Welcome to the TBI-HELP Live Chat

Today's topic is: "From SICU to Acute Rehab…Ultra Early Intervention in Coma and Traumatic Brain Injury"

Our Guest is: Dr. Kathryn Ko, Chief of Neurosurgery, Coney Island Hospital and Chief of Neurotrauma, St. Barnabas Hospital

[18:59:00] MOD: Welcome to our Professional Chat Session. Tonight as our guest speaker we are proud to have Dr. Kathryn Ko, Chief of Neurosurgery, Coney Island Hospital and Chief of Neurotrauma, St Barnabus Hospital. Her topic of discussion is From SICU to Acute Rehabilitation...Ultra Early Interventin in Coma and Traumatic Brain Injury.
[18:59:47] MOD: Welcome Dr. Ko
[19:00:03] Dr.Ko: Thanks for having me, pardon my hoarse voice, I've been out all day sloshing through the snow. I'm happy to be here this evening!
[19:01:22] MOD: Dr. Ko as a Neurosurgeon you must have met many patients with Traumatic Brain Injury
[19:02:06] Dr.Ko: Since one of my areas of interest is TBI, I've met hundreds of such patients (pts) and some have even become friends because I've known them so long.
[19:03:19] MOD: How So?
[19:03:32] Dr.Ko: My experience at the Coma Recovery Unit in the Brady Institute taught me to consider the chronicity of TBI. It was an enlightening experience to not only perform surgery but to then follow these people months to years after the injury. It humbled me to learn that the operation is only a slice of the total challenges that the patient endures long after the incision has healed..
[19:04:08] mod1: What is Ultra Early Intervention for Traumatic Brain Injury?
[19:04:30] Dr.Ko: It is initiating Neuro-rehab in the TBI pt as soon as possible in the best setting. This is based on the simple premise that the Intensive Care Unit (ICU) is concerned with "survival", in contrast the Neuro-rehab facility is focused on "recovery". The faster the pt is in the "recovery" mode the better.
[19:05:40] MOD: How did the Ultra-Early Intervention approach develop?
[19:06:15] Dr.Ko: Dr. Angelo Canedo and myself studied the patterns of referral to the Brady Institute for Traumatic Brain Injury and found that many pts remained in the acute hospital excessively long. We then set up protocols to transfer pts directly from the ICU to Neuro-rehab at the Brady Institute. We enlarged the capabilities of the Neuro-rehab services to accept pts in coma, on respirators and those with other critical care but non life threatening issues.
[19:06:37] MOD: Karen s: how do you best use prednisone after SCI, Doctor Ko?
[19:07:34] Dr.Ko: The data supports using this immediately after SCI.  But not for TBI
[19:10:07] MOD: Why initiate Ultra Early intervention?
[19:10:37] Dr.Ko: We believe that Neuro-rehab intervention in TBI pts is second in importance only to surgical stabilization in determining patient outcome. Because of this we are committed to maximizing the patient's and family's exposure to rehabilitative therapies at the earliest time and not delaying until the patient is declared "medically stable".
[19:11:59] MOD: How did this approach develop?
[19:13:13] Dr.Ko: A matter of getting the pt to Neuro-rehab quicker, in the best interest of the pt.
[19:14:15] MOD: Rob: How important is early intervention i.e. surgery in the rehab. period an success of a pt. with TBI?
[19:14:41] Dr.Ko: Surgery, if needed should be done immediately. What we are advocating is Ultra Early transfer of post op pts. to Neuro-rehab..
[19:14:57] MOD: Rail: At the Brady - did you develop protocols to assist in the early transfer of TBI from the ICU to the TBI-ICU?
[19:15:46] Dr.Ko: Excellent Question Rail!! in the Brady the philosophy was:  If the patient undergoes an operation, then when the pt is surgically stable, as early as post op day 1. If no operation is planned then within 1-2 days. What we have found so far is that there is no medical contraindication to transferring a pt directly from the ICU to an appropriate Neuro-rehab facility immediately after surgery. In other words no patient in our study had a detrimental outcome because of Ultra Early transfer.
[19:16:46] MOD: Rob: How do you initiate E.I. in an acute hospital where there is little knowledge about these techniques?
[19:17:38] Dr.Ko: Start with the Neurosurgeons and the Rehab M.D.s
[19:18:07] MOD: Rail: To follow up - what were the few situations where transfer was contraindicated?
[19:19:27] Dr.Ko: Ultra Early Transfer has to be determined by the Neurosurgeon when the pt is surgically stable. If a patient has high intracranial pressure or other acute Neurosurgical problems requiring further surgery.
[19:21:11] MOD: Isn't it essential that the Neuro-Rehab facility have ICU for some of the beds?
[19:21:39] Dr.Ko: Important point, the Neuro-rehab unit needs to have the facility for Critical Care monitoring, such as in a Coma Recovery Unit. TBI/Coma Recovery Units are dedicated to and better equipped to handle these pts and support the family. Also the length of stay days in the acute hospital ward is decreased, resulting in decreasing costs. These savings could possibly be used toward the neuro-rehab services.
[19:23:58] MOD: What benefits does Ultra Early admission to Neuro-rehab give to the patient?
[19:25:48] Dr.Ko: To emphasize, both the patient and family benefit by moving the pt from the "survival mode" to recovery faster. Therefore it would seem that the pt would progress quicker.
