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Spinal Cord Injury (transcript)
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(SPEAKER)   

Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association.  An association of independent locally operated and community based Blue Cross and Blue Shield plans supporting solutions that make quality affordable healthcare available to all Americans. 

 

(DR. PETER SALGO)

Welcome to Second Opinion where each week you get to see firsthand how some of the country’s leading healthcare professionals tackle health issues that are important to you.  Now, this week we’re going to be discussing spinal cord injury.  And we’re changing the format of our broadcast a little bit.  Instead of me presenting a case, we’re going to be learning from two gentleman, whose lives have been drastically changed by a spinal cord injury.  I’m your host, Dr. Peter Salgo.  And today our panel includes Dr. Brad Berk, from the University of Rochester Medical Center, and Dr. Berk’s wife, who’s also a social worker, Mary Berk, Dr. David Chen from the Rehabilitation Institute of Chicago, Dr. Paul Maurer from the University of Rochester Medical Center, and college student, Charles Durkee.  Alright.  It’s time to get started.  We’ll start with you, Charlie.  Three years ago what started out as a simple attempt to get a family pet out of a tree, it turned into a life-altering event.  Tell me a little bit about what happened.

 

(CHARLES DURKEE)           

Well, it was our little cockatiel.  It got out of its cage and flew up in the tree about twenty to twenty-five feet.  So I go up in the tree, because I’m used to climbing because of the air force.  And so I climb up there.  And one of the branches was a little weak.  I wasn’t sure about it, but I stepped on it anyways to try and get up there, and the branch broke.  I tried to reach ahead for another branch, but I had gloves on and the gloves slipped off, and I just fell backwards.

 

(DR. PETER SALGO)

When you landed, what did it feel like?  Did it hurt?

 

(CHARLES DURKEE)           

No.  I had no pain throughout any of this at all.  When it happened, as soon as I hit the ground, I felt this a wave of numbness come from my head and just go all the way down my body.  And after that, I couldn’t feel my legs.

 

(DR. PETER SALGO)

So your mom and dad were there.  Right?

 

(CHARLES DURKEE)           

Yes.

 

(DR. PETER SALGO)

EMTs arrived?

 

(CHARLES DURKEE)           

Yes.  In a matter of minutes.  They supported me, did everything that they needed to, and then they brought me over to the Mercy Flight, which actually came over. 

 

(DR. PETER SALGO)

Brad—

 

(DR. BRAD BERK)    

Yes.

 

(DR. PETER SALGO)

You had an incident.  Tell me about yours.

 

(DR. BRAD BERK)    

May 30, a little over a year and twenty days ago, I was cycling, and a car appeared suddenly.  And as I attempted to avoid the car, I skidded.  My rear tire blew, and when I went to peddle, I went over the handlebars and landed on my head.  Woke up, said, good news, bicycle helmet did great, but I also, just like Charlie, felt this wave of numbness and realized I couldn’t feel my legs.  And I was looking at my left arm lying there.  And I said, “That doesn’t seem like it’s even attached.”  And then I started panting, because I was having a hard time breathing.  And being a physician, I determined that I had a high cervical fracture.

 

(DR. PETER SALGO)

Now, a high cervical fracture would mean that this is the cervical vertebrae high up in your neck.

 

(DR. BRAD BERK)    

High up, yes.

 

(DR. PETER SALGO)

And that’s where the spinal cord was affected.

 

(DR. BRAD BERK)    

Correct.

 

(DR. PETER SALGO)

And unfortunately, that might have, in your mind, been above the level that controls your breathing, and that might have been affected too.

 

(DR. BRAD BERK)    

Correct.  That’s what I was concerned about.

 

(DR. PETER SALGO)

Now, you didn’t have use of your arms at that point.

 

(DR. BRAD BERK)    

Correct.

 

(DR. PETER SALGO)

But fortunately, the driver stopped.

 

(DR. BRAD BERK)    

He was very nice.  Stopped, came up.  I told him to call 911.  And then I told him to call my family and they came.

 

(DR. PETER SALGO)

Mary, your husband calls.  He says in his best doctor-ish way, “I think I’ve had a high cervical spinal cord injury.”

