by the legal times staff
thelegaltimes.net
Many years ago I suffered a “mild brain injury” which resulted in a seizure disorder. It’s one of those hidden disabilities which are so popular in the news currently. I can function in a crowd, for short periods of time. Overload is an ongoing problem which I have used many different strategies to overcome. My comfort zone has been to avoid anything confusing, busy, noisy or new…but I am not one to give up.
Brain injury is a dilemma for those who suffer from it. You can’t take an hour to explain to people you meet what sets you off, or what overwhelms you. Most of the time you have to just do the best you can.
Some years ago I began Tae Kwon Do classes. During one of the first classes, in the midst of a class routine, I seized. I have the kind of petit mal seizures that allow me to still hear everything going on around me, but I lose the ability to respond. My instructor asked if I was all right and in a moment I was and went on with the class, slightly embarrassed that I just appeared to have something mentally wrong with me. It’s the sort of embarrassment that often defeats those with brain injury…but I prevailed.
I cleverly learned never to position myself where I could see the class in the mirrors…my mind couldn’t process the double load of visual information. I learned that even if I couldn’t absorb a complicated routine on the first run through when everyone else was getting it, the next time I would come back with the information totally processed and be fine. I learned not to panic when I couldn’t filter out the instructor’s voice in a room full of background noise. I became hyper-observant. Over time I developed very complicated coping skills all designed to hide the fact that something was “wrong” with me. I earned my black belt and a heightened control over the seizures, panic and need to withdraw which I started with.
Last summer it was sort of brought to mind again as I took my dog through agility classes. I would listen very carefully to instructions, overworking to filter out the noise around me, and then find that listening didn’t mean processing. It’s somewhat lucky I had a smart dog, she usually picked up on what expectations were before I did. We always came back strong the following class when we both were on the same page. It helped to have a dog to turn to when the overload became too much, she became a convenient time out. We would go home and I would crash, totally exhausted by having to be so hyper-attentive. Much like the exhaustion that came after a karate class.
I was proud of myself for working through coping strategies which enabled me to tackle some pretty major accomplishments. In the end, it didn’t make the brain injury disappear. In some ways it made it harder to live with. People look at the accomplishments and not the effort it took to get there against all odds.
What they don’t see is the toll those efforts took, the amount of “down time” needed to recuperate, the hours I spent in total quiet to give an overworked and low frustration level brain time to recharge. They see independence in the isolation I maintain. They don’t see the meltdowns from overload, because I maintain that isolation. They don’t see how one thing can throw me off track for days. I have learned to cover, hide, avoid and conceal very well. I have even learned it is better to be quiet, because the seizures aren’t so noticed when they do occur. I have hit upon a definition of “normal” that I can live with.
In a world where the press is finally addressing the devastation brain injury can have on an individual, I still wonder if the majority of those affected don’t follow the easier course of creatively coping with their deficits? After all, you’re not likely to advise a prospective employer of your lack of ability to concentrate or tell a potential date that you have a brain injury and sometimes have issues with emotional response. It’s not only a hidden disability, it carries with it the fear of being labeled as “different”. Social awareness is a two-edged sword when it comes to brain injury. The public has been given enough information to acknowledge it exists and not enough information to understand how profoundly it affects the individual living with it.
VA quadruples payment to vets with brain injuries
Date: 9/23/2008 6:23 PM
By PAULINE JELINEK
Associated Press Writer
WASHINGTON (AP) _ The government is more than quadrupling monthly payments to some veterans suffering brain injuries, as the number of such war wounds mounts from the roadside bombings of Iraq and Afghanistan.
The new compensation is based on the assessment that even some troops who have the mildest form of traumatic brain injury could end up with chronic headaches, memory loss, anxiety or other symptoms that will hurt their chances of getting a job or job advancement — thus reducing their lifetime earnings by 40 percent.
In a regulation announced Tuesday by the Department of Veterans Affairs, officials changed the way they evaluate the injuries. Depending on the extent of their injuries, vets now can be judged up to 40 percent disabled in such cases. The previous rating of 10 percent for such injuries was set by a 1961 regulation.
The rating change means that an unmarried veteran, who now receives $117 monthly in compensation, could receive as much as $512. Extra money would also be calculated for troops with spouses and children.
Mild traumatic brain injury is basically a form of concussion that results from severe shaking of the brain after a blast. It can cause blurred vision, insomnia, irritability and other problems.
The VA change represents the “best judgment of medical experts about what the impact” of such injuries is and how best to evaluate veterans who come to the VA for help, said Tom Pamperin, a deputy director for the department’s compensation and pension service.
The change goes into effect in 30 days and those receiving compensation under the old system can have their cases reviewed.
Roughly 1.7 million American troops have served in Iraq and Afghanistan and a RAND Corporation study estimated early this year that up to 320,000 may have suffered a traumatic brain injury. Officials say that the vast majority of the cases are mild — and that most veterans recover in weeks or months. The new, higher disability rating is for the smaller percentage who suffer permanent damage, Pamperin said.
The extra disability compensation is expected to cost nearly $124 million through 2017. That’s based on the assumption that the number of troops who get such payments will rise steadily in the coming years to 5,100 for 2017 from about 800 new cases a year now, Pamperin said.
He said about 200 troops with brain injuries annually went to the VA before the start of the Iraq war, where insurgent use of roadside explosives and car-bombs has made brain injuries, amputations, burns and post-traumatic stress disorder the vast majority of wounds from the campaign. Insurgents are also increasingly using explosives in Afghanistan.
Officials believe compensation levels are already correct for troops with moderate and severe traumatic brain injury that can involve open head wounds.
Though most troops with the severe cases already can be rated at 100 percent disabled, an increase has been approved for additional care they might need. That is, a single vet who needs assisted care can get $3,145 a month compared to the current $2,527 payment.