[19:26:36] MOD: How do family react to the concept of EI as opposed to the feeling of security they may feel in their relative staying in an ICU for an extended period of time
[19:27:50] Dr.Ko: Very good question? The response from the families has been overwhelmingly positive due to the supportive atmosphere of a TBI unit.  Keep in mind that these units have nearly all the critical care functions as an ICU.
[19:28:26] MOD: What kind of early outcomes and progress can we look for with this intervention?
[19:29:49] Dr.Ko: We are hoping to prove that Ultra Early transfer will have a significant impact on getting the pt to recovery sooner.
[19:30:06] Dr.Ko: As Neurosurgeons follow the patient beyond the ICU and OR we will begin to understand that presently our brief role pales in comparison to that of the Rehab specialist who spends months to years with the pt and may have more meaningful impact on that pts life. But more importantly, by following patients long term Neurosurgeons will learn more about the chronicity of the condition and develop surgical strategies to help these pts cope with the challenges of life post TBI.
[19:29:35] MOD: How early is Ultra Early Intervention?
[19:31:08] Dr.Ko: Immediate, as soon as the pt is admitted to the ICU the Neurosurgeon should ask herself "How do I get this pt to a Neuro-rehab unit?" If the patient undergoes an operation, then when the pt is surgically stable, as early as post op day 1. If no operation is planned then within 1-2 days..
[19:31:44] MOD: How will progress occur with this intervention?
[19:32:28] Dr.Ko: Terrific question!! I advocate Neurosurgeons becoming more involved in every phase of TBI from the acute injury through recovery. Also, Physiatrists must welcome input from the Neurosurgeons and accept responsibility for pts with more critical medical issues. .
[19:34:56] MOD: Transfering someone post op day 1 or 2 is pretty radical...how do doc's who are somewhat conservative deal with this aggressive approach...your experience?
[19:36:16] Dr.Ko: Thanks for your thoughtful question. We have proved that Ultra Early transfer does no harm medically to the pt. Getting the Medical establishment to follow is a challenge that is why we have committed this work to scientific study.  American Association of Neurological Surgeons Guidelines on Severe Traumatic Brain Injury should alteast have a chapter on Neuro-rehab. I'm waiting for the authors to ask me to write that chapter.
[19:38:22] MOD: Sue: As a mom of a TBI patient, I can truly say that without this early intervention and a coma recovery unit with a great neurosurgeon, that patient wouldn't have made the progress he has. Thanks Dr Ko.
[19:39:09] Dr.Ko: Wonderful comment!! Not only do I advocate Ultra Early Neuro-rehab but for Neurosurgeons to hang in there with the patient for the long haul. There will be future surgical therapies to help post TBI persons and we need to find these!!
[19:42:36] MOD: Jim: What are some of the treatments that an EI patient would receive that another pt. treated more traditionally would not receive?
[19:42:59] Dr.Ko: Very Important Point!! The patient in coma will receive stimulation techniques in the Neuro-Rehab environment that are not easily instituted in the SICU.  As a preliminary study we examined how much "rehab" a severe TBI pt rec'e in the SICU. We discovered it to be less than 15 minutes if at all per day.
[19:46:28] Dr.Ko: We knew we needed to increase the rehab component of the pts treatment and felt the best way was EI
[19:46:06] MOD: I've seen that Inter Cranial Pressure has been identified as the 'second injury" in TBI - how significant is this as part of the early surgical intervention in these cases?
[19:48:51] Dr.Ko: ICP management is very important and falls within the domain of Critical Care management.
[19:48:52] MOD: Jim: What are some of the newest techniques that would be available to the patient in a E.I. program?
[19:50:25] Dr.Ko: Some of the techniques take into account all the senses including touch, smell, sound and taste, but using those modalities that the pt is familiar with, within their own culture and age. We also ask the family to take a larger role, after all it's the families voices that the pt is most familiar with.
[19:51:46] MOD: vekia: Are there any different rehabilitative measures needed for pediatric TBI pts.?
[19:52:53] Dr.Ko: EI Neuro-rehab would be ideal for peds TBI pts. The pediatric pt has enormous potential for recovery and the earlier in the healing process this is started the better.
[19:54:14] Dr.Ko: The question about novel techniques was so good I have to go back to it. Another innovative approach is to restrain or retard the function of the good or normal limb to force the patient to use the other weaker one. This has had some positive results in the stroke population who in general are older than the TBI population.
[19:57:16] MOD: How can we learn more about this?
[19:57:47] Dr.Ko: Refer to our abstract by clicking on the brain image at: http://www.datatone.com/~kgyrus/
[19:58:37] MOD: Well our time is up for this evening. I want to thank Dr. Ko for an excellent chat sesion and hope that she will join us again in the near future. Please be careful out there with the weather. Take care and see you next week. Thank you Dr. Ko.
[19:58:55] Dr.Ko: It's been my pleasure to be here tonight and to exchange ideas with you all. I leave you with a final thought: "Nearly all the really important lessons in medicine I learned from my patients…"