 

(MARY BERK)          

I didn’t actually answer the phone.  It was our son who answered the phone. 

 

(DR. PETER SALGO)

Okay.

 

(MARY BERK)          

And he said exactly that to him.  And our son called to me and said, “Dad’s had an accident.  We’ve got to go down the road.”

 

(DR. PETER SALGO)

What is it like to see the grave situation before you?

 

(MARY BERK)          

Well, there’s probably nothing worse than looking at your husband lying in the middle of the road.  He couldn’t move, and I said typical, I said, “What should I do?”  And he said, “Call the attending in the ED.”  And then he gave me the phone number. 

 

(DR. PETER SALGO)

He’s still directing things.

 

(DR. PAUL MAURER)          

He’s like a Rolodex.

 

(DR. PETER SALGO)

You with a medical background what was the emotional impact of that right at the moment?  You were awake.  You were directing traffic.

 

(DR. BRAD BERK)    

Yeah, well, that was my response to being terrified.  And when Mary came, I said to her, I said, “I’m so sorry,” because I knew that this was going to be a very long difficult time ahead. 

 

(DR. PETER SALGO)

So you were externalizing right then.  You were talking about the impact on her.  You had a sense it was going to be tough on her.

 

(DR. BRAD BERK)    

Very tough.

 

(DR. PETER SALGO)

Both Brad and Charlie had 911 come.  Both got airlifted to the hospital.  What is the most important first step though when a person falls or is in an accident right at the scene?

 

(DR. PAUL MAURER)          

I think an immediately appropriate thing is to stabilize the spine, to stabilize the head, which can actually be done as simply as gently putting your hands by the angle of the jaw and just gently holding, so that as the person if they are moving around, they move around less if it’s an incomplete injury.  Many times it doesn’t turn out to be a significant cervical injury or a thoracic injury but always best to plan on it being—

 

(DR. PETER SALGO)

Always assume that it is.

 

(DR. PAUL MAURER)          

Assume it is.

 

(DR. PETER SALGO)

How is the spinal cord injury different than other injuries?

 

(DR. PAUL MAURER)          

The spinal cord resides actually in the absolute center of your body.  So it resides very deep within the body.

 

(DR. PETER SALGO)

You got some pictures, I think, of a scan of the neck.

 

(DR. PAUL MAURER)          

We do.

 

(DR. PETER SALGO)

So we can take a look at that.  Perhaps you could—

 

(DR. PAUL MAURER)          

Sure.

 

(DR. PETER SALGO)

—look at them with us and explain a bit.  There it is.

 

(DR. PAUL MAURER)          

If you go to the second picture in the top series.

 

(DR. PETER SALGO)

The middle one.

 

(DR. PAUL MAURER)          

The middle picture.  It’s a very descriptive picture of a fracture of the spine with what we call dislocation.  The head weighs about eight pounds on a very small pillar of bone about that big around.  Sixty percent of the weight of your head actually rides on what are called facet joints, which on the picture to the far left on the top row the little joints, one claw comes to grab the next, grab the next, and grab the next.  And the entire head is held on the body by a system of claws that grab each other.  When—let’s make believe this is a car for just for discussion.  You come out of the seat, and the moment of impact, a series of things happen called the primary injury.  The head hits the windshield, and the head starts to go back.  There is energy transfer.  Just like a cue ball hitting another billiard ball.  There is energy in the cue ball, which transfers to the next ball.  When the head hits the windshield, the head hits the ground.  There is an energy transfer of actual energy into the spinal cord, which rupture cells and tears fibers.  There is then a stretch injury to the cord.  It’s the cord, which is the size of your index finger.  And as the spinal cord stretches, you get stretch injury of fibers, because they tear.  Then as you fall back into the seat, there’s the third component, which is called compression.  Because you can see how these vertebrae if you look at the middle picture, when you get to one portion of the picture, you’ll see the whole sequence of joints is out of line.  Think of them like wooden blocks or sugar cubes stacked—

 

(DR. PETER SALGO)

Down near the bottom there.

