Types of Medical Providers Involved


Trauma ICU Staff

If you’re unlucky enough to have been in a serious accident or have a serious brain injury as a result of a trauma, you may become a patient in a trauma ICU.  A trauma ICU is a special intensive care unit that takes care of the most critical patients in the hospital.
 
Patients in a Trauma ICU have sustained some kind of trauma and are in critical condition. There are many staff persons who handle your care in the trauma ICU.  Everyone from the person who cleans the room to the specialist physicians is important.

The person who cleans the room is cleaning so as to get rid of microorganisms that can invade open skin areas or the lungs and can cause serious and sometimes fatal infections. A person will thoroughly clean your room at least once a day.

There will be a trauma nurse watching and caring for you on a one on one basis.  He or she will monitor your vital signs, provide medication and, if you are on a ventilator, will suction your endotracheal tube or tracheostomy tube every two hours or so. This is important because you yourself can’t handle the secretions that build up constantly in your trachea.   The trauma nurse also manages the settings on the ventilator and watches the telemetry unit which shows your heart rhythm.  He or she also manages the propofol drip, which keeps you in a medically induced coma until your body can mend and the pain level will likely be lower.  Medically-induced comas can save your life in an emergency situation because it lets you sleep while doctors work on saving your body.  If you have a head trauma, you may already be in a coma. 

The aide helps the nurse take care of you.  He or she repositions your body so you don’t get bed sores and helps with things like emptying your urine bag and taking care of oral care while you are in the trauma ICU.  Sometimes all these things are done by the trauma nurse and an aide is not necessary.

Social services is available to help your family with financing your stay or helping with insurance.  He or she will help you arrange aftercare and will help you with any needs you may have during or after your stay in the hospital.

A speech and swallowing specialist will help you learn to eat again after being on a ventilator for several days or longer.  Your muscles of swallowing are weak after having an endotracheal tube in your throat for a period of time and you may have problems swallowing food and especially liquids.  The specialist will evaluate you and will determine if you need thickened liquids for a while so your muscles can recover without you aspirating clear liquids.   Your stay in the hospital will be overseen by a trauma surgeon who will do surgery on you when necessary and will monitor your healing.   You may also be seen by a hospitalist who will handle your medical issues, a neurologist/neurosurgeon if you have brain trauma and other specialists, who will monitor and treat the various problems that come up during your stay.
Occupational TherapistsOccupational Therapy. Occupational therapy is a type of medical specialist who works in conjunction with the physical therapy department in order to maximize patient function.  While the physical therapist works with large motor skills like walking, climbing, getting into bed, and getting in and out of the chair, occupational therapy works with activities of daily living and small motor skills, like manipulating a pen or scissors, turning on a faucet, and writing skills. The occupational therapist is an important part of the therapy team.  Because they work with activities of daily living, they have the chance to improve the patient’s functioning so they are able to go home safely.  For example, they teach kitchen safety and teach the brain injured patient how to cook simple meals, manipulate a knife and fork, and wash dishes.  Kitchen safety means making sure the patient remembers to use pads for protecting themselves around hot dishes and pans, knows how to operate the stove, and knows what to do if there is a kitchen fire. Occupational therapists help with the patient in the bathroom.  They teach them how to toilet themselves, wash their hands, brush their teeth, wash their face, and even bathe in a shower with a shower chair or grab bar for support and safety.  They teach them to dress and undress using devices to help them if needed.  They make special grabbers at the end of a pole so the patient doesn’t have to reach far to put on their pants or grab an object from a high shelf.  Any of the things a patient needs to learn so he or she can take care of themselves is what the occupational therapy goals are. Movement of the fingers is important in many tasks and some patients who have been in the hospital for a long time due to a brain injury have contractures or permanent bending of the fingers and hand.  Massage therapy and occupational therapy can work with the hands so they can function better to be able to manipulate a spoon, fork and knife, a pen or pencil, or other necessary items important in daily living (like a can opener).  These things are practiced in occupational therapy and the patient will be given “homework assignments” so they can begin to get better on their own.   Occupational therapists sometimes hold recreational therapy programs or art programs.  A group of patients get together and work on arts and crafts projects over a period of time, such as two hours 2-3 times a week.  They get to improve their small motor skills in a fun activity, and can make an art project they can be proud of and take home with them. Other recreational activities like putting together puzzles or playing board games can be a solo or group activity that challenges both the mind and the small motor skills. Occupational therapists can work with patients in a hospital setting, in an acute care facility, in an extended care facility, in a clinic or in a private home, depending on patient circumstances.

