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Comorbidity (co-existing) conditions are not uncommon with PTSD and frequently include depression and other clinical disorders. The oppressive symptoms of PTSD feel inescapable to the patient who may self-medicates with alcohol or other drugs which they secure from doctors or from the street.

The co-occurrence of PTSD and substance use is a major public health concern. It is very easy, and somewhat naive, to believe that a patient with PTSD knows immediately how to curb the intake of drugs and alcohol. The patient sees these agents as temporarily lowering apprehension, anticipation, fear, worry and alarm. Doctors become reluctant to address the PTSD symptoms, fearing they will increase the anxiety and, thereby, the substance abuse. Conversely, others fear that if they address the substance abuse, then the patient has no viable means to combat the symptoms of the PTSD. Both positions are inaccurate. The reality is that the addictive behaviors and the anxiety behaviors must be addressed at the same time.

Guest post:

Alexithymic individuals (males more than females) cannot express their feelings verbally. They either act them out (destructively) or hold them in (intrapunitive and equally destructive).

These alexithymic individuals are more prone to develop somatic symptom (formerly somatoform) disorders (excess focus upon bodily complaints). They are also more prone to psychophysiologic – physical – destruction arising from psychological) disorders.

Although a challenge, it is possible to psychologically examine these patients and analyze this pervasive pattern of inability to healthily express emotions.

Family members will often refer the person having this problem. For many of these patients, their bodily focus will decrease when they have the opportunity to discover what they truly feel and how to appropriately deal with these feelings.

Nurses who worked in the emergency department and mental health units reported the highest mean number of violent incidents per staff member, followed by those in the medical and restorative areas. Overall, nurses reported an average of 2 to 46 incidents a year.

A 2010 study found that 75% of the nurses had been involved in 1 or more incidents of workplace violence in the last 12 months and reported a total of 2354 incidents. A fourth of the respondents said they had experienced violent incidents weekly, 27% monthly, and 25% once every 6 months; 23% reported they had never experienced any violence.

More Than Half Experienced Physical Assault

Virtually all of the nurses surveyed reported experiencing verbal abuse, 69% had been physically threatened, and 52% had been physically assaulted in the year before the survey. Violent events were perpetrated regardless of the nurses’ age, educational qualifications, years of experience, and sex.

The nurses said they did not report the violent episodes because they considered such events to be part of the job and because they “happen all the time.”

J Clin Nurs. 2010;19:479-488.

Informed Consent and Anxiety

Informed consent is often structured around insuring that the patient has been duly informed of the risk-benefit ratio of clinical procedures. Informed consent does not always seek to determine the depth to which the patient understands the necessity of a procedure or the process of treatment. Perhaps more important is that the anxiety associated with physical disorders that increases when the patient feels they are stripped of control, and often their own identity. 

Regardless of the amount of time or materials provided the patient, the capacity to internalize the data is then compromised. 

The first impact of anxiety upon cognitive functioning is to disrupt attention and its more complex associated skill, concentration. Regardless of the extent to which the patient is “educated,” the question remains, how much information are they capable of retaining? In the absence of the retained data, to what extent is the patient threatened, confused or alarmed by their own lack of education?

Among the means by which these issues can be addressed by the doctor are the following patient queries:

a. Has anyone spent sufficient time with you explaining both your condition and the treatment recommended?

b. Do you have lingering confusion as to what has been found and what treatment is indicated?

c. Are you able to understand the terms used by those treating you, and are you able to ask questions regarding those terms when you need more clarification?

d. Do you feel that the educational material is appropriate for you or are you being provided with too little data to answer your questions or too much data resulting in increased confusion.

Clarifying these issues is not only critical to the patient’s understanding. It is a necessary step of self-protection for the clinician who might otherwise be blamed for unanticipated negative outcomes. 

As the daughter of an Army Drill Sergeant, I grew up around Fort Jackson, SC. We shopped at the PX, attended the Roman Catholic church on base, bought 29 cent gasoline and went to the movies for a …

Source: The Changing Face of Body Language

I believe the greatest barrier/challenge that faces a new LNC is the ability to manage anxiety in new situations, meetings, presentations or interviews with attorneys.

These are the same problems faced by attorneys in preparing a closing argument.

When I began meeting new attorneys, I know that I did not project self-confidence. I will always be grateful for the ones who hired me despite this shortcoming. I was not convinced of my worth or that I could provide what they needed. I knew the lingo and had read the bullet list of 30 benefits of hiring a legal nurse, but I had not yet delivered those benefits.

I grappled for words that would communicate my competence in case analysis, but I was relying upon the success of others to give me courage.