 

(DR. PAUL MAURER)          

Down near the bottom you’ll see that one of those little sugar cube squares is broken, and the whole pipe is now shifted.  And the spinal cord, the size of your finger, has to dive through about a fourteen-millimeter pipe.  And think, you know, when you’re a kid, you take two toilet paper rolls, and you slide one over the other.  As that column slides out of position, those tubes overlap each other and compress the spinal cord.  So you get energy transfer tearing fibers, you get stretch injury tearing fibers, and then the last event, and this happens in a millisecond, is when the person hits the ground or falls back in the car seat.  We now have this unstable compression that can potentially keep injuring the spinal cord.

 

(DR. PETER SALGO)

And, of course, it’s worth pointing out.  The spinal cord is this main circuit cable of the body.

 

(DR. PAUL MAURER)          

Everything.

 

(DR. PETER SALGO)

So it carries what it carries sensory and motor, so he couldn’t feel anything.  He couldn’t move.  He couldn’t breathe.

 

(DR. PAUL MAURER)          

Everything you feel, your bowel, your bladder, your legs, your arms, everything goes through a ten to eleven millimeter electrical cable.  It’s an amazing, amazing system.

 

(DR. PETER SALGO)

Now, when both Brad and Charlie got to the hospital, they got surgery.

 

(DR. PAUL MAURER)          

Correct.

 

(DR. PETER SALGO)

Right away.  What’s the goal of surgery here?  You’re not going to sew the nerve fibers that have been distracted back together are you?

 

(DR. PAUL MAURER)          

No.  And that’s why as the surgeon, we look at all of these things as primary injury.  In other words, the energy transfer, the stretch, that’s primary injury.  We can’t—they’re honest answers.  You can’t change that.  You know, what occurs in that millisecond, that card has been played.  However, the head is no longer properly attached to the rest of the body.  The bony structure that holds the head in position, and keep in mind, this toilet paper roll analogy, this pipe now, which is only fourteen or fifteen millimeters.  Every time that head moves three or four millimeters, this poor injured cord is getting stretched and compressed again.  So the goal of surgery is to prevent what we call secondary injury.  This is now a picture.  The picture on the left is taking straight through the front of the neck.  We open the back of the neck and put screws in the edge of the joints and lock them together with a rod.  The picture on the right is a very nice picture of a re-established spinal canal now with the screws and the plate holding things together.  It is to prevent secondary injury.

 

(DR. PETER SALGO)

Now what?

 

(DR. DAVID CHEN) 

Well, now is the recuperation.  You know, after the wonderful work that our neurosurgical and trauma colleagues have done to help preserve health and to hopefully optimize the potential for neurologic recovery.  Now, comes the next stage.  You know, one of the challenges with spinal cord injuries and, you know, our two colleagues will attest to that is, the waiting game that comes along with will I recover?  Will my neurologic condition improve?  And the question that I’m sure they have asked and everyone asks is, “Will I walk again?”  And that’s certainly one of the challenges with spinal cord care and rehabilitation that we often times can’t answer.  And honestly, I think, it’s okay to be able to say we really don’t know.  Every injury is different.  Every injury is different.  Even there may be similarities in the nature of their injuries, how they happen, the levels of the injuries that they take place.  But we’ve all seen individuals with very similar injuries.  Their outcomes being very different.  You know, we know from past experience and from what we seen in individuals who’ve we treated that, you know, the progression that takes place with recovery and sometimes the timeline varies significantly.

 

(DR. PETER SALGO)

Brad, Mary, you must have asked the question, “Will I walk again?”  “Is he going to get better?”  What were those first days in the ICU, and that’s where you were postoperatively?  What were those days like?  What questions were you asking?  What answers were you hearing?

 

(DR. BRAD BERK)    

We weren’t asking those questions in the ICU.

 

(MARY BERK)          

I was.

 

(DR. PETER SALGO)

You weren’t asking them because you didn’t want to know, or you were too sedated to ask them, or shock?

 

(DR. BRAD BERK)    

No.  I was working too hard on trying to breathe and being on the ventilator is very uncomfortable.  You have all of these secretions they’re taking care of.  You’re on a lot of medications.  You have a lot of pain.  My injury I lost all sensation from, you know, my neck down.  So I was trying to even understand where I was in space.  The only orientation I have is gravity.  So I was in a very uncertain state those first ten days in the ICU.

