Polytrauma Care: a Delicate Balance for the Military Nurse Case Manager

CLINICAL CARE Polytrauma Care: A Delicate Balance for the Military Nurse Case Manager

Anne M. Cobb, MSN, RNC, CMAC brokering communication between facilities, providers, Nancy Pridgen, MS, RN and families to foster optimization of the discharge outcome. Case management has a pivotal role in ensuring that care arranged prior to discharge is executed after dis- s with every military engagement, the Operation Iraqi charge to foster enhanced continuity of care. Maintaining AFreedom and Operation Enduring Freedom casual- a caseload of patients with polytrauma requires that the ties present unique combat-related healthcare issues. case manager implement a refined organizational and Because of better body armor protection and sophisticated clinical skill set. weaponry, casualties are surviving with complex injuries Since the extensive and complex injuries sustained by the and rehabilitation requirements never seen before. The casualties have not existed previously, it is crucial to antici- casualties no longer have a single injury but rather several pate and address the multiple specialty needs of the casu- injuries (polytrauma or multitrauma), such as traumatic alty.3 Arranging care and subsequent follow-up provisions brain injury (TBI) and blindness, TBI with amputation and pose a variety of challenges, particularly when obtaining prosthetic requirements, or TBI with vision injuries.1 and consolidating required authorizations for care (planned Trauma to multiple organ and sensory systems requires and emergent) and clinical reports from a multitude of complex coordination rehabilitation and a multidiscipli- providers. The need for an average of 7 specialists to treat nary team functioning in tandem. Involvement by the case each casualty exemplifies the intricacy of care. manager is paramount in supporting not only the casual- During 2007, the case management division at our ties and their families but also the providers and facilities medical center case managed an average monthly work- while arranging and staging their care.2 load of 260 polytrauma cases with an average discharge With the increasing presence of polytrauma injuries, rate of 27 cases per month. Each casualty required serv- there is a clear need to organize the casualty’s multiple ices from an average of 7 specialists over a period of 1 to specialty requirements. Situations that encompass treat- 2 years. Depending on the injuries sustained, a cascading ment such as surgical revisions must be considered series of needs was addressed. For instance, if a casualty because they may result in increased rehabilitation received a blast exposure to the face, depending on the requirements. It becomes easy to lose track of the whole extent of injury, the casualty would require the care and picture, making the case management’s role foremost in services of neurosurgery, oral/maxillary/facial surgery, and plastic surgery for reconstruction. If the blast affected an eye, a need for care by an ophthalmologist Anne M. Cobb, MSN, RNC, CMAC, is the Case Management and perhaps optometrist would arise. If there was loss of Department Head at the Walter Reed National Military the eye, subsequent services of a prosthetician would Medical Center in Bethesda, MD (formerly known as the National Naval Medical Center). Her team has been providing result. Should skull structures need to be replaced casualty care case management to the wounded warriors because of the blast, radiology and three-dimensional returning from Iraq in addition to those seeking specialty treat- imaging would be required to fabricate missing ment at the military treatment facility. structures with prosthetics. Nancy Pridgen, MS, RN, is a doctoral student in education, Depending on the extent of facial/brain/eye involve- with a background in nursing education, particularly leader- ship, pediatrics, and behavioral health. Her interests also ment and the casualty’s comprehension, a blind rehabili- include nursing research and adult learners. tation specialist may be introduced during the inpatient Disclaimer: The views expressed in this article are those of stay to assess readiness for rehabilitation. Assistive and the authors and do not necessarily reflect the official policy or adaptive devices such as talking watches may be support- position of the Department of the Navy, Department of ive during the inpatient stay. Early initiation of an evalu- Defense, or the US Government. ation of the casualty by a blind rehabilitation specialist Corresponding Author: Anne M. Cobb, MSN, RNC, CMAC. allows for establishment of rapport with the patient and