Physical Therapists. Physical therapy is a medical condition in which a therapist works with a patient to achieve large motor skills including walking, getting in and out of bed, getting in and out of a chair, standing, and toileting.  Goals are made after assessing the patient and determining where their deficits are and what they need. Deficits can come from the patient’s brain injury or from being bedridden for too long a period of time.  Physical therapists work closely with occupational therapists to help the patient regain the normal activities of function as they are able, depending on their degree of brain injury.    Physical therapy is done by a physical therapist or PT.  The physical therapist is a healthcare professional who works under a physician called a physiatrist, a physician who specializes in physical therapy, gait and movement.  Most of the day to day activities are done by the physical therapist who creates the goals and helps the patient carry them out.   There are physical therapists who work specifically with brain injured patients, helping them gain functioning they lost in the accident or who lost function because of a prolonged hospital stay.  They take a medical history and do a physical exam, trying to see how the patient functions in a regular setting.  They then arrive at a diagnosis before establishing the patient’s treatment plan.  Sometimes laboratory and x-ray services are needed to make a proper diagnosis.  Electromyograms are tested to see if the nerves and muscles are working. Physical therapists also work to prevent disability before it occurs to develop, maintain and restore the absolute maximum recovery possible.  They promote more active lifestyles and sometimes use a pool to introduce easy therapy for patients that have difficulty working with heavy weights.   Physical therapy is a profession that includes several specialties including wound care therapy, neurology, sports-related therapy, orthopedics, pediatrics and geriatrics. Neurological rehabilitation is a rapidly growing field and involves physical therapy designed to help patients with stroke, brain injury and other neurological injuries.  Physical therapy can be done on an outpatient basis, in a rehabilitation facility, in a long term care facility like a nursing home or in an acute care hospital.  Physical therapy can also be done in private homes as a part of home health care.  Physical therapists specializing in sports-related injuries work in fitness centers and in sports training facilities for sports teams.   Physical therapy has been around for a long term in one form or another.  Hippocrates and Galenus were physicians who advocated manual therapy techniques, massage, and hydrotherapy, treating people as early as 460 BC.  Machines to do physical therapy were invented since the 1700s that were designed to exercise the joints.   Physical therapy as a profession was first designed in 1813 in Sweden.  It advocated massage, exercise and joint manipulation.  The first school for physical therapists in the use opened in 1914 at the Reed College in Portland, Oregon.  They taught regular physical therapy techniques as well as spinal manipulation, such as is done in chiropractic.  Some of the first treatments were done on polio patients.  Physical therapists attend varying amounts of education and are recognized by their state as a licensed physical therapist or physical therapy technician or assistant.