 

(DR. PETER SALGO)

Mary, what was it like for you?

 

(MARY BERK)          

Everyone was trying to explain their piece of the puzzle to me.  And what I remember thinking about was I would only hear the positive things.  I only heard when people said there’s a good chance that this could turn out better than it seems at the moment.  And when they were very negative, not negative, but trying to be realistic, I just, I couldn’t hear it.

 

(DR. PETER SALGO)

Charlie, what was it like for you?  What were your earliest memories now after the injury in the ICU in the hospital after surgery?

 

(CHARLES DURKEE)           

To be honest, my earliest memory was hearing my mom snoring and waking me up, because she was asleep on the cot next to me.

 

(DR. PETER SALGO)

Your mom slept in the hospital?

 

(CHARLES DURKEE)           

Uh-huh.

 

(DR. PETER SALGO)

Next to you.

 

(CHARLES DURKEE)           

Yep.  She stayed in there for quite awhile with me. 

 

(DR. PETER SALGO)

That’s a mom.

 

(CHARLES DURKEE)           

Yeah.  And they went through and talked to my mom and dad and told them everything that was going on with it, and they stuck with me the whole time. They were there every day during recuperation and everything.

 

(DR. PETER SALGO)

How important was that kind of support in those first few days?

 

(CHARLES DURKEE)           

Unbelievably important.  I mean it was just a drastic change, and having that much support there was a phenomenal help in getting myself back up to where I needed to be.

 

(DR. BRAD BERK)    

It’s an enormous strength to have your family there.  I have three grandchildren, and even though you’re not supposed to bring little kids up to the ICU, my daughter would sneak them in.  And it was great to see them.  And all of my children were there and Mary was there.  And it’s very comforting at those moments to know that you’re surrounded by people that really care for you and that, you know, want the best for you and are doing everything they can to cheer you on.

 

(DR. PETER SALGO)

You know once the surgery is over, the pain is controlled, the neck has been stabilized.  You’ve done everything you can in the operating room, and the ICU team has gotten you out of the ICU and to someplace where you need to be.  Where do you go next?

 

(DR. DAVID CHEN) 

Well, the next step is to help these individuals to restore some normalcy in their lives.  That’s where rehabilitation comes in to help individuals who—what neurologic function has preserved to really relearn to do things again.  And that’s really what rehabilitation is focused on is to help these individuals to gain some independence back into their life.  And there’s the tasks itself in terms of working with physical and occupational therapists in relearning, strengthening those muscles that have been preserved, strengthening those muscles which may be there but obviously very weak.  But in the last decade, we have come to realize that not only is neuroplasticity take place in the brain, but neuroplasticity also takes place in the spinal cord itself.

 

(DR. PETER SALGO)

And I want to come to that in just a moment.  We’ve covered a significant amount of ground, so why don’t we just stop for a moment.  Let me sum up what we’ve been talking about.  The immediate stabilization of a person after a fall or an accident is critical to the outcome.  A person with a spinal cord injury really needs your help.  Rehabilitation in that sense starts right at the scene.  You can help.  That’s the takeaway here.  I think is that fair?

 

(DR. PAUL MAURER)          

I think that’s very fair.

 

(DR. PETER SALGO)

Now, we are talking about spinal cord injuries today.  And we’re grateful to have Dr. Brad Berk and Charlie Derkee with us.  Both suffered spinal cord injuries due to accidents.  I want to back up just for a moment, because not only are you a victim of this accident, but you’re also an MD.  What was your sense?  I mean going into this and then being on the other side of it.  Did you have a different view of how doctors and patients relate?

 

(DR. BRAD BERK)    

Well, absolutely.  The opportunity that was given me in this terrible situation was to really learn a lot more about what it’s like to be a patient.  How one of the areas that I’m working on now is care.  To really make the inner change of care more beneficial.  We always think about the provider caring for the patient.  But the other way is equally important.  You as a patient can tell the provider how significantly helpful they’ve been.  And that two-way communication, I think, is a really important part.

 

(DR. PETER SALGO)

You mentioned OT, which is occupational therapy.

 

(DR. BRAD BERK)    

That’s correct.

