or more severe injuries, if they go to a SNF, it is very unlikely that they will have access to the care that they would get in an IRF downstream. That's important because the reimbursement parallels the setting of care. A SNF is a fraction of the care and resource that you would get in an IRF. An IRF and an LTAC are both on the order of thousands a day reimbursement, and a SNF is just a few hundred. Understanding the difference between home health, home and community, and then post-acute facilities after inpatient rehab is important. I'll snap past this, but go to the end and just take some questions if you have any. Thank you, Dr. Speer. I have one question. Early MRI in the acute setting, does that help or not so much? I believe it helps quite a bit. There are several reasons for this. One is it's helpful to determine the shearing burden with solid state imaging, and you don't get that at all with a CT scan. Another reason is in these patients that are more severely injured, it helps with anatomic correlation downstream, not just for prognosis, but actually in medication management. I actually have a book over here. I don't know if you can see this on my screen, but most of us trained at a time when we did not have the understanding of the brain that we do now. We now have enough neuroanatomical understanding of the brain that we can actually describe personality disorders in terms of brain anatomy. When I make medication decisions and treatment decisions in the rehab setting, that MRI is critical. We often don't get an MRI because we don't think that it impacts our medical decision-making, but for a rehab doctor, it does. Every treatment we prescribe, every medication we prescribe, we can actually root back to that neuroimaging.

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