Speech and Swallowing Therapy. Speech and Swallowing Therapy Patients who have sustained a brain injury often need the services of the speech and swallowing therapist.  This is a person who has extensive experience with the mouth and throat and can deal with a variety of conditions related to the throat. A brain injured person may have lost speech function for a variety of reasons.  They may have lost a portion of the speech centers of the brain and be in need of learning how to speak words with new parts of the brain.  This is called brain plasticity and involves having other areas of the brain take over for damaged portions of the brain.  Brain plasticity is easier to have in younger children.   This kind of speech damage is called expressive aphasia and can be due to injury to Broca’s area inside the brain.  Broca’s area is located in the right side of the brain and is key to the formation and understanding of speech. The patient may have damaged the motor or sensory parts of the brain and be unable to articulate speech.  The person may have normal speech function but the words are nearly unintelligible because of motor issues or nerve issues making the mouth not want to form the words properly. It’s possible for an injured person to have receptive aphasia.  This is a loss of understandable speech and the understanding of speech due damage to the receptive areas of the brain.  The speech can be nonsensical and the person does not understand commands or anything someone would say. This is a very difficult problem to treat but speech therapy would be the modality to help them. Speech and swallowing therapy also works with swallowing. Due to a brain injury, a person can lose the ability to swallow properly, leaving them with the possibility of aspiration or the swallowing of food or liquid down the trachea instead of the esophagus. This can cause pneumonia. Any patient on a ventilator for a long period of time will have a loosening and stretching of the strap muscles and other muscles involved in swallowing.  They, too, will have difficulty swallowing, especially thin liquids.  When swallowing those liquids, the muscles of swallowing become uncoordinated and the liquid ends up in the trachea resulting in aspiration. In some cases, the speech and swallowing specialist will do a swallow test and have the patient try solid food, thicker food like yogurt, thickened liquids and thin liquids.  If the patient begins to cough while trying any one or more of the items, the speech and swallowing therapist will recommend staying away from foods with those textures until the muscles have healed appropriately. The therapist will recheck the patient periodically to see if the muscles have returned to normal and the patient can eat all kinds of food. Many speech and swallowing therapists work in an acute care hospital setting, treating patients who are freshly recovering from brain-related illness or injury. Others work in acute rehabilitation facilities, sub-acute care facilities, private clinics and sometimes in the patient’s home.

Neurologist
 
When you or a loved one sustains a brain injury, a neurologist will likely be involved in the care and will be the lead physician regarding your case, especially if the brain trauma does not include a surgical condition, such as a hematoma.  The neurologist specializes in nervous system disorders and there are neurologists who subspecialize in traumatic brain injury. 

The neurologist may provide you with medications to shrink the swelling of the brain following the trauma.  One of these medications is mannitol, which draws fluid from the brain and allows the fluid to pass through the kidneys.  Sometimes steroids are given to prevent brain inflammation.   You may develop seizures as a result of your brain injury and the neurologist is responsible for providing you with medications to control the seizures.  Seizures following brain trauma can be temporary, requiring medication for a few weeks to a few months.  Other people will develop epilepsy following a brain trauma and will need medications to control seizures for the rest of their lives.  It all depends on the location and severity of the brain trauma.

Neurologists must go to medical school to become an MD or a DO.  Then they undertake several years of residency in neurology, dealing with every aspect of the human nervous system, including the brain, spinal cord and peripheral nerves.  The residency involves primarily clinical care, touching on other areas of human illnesses besides neurologic illnesses.  Some neurologists go on to specialize by completing fellowships in certain areas of neurology, such as trauma care.  Almost all neurologists are board certified in Neurology and must take a proficiency examination besides their clinical work.  The proficiency examination the doctor must initially take is known as the US Medical Licensing Examination or USMLE, which covers general medical topics.  To be board certified in Neurology, the trained neurology resident must pass a certification examination by the American Board of Psychiatry and Neurology.
 
Neurologists often work at hospitals dealing with inpatients who have moderate to severe neurological injuries and diseases, including brain trauma.  They also have dealings with patients who have stroke, dementia and various neuromuscular conditions.  Some neurologists work for university hospitals, where they are given the opportunity to teach neurology and do neurologic research.  They continue to learn through continuing education, research, and neurological meetings.
 