___
On the Net:
Department of Veterans Affairs www.va.gov
Copyright 2008 The Associated Press.
By PAULINE JELINEK
Associated Press Writer
WASHINGTON (AP) _ The government is more than quadrupling monthly payments to some veterans suffering brain injuries, as the number of such war wounds mounts from the roadside bombings of Iraq and Afghanistan.
The new compensation is based on the assessment that even some troops who have the mildest form of traumatic brain injury could end up with chronic headaches, memory loss, anxiety or other symptoms that will hurt their chances of getting a job or job advancement — thus reducing their lifetime earnings by 40 percent.
In a regulation announced Tuesday by the Department of Veterans Affairs, officials changed the way they evaluate the injuries. Depending on the extent of their injuries, vets now can be judged up to 40 percent disabled in such cases. The previous rating of 10 percent for such injuries was set by a 1961 regulation.
The rating change means that an unmarried veteran, who now receives $117 monthly in compensation, could receive as much as $512. Extra money would also be calculated for troops with spouses and children.
Mild traumatic brain injury is basically a form of concussion that results from severe shaking of the brain after a blast. It can cause blurred vision, insomnia, irritability and other problems.
The VA change represents the “best judgment of medical experts about what the impact” of such injuries is and how best to evaluate veterans who come to the VA for help, said Tom Pamperin, a deputy director for the department’s compensation and pension service.
The change goes into effect in 30 days and those receiving compensation under the old system can have their cases reviewed.
Roughly 1.7 million American troops have served in Iraq and Afghanistan and a RAND Corporation study estimated early this year that up to 320,000 may have suffered a traumatic brain injury. Officials say that the vast majority of the cases are mild — and that most veterans recover in weeks or months. The new, higher disability rating is for the smaller percentage who suffer permanent damage, Pamperin said.
The extra disability compensation is expected to cost nearly $124 million through 2017. That’s based on the assumption that the number of troops who get such payments will rise steadily in the coming years to 5,100 for 2017 from about 800 new cases a year now, Pamperin said.
He said about 200 troops with brain injuries annually went to the VA before the start of the Iraq war, where insurgent use of roadside explosives and car-bombs has made brain injuries, amputations, burns and post-traumatic stress disorder the vast majority of wounds from the campaign. Insurgents are also increasingly using explosives in Afghanistan.
Officials believe compensation levels are already correct for troops with moderate and severe traumatic brain injury that can involve open head wounds.
Though most troops with the severe cases already can be rated at 100 percent disabled, an increase has been approved for additional care they might need. That is, a single vet who needs assisted care can get $3,145 a month compared to the current $2,527 payment.
___
On the Net:
Department of Veterans Affairs www.va.gov
Copyright 2008 The Associated Press.
Hysteria or Conversion Diagnosis Focuses on Perceived Character Flaws, not Relevant Injury Factors
In understanding the stain that the “hysteria” diagnosis has left on our medical science, it is important to distinguish “hysteria” from PTSD. The modern term for hysteria (if there should even be a modern term for it) is “Conversion Disorder”. See DSM-IV 300.11. PTSD is an entirely different matter as it relates to the development of specific emotional problems, as a result of emotional trauma. In Conversion Disorder, the emotional issues of the patient (not traumatically induced symptoms) are converted into physical problems. In Myers’ case studies, he attributed the neurological symptoms of his soldiers to this type of “hysterical” conversion of emotional problems.
The DSM-IV criteria for Conversion Disorder, stresses the likelihood that the patient have a prior history of psychosis.
“A history of other unexplained somatic (especially conversion) or dissociative symptoms signifies a greater likelihood that an apparent conversion symptom is not due to a general medical condition, especially if criteria for Somatization Disorder have been met in the past.”
While such criteria were not formally laid out in his time, Myers seemed to sense the need to show that his soldiers were psychologically weak. With respect to Soldier #1, he said:
“Prior history. –He had been for two months in the Aisne district on the lines of communication, sleeping badly all that time owing to lumbar pains (and toothache during the first three weeks.) He had failed to pass a medical examination some time previously because of renal trouble (abnormal amount of albumin in water) until after a long period of treatment. He had had lumbar pains a few nights before coming to France.”
The significance of the reference to the lumbar pains, seems to be the implication that the emotional stress of coming combat had brought them on.
With respect to Soldier #2:
“As to his past history, he came out to the war on August 13th, and was in the last two days’ retreat at Mons and after at La Bassee. Has slept very badly since the start, often when billeted taking large doses of whisky to procure sleep. Has led a ‘fast’ life and has had recent domestic worry.”
While he has no comment on the prior history of Soldier #3, he stresses the nervousness of the soldier in his narrative.
“A healthy looking man, well-nourished, but obviously in an extremely nervous condition. He complains that the slightest noise makes him start…. His hands became very tremulous and his forehead sweated profusely. He appeared as if about to faint, and says that he felt cold and dizzy, and experienced “round and round movements of the stomach…. He complains that he gets very excited when anyone addresses him.”The use of these implicit (without direct comment on their relevancy) comments by Myers is strongly reminiscent of the character assassination found in Defense neurological and neuropsychological opinions. No where does Myers say these symptoms are related to these character issues, just the “no comment seems necessary.”
While Myers wasn’t working with a formal diagnostic criteria for a “hysterical” diagnosis, the modern definition of Conversion Disorder does at a minimum require ruling out all medical explanations for the neurological symptoms.
“A diagnosis of Conversion Disorder should be made only after a thorough medical investigation has been performed to rule out an etiological neurological or general medical condition. Because a general medical etiology for many cases of apparent Conversion Disorder can take years to become evident, the diagnosis should be evaluated periodically.” DSM-IV, page 493.