192 Journal of Trauma Nursing • Volume 15, Number 4 October–December 2008 family. The rehabilitation specialist is well equipped to blindness, TBI, spinal cord injuries, amputations, and manage the notable degree of anxiety that often exists at burns. Depending on the level of severity and injury, the this time. casualty can and should receive rehabilitation for blindness Regardless of injury, the casualty would receive audi- and TBI and perhaps amputation at the same time rather ology testing and neuropsychological evaluation for blast than segmented rehabilitation. It is the responsibility of the exposure. Depending on the extent of the facial injury, case manager to coordinate with the multiple treatment affected oral structures, such as the mandible, would centers and providers to ensure that the receiving providers necessitate the need for involvement of an oral maxillofa- have the necessary clinical information. cial specialist to address dental needs. Additional impli- Depending on the individual circumstance and readi- cations exist, as often the blast may affect other body ness, the case manager meets and visits throughout the systems, such as hands, arms, and/or legs. The presence hospitalization course to establish a therapeutic relation- of additional injuries would signal the need for additional ship and start the dynamic assessment process including or concurrent rehabilitation with accompanying special- the needs of the patient’s family. Prior to discharge, the ists, such as physical medicine and rehabilitation. case manager reviews the care plan with the family to To ensure effective monitoring of the caseload, an give an overview of the rehabilitation requirements and instrument was developed for the case manager to track validate the specialist treatment plans. The care plan is and trend specialists’ recommendations. This tool was dynamic and expands to include the changes and developed to assist case managers in readily identifying improvements and setbacks along the way. the evaluations and recommendations or treatment sug- gestions rendered by different specialists. The tool serves ■ CASUALTY CARE PLAN TEMPLATE to track the myriad of specialists for each casualty to Safety ensure that the highest quality standard of care is pre- Current or potential. If this patient is physically impaired, served. The tracking tool ensures that each casualty identify environmental hazards during convalescence. receives consultation, and it assists in identifying areas Watch for alteration in mental functioning related to still needing further efforts. Although the tool assists the injuries, medications, psychosocial issues, etc. If the case manager in ensuring all issues have been addressed, patient is cognitively impaired, review with patient/family a more comprehensive care plan is developed in tandem and/or responsible significant other decision-making with the casualty and family members. limitations such as driving, financial/legal decisions, medication administration, ability to call for help, and ■ CASE MANAGEMENT AND CARE PLAN- effects of medications on abilities, which may further NING PROCESS require supervision. Review safety measures needed for Case management is an iterative process in that lessons the patient’s welfare, especially if pain medication and learned from each discharge plan help in further refining medication administration are needed. future planning of needs. The constant evaluation of outcomes decreases unwarranted variation in practice and Psychosocial improves beneficiary and provider satisfaction. Assess perception of current problems related to the casu- Understandably, families desire to have their injured alty and impact on family. Evaluate effectiveness of sup- service member home with them while undergoing their port system. Review patient and family’s coping methods rehabilitation. On the basis of Operation Iraqi Freedom and effectiveness in dealing with current problems. experience, the case managers must be proactive to antic- Discuss family’s expectations (long and short term). ipate, identify, and take corrective action on behalf of the Assist patient and family in identifying personal and col- casualty member and/or families as their needs and cir- lective strengths to cope with current and future prob- cumstances change. lems. Offer supportive services as appropriate. Consider The casualty’s care is coordinated with consideration to the use of chaplain care and other mental health care pro- the timing and pacing of convalescence, reconstruction, fessionals. Review current agencies/community services and rehabilitation requirements. The selection and recom- being utilized. Assess family members’ need for addi- mendation of rehabilitation facilities is based on a delicate tional financial resources such as Traumatic balance of these needs and patient/family preference. Servicemembers’ Group Life Insurance and/or commu- Although patient and family preference is a priority, care- nity resources such as the Navy Marine Corps Relief ful consideration should be made with respect to a facility’s Society visiting nurses and other resources. experience and facility treatment outcomes with military casualties. The casualty may require multiple rehabilitation Disease process stays on the basis of the level, extent, and complexity of Review with patient/family and/or responsible significant injuries. Frequently the injuries and comorbidities include other disease process symptoms/issues and impact on

October–December 2008 Journal of Trauma Nursing • Volume 15, Number 4 193 TABLE 4 Military Case Management

Updated Diagnosis Name Parent command Admit date Service CM SW Trauma PT OT Wounded Camp Lejeune 09/15/08 Motor Vehicle Accident B B 9/27/06 Warrior # 1 (MVA)–Humvee assis- Rollover possible head & tance spine injury w/lower level ADLs

Wounded Hawaii 09/15/06 S/P IED Blast 09/11/06 with D D 09/22/06 — Per 09/24 – initial 09/27/06 – Warrior # 2 OIF trauma, Closed L Vascular – eval with No proximal Tib -Fib Fx, A-Gram goal to order Lateral Plateau Fx, Prox. reveals LLE crutch train as yet FibularFx,? L knee joint arterial system (NWB LLE) injury, Right TM patent from Rupture, 4 compart- level of aortic ment fasciotomies & bifurcation to Anterior tibial artery ankle Ligation on 09/11, Compartment syndrome 09/18/. CT head, spineC/A/P neg.