Neurosurgeon

In brain trauma, you or your loved one might need the services of a neurosurgeon.  The neurosurgeon is the member of the trauma team who is trained in brain surgery.  He or she is especially useful in cases where the brain trauma has resulted in a blood clot or hematoma in the brain.  Following a trauma, there can be a subdural hematoma or an epidural hematoma.  A subdural hematoma is a blood clot between the brain surface and the dura mater covering over the brain, while an epidural hematoma is one which occurs from leaking blood vessels between the dura mater and the skull itself.   Regardless of the hematoma, the neurosurgeon must act quickly to reduce the extra pressure on the brain that is caused by the blood clot.  Too much pressure causes the brain to push through (herniate through) the base of the skull-a problem that is often fatal.  To reduce the chance of this happening, the neurosurgeon burrs a hole in the skull or opens a bigger area of the skull (if necessary) so that the blood clot can be removed and extra bleeding can be controlled.   The neurosurgeon is usually the lead physician in a case where neurosurgery is needed.  He or she will work with neurologists and hospitalists, who will together manage the brain injury and the rest of the patient’s problems. Neurosurgeons undergo a long period of education in order to become Board Certified in Neurosurgery.  They must first go through a regular four year college program, usually having a bachelor’s degree in something like biology, chemistry, or biochemistry.  Then they go through medical school in order to get an MD or DO (doctor of osteopathy) degree.

There is then usually a one year internship in the field of general surgery, followed by 5-7 years in an intensive neurosurgery residency program.  Some elect to undergo a fellowship following residency in order to specialize in a specific area of neurosurgery.  Neurosurgeons are required to take part in continuing education, including reading scientific journals, meetings, medical conferences and research studies.
The neurosurgeon you deal with will likely have a specialty in neuro-trauma.  This is especially true if you are admitted to a level 1 trauma center.  Other subspecialties of neurosurgery include the following:
  • Epilepsy surgery
  • Stereotactic functional surgery
  • Endovascular and vascular neurosurgery
  • Cancer neurosurgery
  • Skull-base neurosurgery
  • Spinal surgery
  • Peripheral nerve-related surgery
  • Pediatric neurosurgery
If you have any type of brain injury, a CT scan or MRI scan will be done in order to determine if you have a condition requiring neurosurgery.  Your neurosurgeon will likely work quickly, doing surgical procedures that can minimize the effects of a hematoma on intracranial pressure.  He or she will follow your care until the surgical aspect of the injury has past.

Neuropsychologist

The neuropsychologist is the specialist in psychology who helps put together disorders of the brain and your behavior.  Brain injuries often come with changes in thinking, memory, and behavior.  The neuropsychologist helps to determine what kinds of changes have taken place in the injured brain and can make recommendations as to treatment options.
 
It is the neuropsychologist who understands the complexities of the brain and how it affects the whole individual when it is injured.  He or she has special training in psychology, usually a PhD in the field, and knows the inner workings of the parts of the brain responsible for how you think and behave.  They work very closely with the neurologists and other doctors responsible for the care of the brain-injured patient.

There are various symptoms you might have that would indicate a visit and evaluation with the neuropsychologist.  These might include:
  • Disturbances of mood
  • Problems with memory
  • Learning problems
  • Other dysfunction of the nervous system
A neuropsychologist has tools and tests to determine even the most subtle of changes in brain functioning.  Besides traumatic brain injuries, these specialists work with patients with stroke, Alzheimer’s disease, Parkinson’s disease and nonspecific learning disabilities.

Because of the complexities of the nervous system, the neuropsychologist uses different tools to see what might be going on in the brain.  One tool is the CT scan or MRI scan, either of which can show brain abnormalities following the trauma.  Another is the neuropsychological evaluation, which includes IQ testing, memory testing, and activities that will determine your ability to partake in daily activities of living.  Personality testing is done to see if there are documentable personality issues going on. These tools help diagnose what is wrong with the brain and help decide what to do about it.

Even your emotions may have changed as a result of the brain injury.  The neuropsychologist can talk to you and can assess these emotional changes that may have affected you.  There are tests to evaluate emotional changes that a neuropsychologist will likely do.

The results of the neuropsychologist’s evaluation of the brain injured patient are compared with test scores achieved by other people of your similar age and education.  As mentioned, brain impairments can be subtle so this kind of extensive testing is necessary.   Once the results have been tabulated, the neuropsychologist can recommend medications, surgery, or rehabilitation therapy to help your brain recover from the injury.
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