Traumatic Brain Injury: Reducing Disparities From the ED Through Rehab

Désirée Lie, MD, MSEd

Disclosures

April 26, 2010

Case History

Mr. Gomez is a married 32-year-old Mexican Spanish-speaking construction worker, with no previous health problems. He was recently discharged from the hospital to a rehabilitation center after a moderately severe closed-head traumatic brain injury (Glasgow Coma Scale score of 9), which he sustained after a fall from a building. At the time of hospital discharge his Rancho Los Amigos level of cognitive functioning[1] was IV (out of VIII) and he was confused and agitated and unable to pay attention to tasks; however, he did recognize his family members. Before his injury he worked full-time and had spent 6 years in the workforce, starting with gardening and landscaping and then, after some job training, joining a construction company as a welder. He is married with a 5-year-old child.

After an inpatient stay of 2 weeks at the rehabilitation center, he advanced from level IV to a cognitive level of VII and was able to follow a set routine and dress and feed himself. However, he had trouble with stressful situations and problems planning and executing higher level tasks. Nevertheless, Mr. Gomez was discharged home appropriately to receive outpatient rehabilitation services twice weekly for 4 weeks, to be reassessed at 1 month.

His wife is now in clinic to see you because you are the primary care provider for the family. Her husband has recovered normal gait and function for household activities and is able to lift light weights, walk, perform household chores, and shop for groceries. However, he has poorer memory than before and has not regained the ability to manage their household finances or read the newspaper. She reports that he used to be a devoted father and enjoyed family functions but he is now apathetic at home, showing little interest in their daughter and in family activities, and he does not socialize with friends and family outside of the home. He also has lost sexual interest in her. He is sometimes stubborn, and although she has encouraged him to return to work or retrain for a different job, he has ignored her suggestions.

She is very concerned about his refusal to attend rehabilitation and additionally their health insurance will no longer cover rehabilitation services at the end of this month and she cannot afford to pay for the visits to the center. He declined to come in to see you with her today, but gave her permission to discuss her concerns about him. What steps can you take to help?

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