Did Myers rule out all medical conditions for the neurological symptoms? Of course not. As discussed in the previous blogs, there are clear neurological, biomechanical and pathological explanations for the amnesia and the anosmia. Much is made by Myers of the partial visual complaints of these three soldiers. Yet other Cranial Nerve damage can account for many of these phenomenon, even without any damage to the eye, or the Optic Nerve. There are references to Soldier #3’s stomach complaints, but anyone acquainted with the vestibular system should recognize these symptoms as being explained by vertigo: “He appeared as if about to faint, and says that he felt cold and dizzy, and experienced “round and round movements of the stomach.” See http://vestibulardisorder.com Further, the reports of sweating and feeling like he is about to faint, is clearly explained by a condition called POTS (postural orthostatic tachycardia syndrome), which would also cause the vertigo. POTS, vertigo, cranial nerve damage – are all clear markers of traumatic brain injury.
The Character Assassination: Soldier #1 back pains prior to deployment; Soldier #2, heavy drinker with domestic problems. While there might be emotional explanations for increasing back pain under extreme stress, that isn’t the type of deep psychosis which would explain an extremely rare diagnosis of “hysteria.” As for his attacks on Soldier #2’s character, one must ask: How many soldiers are heavy drinkers? (Even our current Republican Nominee, John McCain has admitted to hell-raising during his 20’s.) What soldier doesn’t have some worry about his marriage, his family while deployed in a combat zone?
Sleep. Myers discusses sleep with each of his soldiers. But diagnosing hysteria versus organic injury to the brain and neurological system because of pre-morbid problems with sleep, makes as much sense as stating that these soldiers were carrying a gun at the time they were shelled. The soldier who sleeps well, like a soldier who doesn’t carry a gun, is not a oldier to fare well in combat. Combat requires hypervigilance. The soldier who sleeps soundly, especially in World War I, is the soldier who is in peril. One of the most cogent theories of PTSD is that it is a result not of the specific instances of emotional shock, but as a result of the constant need to be hyper-aware. It is the never sleeping well, the need to being always ready to reach for the gun, to leap for cover, that may be the hardest thing for the combat veteran to wind down from, post combat. It may be the inability to shut off the mechanism to never truly sleep, to dream, that causes the surrealistic elements of post combat stress.
Next: We will discuss the elements of PTSD, its roots in combat, and its questionable applicability to more routine civilian stressors. But before this commentary leaves Myers behind, I do want to stress one important point:
Myers was not wrong to factor in the terror at the time of the injury and the precedent emotional vulnerability of the patient. His mistake was to miss the clear organic evidence of brain trauma, brain damage. It may be the terror or the emotional makeup of these specific soldiers, made them more likely to be disabled by the blast injury that might not have disabled a stronger individual. But the diagnosis must begin with a full differential consideration of brain or neurological damage. Once brain damage has been identified, it is fully appropriate to incorporate the synergistic interplay of the vulnerability of each individual, the additive factors of the combat stress such individual was under, and the emotional impact of such injury, on that particular brain.
Myers may not have had all the tools of modern medicine available to him, but he did have the most important: history and examination. He took the history, seemingly quite accurately. He did the examination better than most modern doctor s (especially with respect to the Olfactory Nerve). Where he failed, and perhaps because of British unwillingness to believe the brain could be so easily damaged, was in not believing the realness of his own findings. His soldiers couldn’t smell. They couldn’t remember. They had neurological explanations for the vast majority of their symptoms. Combat emotional stress could certainly explain the rest. Brain injury, by any other name, will still disable.
The Character Assassination: Soldier #1 back pains prior to deployment; Soldier #2, heavy drinker with domestic problems. While there might be emotional explanations for increasing back pain under extreme stress, that isn’t the type of deep psychosis which would explain an extremely rare diagnosis of “hysteria.” As for his attacks on Soldier #2’s character, one must ask: How many soldiers are heavy drinkers? (Even our current Republican Nominee, John McCain has admitted to hell-raising during his 20’s.) What soldier doesn’t have some worry about his marriage, his family while deployed in a combat zone?
Sleep. Myers discusses sleep with each of his soldiers. But diagnosing hysteria versus organic injury to the brain and neurological system because of pre-morbid problems with sleep, makes as much sense as stating that these soldiers were carrying a gun at the time they were shelled. The soldier who sleeps well, like a soldier who doesn’t carry a gun, is not a oldier to fare well in combat. Combat requires hypervigilance. The soldier who sleeps soundly, especially in World War I, is the soldier who is in peril. One of the most cogent theories of PTSD is that it is a result not of the specific instances of emotional shock, but as a result of the constant need to be hyper-aware. It is the never sleeping well, the need to being always ready to reach for the gun, to leap for cover, that may be the hardest thing for the combat veteran to wind down from, post combat. It may be the inability to shut off the mechanism to never truly sleep, to dream, that causes the surrealistic elements of post combat stress.
Next: We will discuss the elements of PTSD, its roots in combat, and its questionable applicability to more routine civilian stressors. But before this commentary leaves Myers behind, I do want to stress one important point:
Myers was not wrong to factor in the terror at the time of the injury and the precedent emotional vulnerability of the patient. His mistake was to miss the clear organic evidence of brain trauma, brain damage. It may be the terror or the emotional makeup of these specific soldiers, made them more likely to be disabled by the blast injury that might not have disabled a stronger individual. But the diagnosis must begin with a full differential consideration of brain or neurological damage. Once brain damage has been identified, it is fully appropriate to incorporate the synergistic interplay of the vulnerability of each individual, the additive factors of the combat stress such individual was under, and the emotional impact of such injury, on that particular brain.