 

(DR. PETER SALGO)

PT, physical therapy.  There’s therapeutic recreation, right.  There’s speech therapy.  They’re going to be seeing nurses and psychologists.  This is all a big mix.  How does it all work together, and what is the object of all of this?

 

(DR. DAVID CHEN) 

It’s the ultimate sort of a team concept.  You have a team of professionals who are all specialized in their particular areas working to help this individual again to restore normalcy and independence in their lives.  I think Brad said it well that, you know, I think as healthcare providers, sometimes we get a little bit caught up in because we work with these individuals in these particular conditions all the time, that because of our experience, we should know what this person needs.  But, I think, there’s nothing farther from the truth in terms of the need to hear from the patient and the family themselves that we need to hear their feedback and to know what’s working well for them and what’s not working for them.

 

(DR. PETER SALGO)

Brad, what was your experience like?

 

(DR. BRAD BERK)    

Well, I actually went down to a dedicated rehab facility in New Jersey called Kessler.  And they’re—I was on a whole floor of spinal cord injury patients.  And there was a lot of interaction among the patients.

 

(DR. PETER SALGO)

Was it helpful?

 

(DR. BRAD BERK)    

Very helpful.  I always tell the story about lunch class.  We would all have to go to lunch at the same time and learn how to eat again.  And during that time, we’d talk about a variety of issues that we were encountering and exchanged a lot of information.

 

(DR. PETER SALGO)

Mary, you not only are a family member, you have a skill set.  You’re a social worker as well.

 

(MARY BERK)          

Uh-huh.

 

(DR. PETER SALGO)

And as you go—as your husband went through rehab, I was actually using the royal we, because I suspect you’re going through this in tandem in a very real sense.

 

(MARY BERK)          

Uh-huh.

 

(DR. PETER SALGO)

You need education too, don’t you?

 

(MARY BERK)          

Absolutely.

 

(DR. PETER SALGO)

You have to provide and be provided with a different skill set, because once rehab is over, there is still problems going forward.  Right?  There’s impaired skin sensation, bladder, bowel control.  How much of that was a learning experience for you?

 

(MARY BERK)          

Oh, it’s a huge learning experience.  And the thing that was distressing as a family member was I never quite got the concept of progression.  People would say, “He needs this assistive device.”  And I would think, “Are we done?  That’s as far as he’s going?  And so you mentioned communication.  And it’s so vital, because this was nothing I had any experience with prior to this.  And there were so many things about it that I had to learn.  And all the while sort of negotiating with him about what he was trying to learn.

 

(DR. PETER SALGO)

But you know at the end of the day, the real question is, can I reverse the injury?  That’s the core question.  Right?  And you alluded to that by the word plasticity.  Why don’t you—tell me what plasticity means.

 

(DR. DAVID CHEN) 

Well, I guess, plasticity in its simple terms is sort of a rewiring or reworking of the networks and of the nerve transmissions that take place in the brain.  And that we think take place also in the spinal cord to help to regain back function in the areas that have been injured and impaired because of a medical condition.

 

(DR. PAUL MAURER)          

That’s where the hope is.

 

(DR. PETER SALGO)

What does hope mean to you?  Do you have hope?

 

(DR. BRAD BERK)    

Yes, of course.  One always hopes, and spinal cord recovery is not linear.  It goes and starts and stops.  So you reach a plateau, and you’re always wondering, “Is that it?”  And then you see some more progress.  And so that’s what gives you hope is every time you progress, you have hope.  At some point, of course, most people plateau, but I think the old teachings that ninety percent in the first year are really not true.  That people continue to progress for many years.  And neuroplasticity has a broader context for me.  And that it also includes compensation.  And that you can compensate for one thing you can’t do by figuring out another way to do it.  And so my brain has done a good job now of reprogramming itself to use visual cues when I don’t have sensory cues.

 

(DR. PETER SALGO)

Mary, what do you mean by hope?

 

(MARY BERK)          

I think just reaching a point at which he’s comfortable with where he is.  It started out I hoped he could walk.  And then it became my hope he could use his hands and walking didn’t seem so important.  And now I just hope that he reaches a point that’s comfortable.  That he feels good about what he can do.