Wounded Camp Pendleton 08/15/06 Gunshot wound to left G G Plan will be med- PT Rec. DC NA Warrior # 3 side of chest and ical transport home No abdomen to TAMPA assistive devices

Wounded Camp Lejeune 08/08/06 IED blast, R & L femur fx, J J 9/25/06-pas- no request Warrior #4 R tibial fx, nondis- sive stretch, placed L1L2 R trans- isometrics, verse fx, STI L gluteus bilat L trunk maximus & L post rote, OOB thigh Monday and cont. dangle

Wounded TPR West 09/21/06 S/P IED injury 06/05/06. L L 09/26 – Per 09/26 - Seeing 09/26 - No Warror # 5 Readmit 09/21/06 for patient report today. order LLE TSF adjustment they will likely yet and R knee recon- postpone knee struction reconstruction and reschedule for Nov. PT will return to VAMC Minneapolis for ongoing inpatient physical rehabilitation until surgery resched- uled

194 Journal of Trauma Nursing • Volume 15, Number 4 October–December 2008 Infectious ST TB I Audio Neuro Opthal Ortho Mental Health OMFS Plastics Disease 9/26/06 Consult 9/27/06 tested, NA Pending 9/25/06 consult Cont VANC assist pending WNL in right evalu- ordered Day 8, w/ADLs ear, loss of ation LEVOQUIN hearing results Day 2 @ 600 Hz left ear 09/27-Not as 09/27 - STSG 09/22 – (–) yet but Lat LLE war cx; patient does wound 09/25. removed have rup- from con- tured R TM tact isol

NA TBI Screen Pt requires NA NA NA Pt depressed, NA NA On abx, perfor- inpatient withdraw meropen- med rec TBI rehabili- em inpatient tation @ TBI Tampa VA NA 9/25/06-TBI 09/18/06-c/o R NA 09/05/06--POD 8 09/18/06–wounds 10/18/06- Inpatient otalgis/ s/p STSG to examined in Acinetob recom- tinnitis, scrotum, left OR today, skin acter mended, transient- post thigh, grafted areas from R pt demon- testing flap to LLE actively con- BKA strated apparent in and ex fix tracting, minor frontal L ear only placement distal debride- dysfunc- POD 34DSG ment done, tion, in OR with flap has good attention plastics POD contact with deficits 12 Fournier's wound bed gangrene debridement

09/26-NA 09/26-Needs 09/27-No audi- N/A N/A 09/25 - TSF 09/26 - Has NA NA 09/26 - 3 mo f/u. ology fol- adjustment. not seen Consult Trying to low-up per- Planned R yet to ID as arrange formed at Knee reconst patient on this Minneapolis 09/27 but may have admit so will con- likely will not pin site tact audiolo- be done 2nd infection gy here to to possible and may complete infection at be placed pin site on IVAB.

October–December 2008 Journal of Trauma Nursing • Volume 15, Number 4 195 family life. Assess patient/family’s ability to understand ties to prepare for separation from the military. As the injuries. Assess patient/family’s understanding of military engagement continues, these interventions are recovery/rehabilitation process and long-term plan. becoming more critical in assisting the casualty to tran- Review potential for infections with corresponding sitioning to civilian status. In many instances, the mili- action plans. tary has been the only “family” and stabilizing influence in the casualty’s life. In an effort to better support the casualty’s transition to the next phase in his life as a vet- Medications eran, the military case manager must partner with the Verify correct medications, dosages, strengths that are Veteran’s Affairs case manager and federal recovery care available at home. Review and reinforce purpose, coordinator. Emotional support is the chief priority at actions, and adverse effects. Instruct on medication this critical juncture and must remain ongoing through- changes and plans for obtaining refills. Address effects out this vulnerable time. The process and transition must and interaction on body systems. be transparent to support service member’s reintegration into the community.

Activity REFERENCES Assess functional status and ability to perform activi- 1. Department of Veterans Affairs. Veterans Health Administration ties of daily living/instrumental activities of daily Handbook. Washington, DC: Department of Veterans Affairs; 2005. living. Review current activity and tolerance. Review VHA Handbook 1125.1. http://www1.va.gov/vhapublications/ allowed activity and any current physical therapy/ ViewPublication.asp?pub_ID1317. Accessed June 28, 2008. occupational therapy (PT/OT) home plans if indicated. 2. Cobb AM. Case managers care for casualties of war. Case Point. Identify if medical clearance is needed for increased 2006:29–32. 3. Aiken LJ, Bibeau P, Cilento B, Lopez E. Stateside care of marines and activity. sailors injured in Iraq at the National Naval Medical Center in Bethesda, Should the casualty have permanent disabilities, the Maryland. Crit Care Nurs Clin North Am. 2008;20:31–40. http:// case manager needs to reinforce the outcome opportuni- www.ccnursing.theclinics.com. Accessed June 1, 2008.

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