Myers may not have had all the tools of modern medicine available to him, but he did have the most important: history and examination. He took the history, seemingly quite accurately. He did the examination better than most modern doctor s (especially with respect to the Olfactory Nerve). Where he failed, and perhaps because of British unwillingness to believe the brain could be so easily damaged, was in not believing the realness of his own findings. His soldiers couldn’t smell. They couldn’t remember. They had neurological explanations for the vast majority of their symptoms. Combat emotional stress could certainly explain the rest. Brain injury, by any other name, will still disable.
Lancet Case Study of Three World War I Soldiers with Shell Shock
As introduced in yesterday’s blog, Captain Charles Myers, a British Physician authored a significant case study of three wounded soldiers with shell shock in the Lancet, the publication of the British Medical Society. See C.S. Myers, “A Contribution to the Study of Shell Shock” The Lancet, on February 13, 1915 page 316-320.
Myers begins his discussion of the three cases by calling them “remarkably similar.” All three soldiers were
• Injured by a by shells bursting near them;
• Had sleep problems before their injuries,
• Had memory disturbances after their injuries;
• Had vision affected;
• Had disturbances of smell and taste.
And quite significantly to Myers, despite the proximity of the blasts, none had any significant disruption in hearing.
Soldier # 1:
Myers describes the first soldiers case as follows:
Soldier # 2:
“During the (retreat) from this trench at 1:30 p.m., they were “found” by the German artillery. Up to that time he had not been feeling afraid; he had rather ‘been enjoying it’ and was in the best of spirits until the shells burst about him… He was trying to creep under wire entanglements when two or three shells burst near him. As he was struggling to disentangle himself from the wire, three more shells burst behind and one in front of him. After the shells had burst he succeeded in getting back under the wire entanglements. … Immediately after the shell burst in front of him his sight became blurred. It hurt his eyes, and they burned when closed. At the same moment he was seized with the shivering, and the cold sweat broke out especially around the loins “like a punch on the head, without any pain of it’. The shell in front cut his haversack clean away, bruised his side, and apparently it burned his little finger. …
“When he got to treatment… he was crying the whole time and worrying as to whether he was going blind. … At the dressing table station he was crying and shivering; he was taken thence to a hospital by horse ambulance… He thinks he must have slept on the ambulance, as he remembers nothing. (Emphasis in original.)
Three months post injury ‘says he has lost the sense of taste and smell since the shell’s burst around him.’
Woke up last night and found himself crying: ‘not thinking of anything in particular’.
Past history: He had been for two months in the Aisne district on the lines of communication, sleeping badly all the time owing to lumbar pain… He had failed to pass a medical examination some time previously because of renal trouble.
Soldier # 2:
Myers says of the second soldiers combat experience:
“The patient says he was buried for 18 hours owing to a shell bursting and ‘blowing in’ the trench in which he lay.”
This soldier also has lost his sense of smell and much of his sense of taste. While some “memory” of the events around the time of his injury returned, comparison to his later description of events was not consistent with what other soldiers who survived the battle remembered. While Myers seemed troubled by the conflict in these stories, it can clearly be explained by the brain injury symptom of “confabulation”.Soldier # 3:
Myers detailed the history as follows:
The patient says was blown off a heap of bricks, 15 feet high, owing to a shell bursting close to him. Thinks he must have fallen into a pool of water, as he next remembers finding himself, about 3 p.m., the same afternoon in a cellar near a church with his clothes drenched. He does not know how he got there or how he left the cellar, but he remembers being in another hospital before he was admitted here.”
Myers details this soldier’s symptoms as follows:
“A healthy-looking man, well-nourished, but obviously in extreme nervous condition. He complains that the slightest noise makes him start. His legs feel weak and he has pain in the precordial region. His sight has been very much impaired since the shock. …
He has slept very little the last two nights. Hands tremulous. Knee jerks normal, but the first attempts to evoke them provoked a spasm of the calf muscles and a few general convulsive movements as the patient lay in bed. His hands became very tremulous and his forehead sweated profusely. He appeared as if about to faint and says that he felt cold and dizzy, and experienced round and round movements of the stomach. … The slightest touch on the legs provoked well-marked spasm of the quadriceps muscles of the same thigh. Extensor muscles of the toes appeared to be in a state of clonic contraction.
Left nostril fails to detect smell of ether, peppermint, eucalyptus, ammonia, carbolic acid, or iodine tincture, all of which are at once recognized when placed beneath the right nostril. No signs of nasal obstruction. Taste: Only tastes very strong solutions of sugar, salt and acid…”
Conclusions. Myers, after discussing the three histories, ends his paper with this comment:
Comment on these cases seems superfluous. They appear to constitute a definite class among others arising from the effects of shell-shock. The shells in question appear to have burst with considerable noise, scattering much dust, but this was not attended by the production of odor. It is therefore difficult to understand why hearing should be (practically) unaffected and the dissociated “complex” be confined to the senses of sight, smell and taste (and to memory). The relation of these cases to those of “hysteria” appears fairly certain.
Thus, at a critical juncture in military medicine, with all the observational facts recorded to shift the focus to brain injury, the theory of hysterical illness raises its specter. That pattern gets repeated and becomes the cornerstone of far too much bad diagnosis – even to this day – at least in forensic neurological practice.
Myers’ choice of the word “hysteria”, is now replaced by the words “conversion disorder”. Myers might have been a pioneer – a leader in the field of military medicine in 1915 – yet his ignorance relative to what we know today about brain anatomy, is significant. The two most predictable markers of brain injury are loss of memory for events around the time of the injury (amnesia) and the loss of smell. He dismissed these findings. Further, he clearly lacked any basic understanding of the biomechanical forces which result in brain injury. While his ignorance is understandable, the ongoing use of these ridiculous psychiatric excuses for clear-cut neurological phenomenon, are not.