 

(DR. PETER SALGO)

Charlie, what’s your hope?

 

(CHARLES DURKEE)           

Eventually, to possibly walk if anything happens in the near future with any medical breakthroughs.  But my hope isn’t that—that’s only a partial of it.  I’d like to get further and become better with my upper body and replace what I can’t use on the lower body with that.

 

(DR. PETER SALGO)

What’s your hope in this field?

 

(CHARLES DURKEE)           

Well, in some ways sort of opposite to what Mary is saying.  My hope is that, you know, individuals who sustain these type of injuries aren’t ever satisfied with sort of where they are.  So much of rehabilitation, so much of what individuals can and often do accomplish happens because of the drive that comes from them from their inner strength and from their desire to keep going.

 

(DR. PETER SALGO)

Let me pause for a moment.  Rehabilitation of the whole person, not just the physical injury is important for a person with a spinal cord injury to get back to life, being as functional and as independent as possible is a goal of rehabilitation, very important goal.  And it’s a hope.  All right, now, Mary, what advice do you have for people who’ve had the injury, for doctors, for family members, for bystanders?  It’s a big question.

 

(MARY BERK)          

It is a big question.  I don’t think family members hear at the beginning what’s told to them.  And I think providers think, well, I informed the family about this.  I told them what to expect.  There has to be some mechanism to continuously speak to family members, because you get to different stages, and you start to understand more, and you start to have some frame of reference that you didn’t have before.  So that’s what I would hope from providers.  I think family members have to assume a huge amount of responsibility in trying to learn everything they can about the injury.  I think they need to talk to other people who’ve gone through it.  I think they should never take no for an answer.  And then, of course, there’s the whole learning to be, in our case, a couple again around a very different new normal.  So I guess it’s just persist, and don’t stop asking questions and be hopeful.

 

(DR. PETER SALGO)

Hope again.

 

(MARY BERK)          

Uh-huh.

 

(DR. PETER SALGO)

But if I watch your face, this is a very emotional time for you.  Isn’t it, this past year or so, year and a half?

 

(MARY BERK)          

Well, his life wasn’t the only one that got turned upside down.  You know, our whole family changed dramatically as a result of this.  And anybody’s family would.  And you just go through it and try and figure out what to do today.  You stop looking at the future.  You just work on today.

 

(DR. PETER SALGO)

Charlie.

 

(CHARLES DURKEE)           

I completely agree with that.  For my family, everything got completely changed.  Not only mentally but also physically.  The housing got changed.  Everything got changed, interior.  And for the family, I mean, my entire family had to learn to cope with having me around to—as far as getting in and out of vehicles, they helped with that.  And mentally, they, you know, it’s a huge burden on them.  I mean I would assume.  I haven’t actually asked them that.

 

(DR. PAUL MAURER)          

Yeah, nervous system recovery is a marathon not a sprint.  And if people, if the families exhaust themselves the first three weeks, they won’t be there for the rest of the game.  She has a limit.  I don’t care.  You can be Mother Theresa.  Everybody’s family has a limit.

 

(DR. PETER SALGO)

And speaking of pace and time, we’re out of both, which is terrible, because we could go on with this discussion for a long time.  But that is the nature of television.  You, however, can continue this conversation on our website, secondopinion-tv.org, O-R-G, where you’ll find transcripts, videos, more about spinal cord injury and other healthcare topics.  And I want to thank you for watching.  I want to thank all of you for being here. 

 

(DR. PAUL MAURER)          

Thank you.

 

(DR. PETER SALGO)

This has just been an outstanding, incredible conversation.  And it did take—I know—you may do this a lot, but it does take courage to come out and talk about your problems on television.  So thank you both, all of you for being here.

 

(DR. BRAD BERK)    

Pleasure.

 

(DR. PETER SALGO)

I’m Dr. Peter Salgo, and I will see you next time for another Second Opinion.

 

(SPEAKER)   

Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association.  An association of independent locally operated and community based Blue Cross and Blue Shield plans, supporting solutions that make quality affordable healthcare available to all Americans.

 

(SPEAKER)   

Second Opinion is produced in association with the University of Rochester Medical Center, Rochester, New York.