Thursday, August 25, 2011

New Technology, Battles For Programs In ER Doc's Future

EDITOR'S NOTE: This is the the third article in a three-part series about Dr. Gary Witman, an emergency room doctor at Good Samaritan Medical Center, who last summer lost the use of his arms and legs after a rogue wave paralyzed him while at the beach.
Links to previous articles and Dr. Witman's personal blog are below.

By Lisa E. Crowley
BROCKTON—Nearly a year since the accident that has left him paralyzed from the neck down, Good Samaritan emergency room Dr. Gary Witman has had his voice return after vocal cord damage and just Wednesday afternoon he was able to move his thumb—a seemingly small, but enormous feat during what is expected to be years and decades of therapy that will coincide with battles with health insurance representatives for costly programs Witman will need to regain whatever movement in his body he can.
“The first thing they say is ‘No,’ You have to fight for everything,” said Dee Dee exasperatingly when she talks about paying for Gary’s extensive, and expensive medical care during the initial two months of recovery and a year’s worth of subsequent rehabilitation that began last fall when Gary was flown from Massachusetts to Craig Hospital in Englewood, Colorado—one of the few spinal cord rehabilitation facilities in the U.S.
They would have loved to stay in Boston at Spaulding Rehabilitation Hospital, well-known for physical and rehabilitative therapies, but Spaulding, Gary said, offers general care and he needed specialized treatment offered at Craig, and other centers like Shepherd Center in Atlanta or Kessler Institute of Rehabilitation in New Jersey. 4k3BqJaYF_Y/s1600/wedding2.JPG">
The Witmans—through help from family and friends--now have a handicapped van which they have used to travel to Los Angeles for daughter Samantha’s wedding, a week later to Philadephia for another wedding and Toronto, Canada for business reasons, and Baltimore, Maryland for a month-long battery of intensive therapies at Kennedy Krieger Institute.
Last fall when Gary had to leave Brigham and Women’s in Boston for Colorado for physical rehabilitation, the only available option was a medical evacuation flight via jet plane.
“It cost $18,000 to fly him to Colorado,” Dee Dee exclaimed. The flight was denied at first.
“What was he supposed to do? Take a bus," she said.
If an $18,000 flight wasn’t enough, during the 21 days Gary was in Brigham and Women’s surgical ICU it cost $15,000 per day, or about $315,000.
After countless phone calls and the help of Susan Brown, the benefits manager for Good Samaritan, the flight to Colorado was assured, however the battle over payments, Gary’s eligibility for government medical programs, and their desire to attain the best services, therapies, technology and rehabilitative programs—traditional or experimental--is expected to be a life-long, day-to-day battle.
"They deny, and deny, and deny," Dee Dee said. "You'd think they were they to help people. I think they get paid to deny," she said.
A recent study by the Christopher and Dana Reeve Foundation found approximately 5.6 million people, or 1 in every 50 Americans, suffer partial or complete paralysis.
The number one cause of paralysis is from a stroke, followed by multiple sclerosis and then spinal cord injuries which are mostly caused by motor vehicle accidents, work-related incidents, and sporting or recreational activities.
Whether a paraplegic or quadriplegic, patients and their families face a mountain of costs, paperwork, and red-tape associated with their new lives in wheelchairs.
According to the National Spinal Cord Injury Association, the average first year costs for quadriplegics— is about $400,000.