In the coming blogs, we will look at the clues to a proper diagnosis in these three cases histories: amnesia, loss of smell and the biomechanical and neuropathological explanations for brain injury.
From our frequent contributor, Cindy:
Hi Everyone,
Just had a “cognitive workout” in the container garden today, and thought I’d share some of my adventures and problem-solving with you. While surfing the web, I came upon a gardening practice which I had never heard…growing tomatoes upside! There are supposedly many benefits of this: 1) better air circulation which equals less diseases, 2) tomatoes aren’t on the ground as long, therefore rot less, and 3) pesky animals who also like to eat tomatoes have a harder time reaching them.Last weekend I purchased a Grape Sweet Olive Tomato plant and prepared a container to be used for my upside down tomato pot. Using a 5-gallon paint bucket, I cut out a 3″ hole in the bottom of the bucket, and did the same thing to an item I found to use as a lid.My first cognitive challenge was: How do I put the dirt in the bucket without it falling out the other end when I turn it upside down?Answer: Put a coffee filter over the hole.Next step: Fill bucket with dirt.Next cognitive challenge: My lid is not a snap-on lid and I didn’t have enough dirt to completely fill the bucket. How do I keep the dirt from falling out this end when I turn it over to plant the tomato plant?Answer: Stuff plastic bags over the dirt along with a lid about the size of the bucket and turn on its side.Next challenge: How do I plant the tomato plant?Okay, the coffee filter pulls away easily, but now the dirt is falling out both ends. How do I keep it from falling out the bottom hole once I hang the plant upside down?Solution: Cut a slit in a paper plate with a hole in the center to put around the tomato plant. But the plate is so big, I can’t fit it into the 3″ hole, even when I crumble it up to make it more pliable.
Solution: Cut the plate down so that it is slightly larger than the hole that was cut.
Ahhhh, final success!!! The tomato plant is hanging upside down without the dirt falling out!!!!
Good job Cindy. I am always delighted to see the creative ways that she finds solutions to the challenges she faces.
TBI Survivor Uses Internet to Assist with Brain Injury Disability – Part II
Yesterday, a former client of mine, began this two part series on how to use the internet to help connect with those who were willing to assist her in accommodating her disability. Today, she addresses the question she ended yesterday’s blog with:
What do I do so that my friends and neighbors don’t begin to dread getting emails from me? What can I do to make them fun, interesting and maybe even enjoyable?One of the strengths that Cindy has maintained, is an immense creative capacity and the ability to express herself on the challenges she faces in daily life. And she spells a lot better than I do.
A thought came to me the day before a neighbor came over to help me clean up one of my flowerbeds. This particular flowerbed had been overrun with mint. I love mint, but the flowerbed is too far away for me to easily access it. Last year, I started a container garden to attract hummingbirds and butterflies. This year, I decided to expand by adding herbs and vegetables in some containers.
Since I was going to plant some of this mint in containers, I thought maybe some of my friends and neighbors might like to do the same. As we pulled up the mint, I cut them into individual plants which could be planted. My neighbor helped me take pictures of the process showing how to plant mint into a container.
Now I had something I could offer to my friends and neighbors. In addition to my “How to Plant Mint in a Container,” I also put together a few mint recipes. I sent out an email providing information, recipes, and the offer of mint plants to either plant or use in recipes. Last year, I took pictures of my container garden, including the caterpillar nursery filled with parsley, dill, and yes, even little caterpillars.
Hopefully, by doing things like this, I’m hoping that people want to spend time with me because I’m still interesting, not because they pity me. It’s been a fascinating challenge, and so far, this seems to be working. Some tell me they enjoy seeing my pictures and hearing about my experiments.
When I told one of my friends that I wanted to try growing pole beans on bamboo poles lashed together in a teepee fashion, she told me to let her know when I wanted to do it. Her 2 sons who are boy scouts learned how to lash things together and would be happy to practice how well they can use their skills in a practical application. In fact, she told me they have a saying with regards to the art of lashing: “If your frap is crap, your lash will be trash.” (Now I have something else interesting to learn….what the heck is a frap??? I’m not even sure I’ve spelled it correctly.)
My psychiatrist thinks I have come upon a great idea that may benefit not only people with handicaps, but also the elderly and others who need assistance and feel socially isolated. I know I am lucky to have retained many strengths from which to build upon. I know others might not feel as capable. But perhaps there are family members or friends who can initiate or facilitate these kinds of ideas, so that their loved one and the caretaker both have a larger support system. These are services which are greatly needed, but seldom provided. So, for now, we have to learn to think out of the box.
Cindy from Cinci
The Emotional Adjustment to Brain Injury
EDITORS NOTE: Continuing with this week’s theme of the emotional impact of brain injury, I have another post from a TBI advocate/survivor I want to share. Kimberly was referenced on our blogs a few weeks ago with respect to seizure dogs and she started following our blogs at that time.
Hello, Mr. Johnson:Kimberly’s is a success story, but only because she was able to move past the emotional and adjustment issues that plagued her. And my take is that her dog helped her make an emotional connection that greatly assisted in that process. There is something special about the connection between the canine and the human. Maybe it should be at the cornerstone of all brain injury rehab.
My name is Kimberly Carnevale, founder of Canine and Abled, Inc. You wrote about me and my program in a recent blog. I’ve since followed your blog, and was happy to learn that you are educating about the “invisible” nature of brain injury; something that I struggle with everyday.
When I first was injured, I would try to “hide” my impairments from others. I was confused at how to React to other’s reactions to my injury. To be honest, I think I was very surprised and disheartened at people’s lack of support/understanding of my deficits. I fed off of other’s discomfort at my differences. I felt guilty at the behavior I had trouble controlling, was embarrassed when I couldn’t remember things I knew that I knew, and was self-conscience living in a body that “looked” fine, but as it’s captain, I knew was anything but fine.