Amy Cuddy is a social psychologist with a fascinating story (find her on TED talks and read her book, “Presence”). She combines multiple philosophies and her own experience to describe that hard-to-capture essence of convincing others that you are worthy.

Convincing others of your worth begins with conviction that you have the qualities you wish to impart. When you truly believe in what you do and who you are, others will also believe. I know after ten years and many hundreds of cases from all sides of the law that I am who I say I am.

True authenticity is not memorized or rehearsed; it comes from the heart.

Stroke and CHI – Key Concepts for Legal Professionals.

Head injuries or brain damage can occur anywhere – in the workplace, in an MVA, in medical malpractice, toxic torts, a domestic fall, and environmental exposures.

Litigated head injuries generally arise from two sources:

1. Accidents
a. blunt trauma (fall, violent blow or MVA)
b. penetrating trauma (gunshot)

2. Medical causation (stroke)
a. ischemic (a clot blocking blood flow to a major artery)
b. hemorrhagic (rupture of a major artery causes damage to the brain)
c. TIA or Transient Ischemic Attack (symptoms resolve within 24 hrs)

In all instances, brain injury is affected by blood: either blocked flow (ischemia) or bleeding that puts pressure on another area, damaging tissue. The location of the injury is the most important determinant of the severity and likelihood of recovery.

Key Concepts

• Rate and degree of recovery after brain injury is quite variable

• The most common form of traumatic brain injury is the subdural hematoma (SDH), with a mortality rate ranging from 50 – 90%. A significant percentage of these deaths result from the pressure on the brain that develops in the days after injury. Treatment of the SDH depends upon the location and age of the lesion. Because bleeding is not static, “Early and sometimes repeated CT scanning may be required in cases of clinical or neurologic deterioration, especially in the first 72 hours after head injury, to detect delayed hematoma, hypoxic-ischemic lesions, or cerebral edema.”

• Approximately 20-30% of patients will recover full or partial brain function. However, post-operative seizures are relatively common in these patients.

• Although recovery from TIA (transient ischemic attack) occurs within 24 hours, these patients may be at a high risk for falls if they may regain mobility before being aware of their surroundings.

• Strokes arising from blood clots usually require anticoagulation therapy to prevent further clotting, but improper medication management can result in a fatal hemorrhage

• Because patients can “go bad” quickly, frequent monitoring of vital signs, ICP (intracranial pressure) measurements, lab values, pupil checks and level of awareness is crucial.

• A critical part of assessment includes changes, even by one point, in the Glasgow Coma Scale

The Glasgow Coma Scale (GCS) numerically represents the level of consciousness and is based upon a 15-point scale for estimating and categorizing the outcomes of brain injury. The patient who is unable to respond verbally or follow commands can nonetheless have a reflexive response to painful stimuli. Families do not appreciate this form of assessment, but the patient’s physical response tells a great deal about how the brain is processing this noxious stimulus. The following signs are associated with a poor prognosis:

• A Glasgow Coma Scale less than 8 in the field
• A Glasgow Coma Scale less than 5 in the ER
• Unequal/changing pupil size
• Motorcycle accident (direct head impact and no airbag)
• Problems with ventilation, further depriving the brain of oxygen

A patient with an acute and severe brain injury may be placed into a medically induced coma to protect and allow the brain to rest by slowing metabolism. Mechanical ventilation controls oxygen and carbon dioxide levels that can aid in reduction of swelling, and sedation allows an override of the patient’s breathing, which is often labored and dysfunctional.

Pain should be managed effectively because it can lead to a rise in intracranial pressure. An intubated patient is treated with short acting sedation and analgesia until time for weaning.

Claims for pain and suffering in the unconscious patient should consider:

• The victim’s awareness of impending danger prior to the head injury (an assertion of this awareness has been successfully argued even with death cases)

• Successfully communicating to a jury the difference between purposeful movements and reflex, and

• Evaluation of post-injury residuals established by Medical Cost Projection or Life Care Plan.

Putting post-injury impairment into perspective, it is very important to know the level of prior intellectual and emotional functioning. This information is sought by defense counsel in quantifying financial responsibility, and is equally important to plaintiff’s counsel in supporting a reasonable demand.

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Alice Adams is a veteran RN who has cared for many acute head injury patients. She has been a legal nurse consultant since 2006 and lives in Atlanta, GA. She evaluated the injury cases in the 2007 Bluffton University Baseball team’s tragic accident and fatalities, and is very active compiling Medical Cost Projections and providing medical analysis for >40 attorneys and law firm.

http://www.aliceMadams.com nurseatlanta@gmail.com 404.771.5155