“You have to stay on them. They say no to everything and hope you’ll go away,” Dee Dee said, vowing to fight for every therapy and every penny they are entitled to.
Mountains of costs are compounded by mountains of medical complications.
People who have been paralyzed have a multitude of secondary medical complications such as cardiovascular, respiratory, bladder and bowel function problems, sexual function and temperature control issues, skin care and bed sore worries, and loss of touch and feeling—a loss of sensation that is a new disorienting sensation for paralyzed people.
Depression is a constant plague for patients, and Gary said he counts himself lucky, because through it all he never became darkly depressed or, like so many others who have suffered catastrophic injuries, contemplated suicide.
“I wanted to live and I have so many people to thank for helping me get here,” Gary said—topping the list wife, Dee Dee, his children, friends and colleagues. ““I don’t think of myself as a quadriplegic or a tetraplegic,” he said. “I think of myself as someone who can’t do all the things I used to do.”
While there are a lot of things he can’t do, like ski down the slopes with Dee Dee or save patients in an emergency room, there are a lot of things he can do—especially with his mind—which both Dee Dee and Gary agree is a miracle that he didn’t suffer any brain damage.
After more than three months at Craig Hospital in Colorado many medical problems Gary suffered were resolved including, anemia and hypoxia, severe deficiencies of much needed oxygen to his body tissues; excessive edema or swelling caused by excessive fluids in body tissues; and the need to use a feeding tube for nutrients.
While medical problems were resolved, he underwent aggressive physical and occupational therapies designed to get him back into a “normal” role as fast as possible, but with the caveat that normal would be much different than a few short months ago before the accident.
“The reality began to set in that tetraplegia is a life-long condition and one is not going to get up and walk,” Gary said.
What has been a god-send is a computer and software that function on a “sip-and-puff” system that allows Gary to operate a motorized wheelchair and Dragon voice-activated software that lets him use a computer to surf the Web, communicate with family and friends on his blog, “The Life and Spines of Dr. Gary,” possibly rejoin the staff at Good Samaritan in some way, and create presentations like the one he gave about his experience in May when he returned to the hospital for the first time.
Technology such as Dragon software and the sip-and-puff wheelchair have made a marked improvement in the quality of life for many paralyzed people.
Medical advances have also changed the prognosis for spinal cord injured people.
A generation ago, patients with paralysis had few options to increase their mobility and advice was to not try, or shouldn’t or couldn’t try, because it wouldn’t help anyway—there’s no cure for paralysis.
Since, due to advocacy and fundraising by non-profit organizations like the Christopher and Dana Reeve Foundation numerous experimental methods have been initiated, and in some cases have helped some people actually walk again.
Functional electrical stimulation, the sending of an electrical current or wave to the muscles and nerves, has been an integral therapy since the 1980s when a paralyzed college student, Nan Davis made headlines in 1983 when she got out of her wheelchair and, powered by a special functional electrical stimulation system, walked to the stage to accept her diploma.
Since the ‘80s, functional stimulation has taken on many forms including a device used at home called an EMPI, and an exercise bicycle that has shown dramatic benefits, not only in increased movement, but offers the benefits of exercise—increased heart and lung function, building of muscle and bone mass, and improved strength and stamina—for those who cannot exercise on their own.
In Massachusetts the only functional electrical stimulation cycles to be found, Gary said, are at Braintree Rehabilitation Hospital in Braintree and Boston University Medical Center in Boston.
Dr. Steve Williams, chair of Rehabilitative Studies and head of New England Regional Spinal Cord Injury Center at BU Medical Center, has been treating Witman for many months now and is pleased with Witman’s progress which has gone from an A on the American Spinal Cord Injury Association, or ASIA scale, or having no movement below the neck at all, to a C, where there is some sensation below the level of injury.
However he doesn’t want to be too pessimistic or too optimistic, and notes spinal cord injury patients usually show the greatest amount of improvement in the first and second years after injury.
“He’s got a long way to go,” Williams said.
Williams said the stimulation cycle helps increase brain activity in an unusual way—through the soles of the feet.
“We don’t know how or why,” Williams said, but data has shown the pedals of the bike stimulate the soles of the feet which send electrical messages from the feet, up the legs, through the torso and to the brain and back.
Stimulation has been shown to increase nerve activity in the brain, which increases movement and range of motion, but it is a slow, grueling process, that for some can be miraculous, and for others, it all depends.
“Yes, I have seen people who have been paralyzed walk, but, like every person, every injury is different,” Williams said.
Dee Dee said the bike gives Gary an obvious lift and they have seen a noticeable improvement in all areas. “It’s very exciting when Gary is on the bike. He shows so much improvement,” Dee Dee said.
Williams said Witman’s case is unusual because Gary did not hit his head on the beach sand—which would have made sense that he suffered severe neck and spine injury.
Mind-boggling to all—medical personnel included—is that the wave caused the injury to Gary.
In most circumstances it is the impact the head, neck or spine takes from an accident, wave or otherwise that causes bones to snap or fracture causing pressure on the spine which results in paralysis.
The accident did not cause any bones to break or fracture, and there was no sign of injury to his vertebrae. What was found was a “perfect storm” of bleeding in his spinal cord from C-3 to C-5, and edema, or fluid, through the rest of the spinal canal caused by the force of the wave, only.
“When he was knocked down the bone moved against the spinal cord,” Williams said. When Gary’s spinal cord was pinched by the bone the cells it caused bleeding in the spine and cells--neurons—died because of the bleeding.
The death of the cells, Williams said, causes messages to be sent to the brain telling the brain the cells are now dead. Because the brain has been told the cells are dead, messages from the brain no longer tell those body parts to move because they will no longer work.
In essence, Williams said, communication to the spine from the brain no longer takes place.
The only explanation for Gary’s injury is that in 1994, Witman was diagnosed with spinal stenosis, a narrowing of one or more areas of the spine that can cause pressure on the spine which can result in paralysis.
He had surgery about a year later. Sixteen years later, Dee Dee and Gary hypothesize it was the stenosis and subsequent surgery that not only caused the paralysis, but probably saved his life because there was enough elasticity in his spine to prevent a death-causing fracture.

“If it was another person, that person probably would have died,” Dee Dee said. “It caused his injuries, but it probably saved his life. That’s the irony,” she said.
A creepy remembrance trickles in when the Witmans are reminded of the stenosis surgery.
When Gary was flown to Craig Hospital in Colorado for rehabilitation, the plane made a stop to refuel. The plane refueled in Rockford, Illinois, the same city signs of stenosis in Gary’s spine first appeared 16 years before.
Gary is willing to try cutting-edge and experimental treatments in his attempt to find a cure for his paralysis.
He has researched new advancements in stem cell research. Witman has his eye on surgically implanted spine electrical stimulation that in an article in Lancet medical journal in May helped a 23-year-old paraplegic, after more than two years of experiments and stimulation, stand, with assistance for balance, on his own two feet for about 4.25 minutes and was able to take a few steps.
Witman said he is willing to face experimental electrical stimulation to his brain, a risk he is willing to take if it will help him regain movement, or possibly walk.
“I’ll be a human guinea pig—what have I got to lose,” Gary said.

Click here to read Part 1 of Dr. Witman's story...

Click here to read Part 2 of Dr. Witman's story...

Click here to visit Dr. Witman's blog, "The Life and Spine of Dr. Gary B. Witman," ....

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