Everyone used to say, “you look wonderful!”…but that’s only because on the days that my cognition was impaired, I would retreat into my shell, not emerging again until I felt fairly “normal” again. I felt as though people only accepted me when I didn’t show signs of my disability, and were uncomfortable dealing with my cognitive issues; and so I locked them (and myself) away until they subsided. It was a very solitary and depressing way to live.
If you have a broken bone, folks are prone to be more compassionate because they can see the cast, or limp or other physical sign. If you are brain injured, no one but you experiences the overwhelming anxiety of trying to manually process the environment and deal with the wide spectrum of emotions that overtake you at any given moment.
It wasn’t until I gained much-needed support through TBI groups, that I started to feel differently about my disability. I found that I wasn’t alone, and didn’t need to be embarrassed by my deficits any longer. While I once was apologetic about my service dog (the ONLY thing that made my confusing and overwhelming life bearable), I now hold my head high and am proud to be accompanied by the noble friend who offers assistance, safety, and never-ending emotional support.
I would like to personally thank you for educating people about hidden disabilities, and thank you for telling my story in your posts. If I can ever be of assistance to you in any way, please do not hesitate to ask.
All my best,
Kimberly Carnevale
Author/Motivational Speaker/Disability Advocate
President, Canine and Abled, Inc.
“Taking The Dis Out Of Disabled”
www.canineandabled.com
www.KimberlyCarnevale.com
canineandabled@aol.com
Footprints of Invisible Brain Injury
Last week, we talked about the term “invisible injury” as used by the Brain Injury Association, to describe brain injury and its application to discrimination against seizure dogs. That topic transitions to today’s blog about how we identify an “invisible injury”, such as brain injury.
So how do we see the invisible? Well if we are in Hollywood and we are talking about the invisible man, we wrap him in bandages, or look for the footprints. Footprints: remember the legendary story of the million posters of “Footprints in the Sand”? http://www.footprints-inthe-sand.com/ Well how are we to know from the footprints that the ghost of brain injury is lurking beneath the surface?
Identifying brain damage is a complex problem of looking thru skin, skull and normal tissue, to see what may be microscopic pathology, without peaking. This is the ultimate Xmas present-type guessing game to identify what is in the package, with no shaking allowed. Yesterday we discussed the discrimination of society in favor of the service dog for the blind versus the service dog for the brain injured, because of the visible evidence of that disability. But all we are seeing in a blind person is the footprint of pathology as well. We cannot see the blindness; what we see is the footprint of behavior changes because of the blindness.
With apologies to the blind: we might see the sunglasses, we might see the cane, we might see that the eyes don’t look directly at us or other things. We see the seeing-eye dog. While we can’t see the pathology, we see the evidence of the pathology in a pattern we almost instantly recognize as patterns of blindness. The pattern of the footprint tells us that someone is blind.
Why is that pattern so much harder to see in the brain injured? It isn’t always. Many brain injuries come with physical disabilities – problems with tone, with motor skills, with walking. While not as visually recognizable, many brain injuries come with speech deficits that are recognizable as soon as you hear the brain injured person try to communicate. Yet, profound brain injury can occur in a pattern that doesn’t fit either the physical or speech disability pattern. Frontal lobe deficits may become obvious over time, but it is thru the pattern of behavior that we can see these deficits, not just a quick sense of what our eyes and ears are telling us.
Next: Identification of Patterns in the Sand
So how do we see the invisible? Well if we are in Hollywood and we are talking about the invisible man, we wrap him in bandages, or look for the footprints. Footprints: remember the legendary story of the million posters of “Footprints in the Sand”? http://www.footprints-inthe-sand.com/ Well how are we to know from the footprints that the ghost of brain injury is lurking beneath the surface?
Identifying brain damage is a complex problem of looking thru skin, skull and normal tissue, to see what may be microscopic pathology, without peaking. This is the ultimate Xmas present-type guessing game to identify what is in the package, with no shaking allowed. Yesterday we discussed the discrimination of society in favor of the service dog for the blind versus the service dog for the brain injured, because of the visible evidence of that disability. But all we are seeing in a blind person is the footprint of pathology as well. We cannot see the blindness; what we see is the footprint of behavior changes because of the blindness.
With apologies to the blind: we might see the sunglasses, we might see the cane, we might see that the eyes don’t look directly at us or other things. We see the seeing-eye dog. While we can’t see the pathology, we see the evidence of the pathology in a pattern we almost instantly recognize as patterns of blindness. The pattern of the footprint tells us that someone is blind.
Why is that pattern so much harder to see in the brain injured? It isn’t always. Many brain injuries come with physical disabilities – problems with tone, with motor skills, with walking. While not as visually recognizable, many brain injuries come with speech deficits that are recognizable as soon as you hear the brain injured person try to communicate. Yet, profound brain injury can occur in a pattern that doesn’t fit either the physical or speech disability pattern. Frontal lobe deficits may become obvious over time, but it is thru the pattern of behavior that we can see these deficits, not just a quick sense of what our eyes and ears are telling us.
Next: Identification of Patterns in the Sand
Service Dog Discrimination Issues
EDITORS NOTE: Yesterday, we talked about the “invisible injury” nature of brain injury, specifically with respect to public recognition of the role of seizure dogs. I had intended to next write about seeing the invisible, thru following the patterns of the footprints, but have decided to wait for that until tomorrow. I received this comment on seizure dogs from one of my readers, and felt it should go next.
Whether that person be:
Physical Disabled – Guide, Hearing, Mobility, Medical Alert, etc.
Social/Emotional/Mental Disabled- Autism, Acute Issues (phobia to leave home, socialize, depression, etc.)
