Albert is thirty-seven years old and an Acquired Brain Injury (ABI) patient at The Salvation Army Toronto Grace Health Centre (TGHC).
Just a little over a year ago, on September 6, 2016, Albert was admitted to Sunnybrook Health Sciences Centre (SHSC) suffering from head trauma as a result of a self-inflicted gunshot wound. At the time of this medical emergency, Albert had been living at home with his parents. After hearing the gunshot, his parents found him in his room and called 911.
“After the paramedics arrived,” said Teresa, his mother, “it seemed to take a long time before they stabilized him so he could be transported to the hospital. The situation was critical,” continued Teresa, “there was a lot of uncertainty about Albert’s condition. But all I could do, all our family could do was remain hopeful that Albert would survive.”
After Albert was admitted to SHSC, the neurosurgeon told the family that for the first few days they would keep Albert stable, but given the severity of his underlying injuries they would not resuscitate him if he went into cardiac arrest. The family was also told that for the first month after an acquired brain injury patients are considered to be at a high risk for infection. The family held on to what little hope they could find.
During the three days following Albert’s admission to the hospital, brain tissue slowly leaked from Albert’s wounds. The bullet had passed through his head completely, perforating both the left and right hemispheres of his brain. Because there was a fair amount of necrotic tissue (dead or devitalized tissue) discharging from Albert’s wounds, the neurosurgical as well as the infection health care team decided to surgically irrigate his wounds to avoid infection.
Incisions were made to enlarge Albert’s wounds so they could properly flush them. The surgical team then was able to suture one of his wounds, but the other wound required more tissue to close it. It was then decided that they would wait for the plastic surgeon’s assessment.
The SHSC neurological health care team also preformed a somatosensory evoked potential (SSEP) test on Albert. The test involves the creation of an evoked potential through the use of a physical stimulus (usually a small electric pulse). Electrodes are positioned over particular areas of the body and the responses of the brain are then observed via an electroencephalogram (EEG). By analyzing the SSEP pattern, the neurologist can get an idea of how well sensory nerves are working. These tests are done seven to fourteen days after a patient’s admittance and give a good indication for a meaningful outcome. Albert’s readings were very low and extremely faint.
At the end of a month-long stay in intensive care, necessitated by a persistent infection and fever, Albert required another operation to irrigate his wounds. After the neurological and infection health care team did an extensive flushing of his wounds, Albert also received a skin graft to heal the wound on the left side of his head. He had earlier received a tracheostomy tube (ventilator), and Albert now also required a gastrostomy tube (feeding tube). All of these interventions helped to stabilize Albert. Nevertheless, his condition was still serious. During the next few months, Albert would suffer from hemifacial seizures, muscle spasms, and hiccups that would last for hours.
According to Albert’s sister Joyce, the family, including her parents, Charles and Teresa, her other sister, Norine, and Albert’s girlfriend Angela, were at SHSC twenty-four hours a day. “We gained strength in seeing hope,” said Joyce. “We scoured the internet,” she continued, “to find severe situations and stories where people survived and recovered. It inspired us to try different things, anything that would stimulate the brain.
“Even though Albert was non-responsive, we talked to him, told him we knew he could hear us and that we knew he might not be able to respond. We recounted events with him to spark memory and did physiotherapy exercises while saying the parts of his body we were working on to help him differentiate, even if it was subconsciously. We told him to stay strong and keep fighting because we love him so much. Our family and friends and their network prayed for our family and Albert’s recovery.”
Over the next four months Albert slowly became more responsive. In December 2016, the family was told by the SHSC health care team that in order to improve further Albert would need rehabilitation. His neurosurgeon told Albert’s family that because of his care needs Albert would need to be transferred to a rehabilitation facility that could also provide complex continuing care. The family was given a list of rehabilitation facilities they could visit.
The family visited a few of the facilities, but according to Joyce none seemed suitable for Albert. On a recommendation made by Albert’s social worker at SHSC they made an appointment to see Jake, the Executive Director Programs at The Salvation Army Toronto Grace Health Centre (TGHC). “After taking a tour of the TGHC and talking with Jake,” Joyce said, “ I remember standing in the TGHC parking lot with my mother. It was the first time we weren’t crying, [the first time we] felt a real hope. [We felt] that this was going to be a good place for Albert.”