One of the sad notes in the discrimination against service dogs is the current move to enact breed specific legislation in many areas. Due to the large numbers of unwanted pit bull type dogs, many are being rehabilitated as service and therapy dogs, including impounded dogs from the Michael Vick case. Once placed in a home these highly trained dogs provide a quality of life which would be impossible otherwise. In some places, BSL allows law enforcement to physically remove and euthanize these service dogs, or, to require muzzles which inhibits the dog’s ability to perform tasks for their handlers. Many BSL laws require $1,000,000 in home owner’s insurance which is difficult for those disabled people who rely upon their service dogs.
Pit Bull type dogs are ideal for service dogs. Small and compact, they are still strong enough to pull a wheelchair and carry backpacks, their coats are easy to maintain. They have confidence to function in public but were also bred to be submissive to humans. Even Helen Keller owned a pit bull.
Because the ADA is a federal law, it should override any state or local legislation when dealing with service dogs, no matter what the breed. Restricting pit bull service dogs in some areas violates what the US Supreme court has deemed a fundamental right, the right to interstate travel. In theory, all service dogs are protected under federal law and in some states such as California, to harm a service dog is a felony. However, if you call the Department of Justice, you will receive varied responses on your inquiry as to the rights of your service dog in BSL states, or your right to travel with your service dog through areas which have BSL legislation. Legally, pit bull service dogs are protected federally, but it will be a case by case decision to decide the fate of handlers and their dogs.
According to the ADA:
BUSINESSES MAY NOT:
* Require special identification for the dog
* Ask about the person’s disabilitiy
* Charge additional fees because of the dog
* Refuse admittance, isolate, segregate, or treat this person less favorably than other patrons
The ADA defines a service animal as any guide dog, signal dog, or other animal individually trained to provide assistance to an individual with a disability. If they meet this definition, animals are considered service animals under the ADA regardless of whether they have been licensed or certified by a state or local government.
Thank you Becca for this fine contribution. And of course, if other readers would like to add something in response to any of my blogs, I will consider posting their comments here as well.
Well it is a bit off topic, the lawyer and the dog person in me, can’t really resist jumping in on this topic. I have been a poodle person for years, yet the best dog I know resembles a cross between a border collie and a lab. She is sort of black, with just enough white on her face to look like she has a little border collie coming thru. She has web feet and loves to retrieve. She has the border collies energy and intelligence, with the goofy affectionate people bonding people you might expect to see in a good lab. The so-called experts tell me this dog is a Pit Bull. I know dogs and this is a good dog.
In law school I learned the principles of legislation and discrimination. The lay person thinks that discrimination is a bad thing, because the term is usually applied to racial or religious issues. But all laws discriminate. The theory of a law is you define legal versus illegal conduct, based upon a definition of some type. That definition is a discrimination. Now the legal issue is whether that form of discrimination is legal or constitutional. Unconstitutional discrimination primarily includes discrimination against race or religion, and certain other protected activities. But a discrimination while appearing constitutional, can still be illegitimate if it serves no rational state interest.
A law serves no legitimate state interest if the stated basis of the law is irrational as applied to the class against which the discrimination is aimed. I would not argue that the state does not have an interest in controlling unsafe animals. I would not advocate a law that allowed tigers to roam free. A law that prohibited predatory SPECIES of animals to be off leash in a dog park, is certainly legitimate. I do not want my dog eaten by a mountain lion.
But all dogs are the same species – the DNA of different breeds are virtually indistinguishable. It is an old cliche: there are no bad dogs, only bad owners. I wouldn’t go quite that far. There are some bad dogs, just like there are some bad people. But I can’t accept that there are any bad breeds. But let us assume that there was a particular breed, lets call them the Saber Dog breed, that was in fact a universally dangerous animal. Now in my artificial world, all Saber Dogs would have fangs like a saber tooth tiger, and since no other dogs have such teeth, we would know they were dangerous animals on sight, and we would have a rational law that could be applied.
But the similarities between breeds are staggering. As well as I know dogs, I am still not convinced that my favorite dog is really a Pit Bull. If she is a Pit Bull, she is the second Pit Bull I have known well who was smart, playful and liked to run around until she dropped chasing and being chased by other dogs. So based upon my experience, that makes her breed a good, pleasurable breed to own or just spectate.
I challenge anyone to define a law prohibiting Pit Bulls that can be enforced on a visual inspection that is not at risk for being overly broad and excluding “safer” breeds. How much do you have to mix with a boxer, or a lab, or a rottweiler to make them look a little too much like a Pit Bull?
I do believe there are bad dogs, but I am convinced that 90% of the problems with dogs stems from the dogs not getting to run around freely at times and not getting to play with other dogs. A dog park solves both of those problems. Not allowing a breed which the regulators have identified as potentially being dangerous, to engage in the kind of activity which would reduce their danger, is totally irrational.
In summary, dogs are wonderful animals. Something about their DNA as a species gives them a special bond with human beings. They will become your best friend, if you allow them. But that trait is spec
ies specific, not breed specific. Breeding is almost entirely about looks, not temperment. The best dogs are often mutts. In fact, all dogs are essentially mutts. You only get into trouble breeding dogs when you interbreed them. No law can be defined to discriminate between the good dogs and the bad dogs. To base a discrimination on whether this particular “regulator” thinks they look too much like a dangerous dog breed, is positively Un-American. Especially when you consider the breed is named “American Pit Bull Terriers.”
And that is my humble opinion.
The Need for Periodic Followups after a Concussion
As I discussed yesterday, if the person is seen the day after the concussion, there is a fertile opportunity to actually test the injured person’s memory formation, to see if they are in an amnestic period. Yet, no where in the Facts for Physicians Toolkit, does it call for a return visit the next day.