Albert continued to progress, and just before he was admitted to the TGHC in February 2017 he had his trach–tube (ventilator) removed.
“I can’t say enough good things about the TGHC staff,” said Joyce. “They have been wonderfully supportive through such a difficult situation. When Albert was at SHSC and muscle atrophy was taking effect, we had investigated the benefits of FES/EMS (functional electro muscle stimulation and electro muscle stimulation). The first time we met with Jake, I asked him about FES/EMS. He said, ‘they use it in wound care and that he was recently at a conference about FES/EMS and the speaker was Dr. Milos Popovic.’ I was impressed because our research had led us to the same doctor. Jake mentioned a few other technologies that the TGHC was working on, which gave us the confidence that this was a facility that was about helping people get better.”
FES is a technique that uses low-energy pulses to artificially generate body movements in non- functioning limbs. EMS uses a stimulator to deliver electrical impulses to the body, in order to make the muscles contract. Impulses are sent from the device to a series of electrodes, which are placed on the skin over the muscles being targeted.
After Albert arrived at the TGHC, the family wanted him to start as soon as possible on the EMS device. “Jake,” said Joyce, “organized a lunch-and-learn session for the health care staff at the TGHC, with Dr. Kristin Musselman, a physiotherapist and scientist who works with EMS devices and who was referred to us by Dr. Milos Popovic. Jake did a little more research and some analysis, and shortly after the session he purchased an EMS device for the TGHC. Albert we believe has benefited from the EMS. No other facility would work that quickly and with so little friction. It was amazing to see.”
Apart from this treatment, Albert has participated in the TGHC Taste and Wake programs in recreational therapy. He would alternate four times a month between these programs. The Taste program’s goal is to help increase patients’ quality of life through sensory stimulation. It involves monitoring swallowing abilities and promotes reminiscence. Food not only serves as fuel for the body, but also provides pleasure and comfort. Under the supervision of Lisa, Albert’s speech-language pathologist, he has progressed to being able to swallow solid food. Although Albert still requires a g-tube for feeding, he has now ventured into the culinary delights of a hamburger and pizza. Lisa continues to work with Albert on speech and communication. The Wake program’s sensory-focused activities are designed to provide environments in which people with disabilities like Albert can have the opportunity to use their senses. The goals are to elicit responses through sensory stimulation and increase stimulation to the senses (tactile, olfactory, visual and auditory).
The TGHC has expanded its Complex Continuing Care (CCC) program to include ABI patients, who because of their physical state require the slower-paced approach of a low tolerance, long duration (LTLD) rehabilitation program. The LTLD program involves a longer course of rehabilitation than traditional active rehabilitation programs and is adjusted to the patient’s tolerance.
Albert has made progress in the TGHC’s LTLD program. His sleep/wake cycle has normalized, and he has become more aware and engaged with people. His perception has improved, and he is now able to make eye contact and track objects. His physical development has also improved — whereas before he could not move his arms, he now has active movement. As a result of these improvements, his rehab team can now incorporate more layers of activity. They are now able to work on helping him with the activities of daily living, like brushing his teeth. Such activities require multiple layers of cognitive activity and are multifaceted. In Albert’s previous cognitive state they would simply not have been possible.
The TGHC’s LTLD program delivered the slower paced rehabilitation therapy that Albert needed initially and he is now ready for a more aggressive rehabilitation. His rehabilitation team is ready to work with him more frequently during the day when Albert is more physically awake and when he can most tolerate the physical activity. This will allow the rehab team to maximize his rehabilitation for a better outcome.
The TGHC staff recognizes that Albert has a very loving and supportive family, one with a strong level of commitment to getting him better. This level of commitment and engagement by his family has impressed the TGHC staff. The family believes the TGHC was the right place for Albert and that the staff understands their journey. When Joyce said they scoured the internet to find severe situations or stories about other ABI patients who survived and recovered, it was their intention to tell Albert’s story so other families experiencing a critical situation of their own, could gain strength in seeing hope.
By Gerry Condotta