In the sports situation, the athlete doesn’t get back into the game if he or she is symptomatic at 15 minutes. So what does that mean? They don’t determine that the person is able to go back into the game at two minutes, they wait fifteen minutes. If there are no symptoms at 15 minutes, they send them back in. If they are symptomatic at 15 minutes, they don’t get back into the game until their symptoms have cleared for a significant period of time.
If it is classified as a significant concussion, they don’t get back into the game until their symptoms have cleared for seven full days. Now here is what is significantly different about the way that average people who get head injuries, brain injuries in motor vehicle accidents or falls are treated different than an athlete.
With an athlete, let’s take an NFL quarterback, there are millions of dollars at stake as to whether or not and when, that person can play again. That means that every day that such person continues to be symptomatic it is a problem. Which of course means that every day some expert in the field of brain injury or at least in the field of sport concussion, is evaluating them to see if they are still symptomatic.
If we could take that model of daily evaluations to see if symptoms have cleared and apply that to injuries that happen in motor vehicle wrecks , I believe we would be able to sort out the accidents and brain injuries that are significant from those that are not.
What I would like to see is a change in two significant things in respect to people who have concussions in motor vehicle accidents and other accidents are treated. First, there has to be an analysis done of memory not confusion in the ER, as discussed previously on this blog. Second, we need to demand a 24 hour follow-up, preferably at the same facility.
Sorting out confusion from amnesia at the ER on the day of the event is only going to tell us what is going on in the first three or four hours. “Brain injury is a process, not an event. “ (T Gennarelli) It can take 72 hours for the full effect of brain injury to start impacting on the mind. So more important than asking better questions about amnesia on the day of the accident is to ask them something the next day.
I have two classes of concussion cases. Those where the people went to the ER on day two, and those where they didn’t. In almost every case where the loved ones of the injured person were concerned enough about injured person’s behaviors that they took them back to the hospital, I was able to prove a brain injury occurred. It wasn’t that the second day’s ER staff was so much more competent. It was that by day two, it had become so much more obvious that a concussion had occurred.
When you go to see the doctor 24 hours after your concussion and it is a significant concussion, even busy doctors in the emergency room will spot amnesia and even if they aren’t confused about what happened in the accident, they are confused about what they have been doing.
If we believe it is important to treat those with lasting effects of concussion, we must identify those who are the highest at risk. If we are really going to improve how we sort that out, the key is to make sure they go back to the doctor, preferably the same emergency room. If we change this protocol, we also need to change forms, like the ACE form from the CDC, to tell the doctors what to ask, like: “What did you do since you left here?”
If the patient can only remember a few things, they are probably having amnesia. If they can remember all of it, then they probably don’t. If they don’t remember anything, then it is a significant head injury.
We must change the way we look at the long term potential for a head injury, brain injury, in the 24 hours after the accident. We must start giving the accident victims the same type of care and concern we give athletes who are injured in sports.
In the sports situation, the athlete doesn’t get back into the game if he or she is symptomatic at 15 minutes. So what does that mean? They don’t determine that the person is able to go back into the game at two minutes, they wait fifteen minutes. If there are no symptoms at 15 minutes, they send them back in. If they are symptomatic at 15 minutes, they don’t get back into the game until their symptoms have cleared for a significant period of time.
If it is classified as a significant concussion, they don’t get back into the game until their symptoms have cleared for seven full days. Now here is what is significantly different about the way that average people who get head injuries, brain injuries in motor vehicle accidents or falls are treated different than an athlete.
With an athlete, let’s take an NFL quarterback, there are millions of dollars at stake as to whether or not and when, that person can play again. That means that every day that such person continues to be symptomatic it is a problem. Which of course means that every day some expert in the field of brain injury or at least in the field of sport concussion, is evaluating them to see if they are still symptomatic.
If we could take that model of daily evaluations to see if symptoms have cleared and apply that to injuries that happen in motor vehicle wrecks , I believe we would be able to sort out the accidents and brain injuries that are significant from those that are not.
What I would like to see is a change in two significant things in respect to people who have concussions in motor vehicle accidents and other accidents are treated. First, there has to be an analysis done of memory not confusion in the ER, as discussed previously on this blog. Second, we need to demand a 24 hour follow-up, preferably at the same facility.
Sorting out confusion from amnesia at the ER on the day of the event is only going to tell us what is going on in the first three or four hours. “Brain injury is a process, not an event. “ (T Gennarelli) It can take 72 hours for the full effect of brain injury to start impacting on the mind. So more important than asking better questions about amnesia on the day of the accident is to ask them something the next day.
I have two classes of concussion cases. Those where the people went to the ER on day two, and those where they didn’t. In almost every case where the loved ones of the injured person were concerned enough about injured person’s behaviors that they took them back to the hospital, I was able to prove a brain injury occurred. It wasn’t that the second day’s ER staff was so much more competent. It was that by day two, it had become so much more obvious that a concussion had occurred.
When you go to see the doctor 24 hours after your concussion and it is a significant concussion, even busy doctors in the emergency room will spot amnesia and even if they aren’t confused about what happened in the accident, they are confused about what they have been doing.
If we believe it is important to treat those with lasting effects of concussion, we must identify those who are the highest at risk. If we are really going to improve how we sort that out, the key is to make sure they go back to the doctor, preferably the same emergency room. If we change this protocol, we also need to change forms, like the ACE form from the CDC, to tell the doctors what to ask, like: “What did you do since you left here?”
If the patient can only remember a few things, they are probably having amnesia. If they can remember all of it, then they probably don’t. If they don’t remember anything, then it is a significant head injury.
We must change the way we look at the long term potential for a head injury, brain injury, in the 24 hours after the accident. We must start giving the accident victims the same type of care and concern we give athletes who are injured in sports.