COMPLEX CASE: MULTIPLE TRAUMAS FROM TORNADO

In summer 2021, a tornado hit Chicago's west suburbs. For one patient, this event led to multiple traumas and complications. Nelson M. McLemore III, MD, a physiatrist at Northwestern Medicine Marianjoy Rehabilitation Hospital, shares his experience with this complex case.

Q: Tell us about your patient and the injuries they sustained during the tornado.

The patient was a 34-year-old female who was 28 weeks pregnant. The patient was in her home during a tornado when a tree crashed through the window and struck her on her left side.

Q: What initial care did she receive, and for what complications?

On arrival to a level one trauma hospital on June 21, 2021, the patient was noted to have significant bleeding from a left neck laceration. Patient was confused and pale appearing on arrival and unable to move her left hand or follow commands. She was diagnosed with a left hemopneumothorax and had a chest tube placed. A chest arteriogram CT scan showed nonenhancement in her left subclavian and left vertebral arteries. The patient also had obstetric ultrasound which revealed intrauterine fetal demise. She was transferred to a different medical center for a higher level of care, where she stayed from June 21 to July 31, 2021.

At this trauma center, she underwent neck exploration on June 25, 2021. Her neck wound was closed at that time. She had left arterial doppler that revealed suspected occlusion of proximal subclavian artery which vascular surgery evaluated and did not recommend intervention. Further imaging revealed that the patient suffered left first through fifth rib fractures, displaced C6 spinous process fracture, bilateral C6-T1 transverse process fractures and T2-T5 transverse process fractures.

During this time, a code stroke was also called due to the patient’s decreased level of consciousness. An MRI revealed multiple regions of acute-subacute infarcts involving bilateral cerebellum, occipital lobes, and parietal lobes with local edema and mass effect. Severe mass effect was noted in posterior fossa, for which she underwent posterior decompression. Hospitalization was significant for diagnosis of right femoral deep venous thrombosis, for which she was started on Eliquis®.

Due to chronic respiratory failure, she required tracheostomy and gastrostomy feeding tube placement on July 22, 2021. The course was further complicated by healthcare-acquired pneumonia and C. difficile colitis. An orthopaedic surgery evaluation of her left scapular fractures and clavicle fracture recommended no surgical intervention and continued left upper extremity sling immobilization.

Q: What did you observe when the patient arrived at Marianjoy Rehabilitation Hospital?

The patient was admitted to Marianjoy on July 31, 2021, for acute inpatient rehabilitation. She had severe cognitive, linguistive impairments, dysphagia and was dependent in all self-care and mobility. She had persistent paralysis to her left upper extremity, and her MRI revealed diffuse edema and enlargement of brachial plexus with loss of normal architecture and morphology possibly related to posttraumatic avulsion injuries.

The patient made functional gains during therapy, however, she still required maximal to dependent assistance for self-care and mobility with no active movement involving left upper extremity.

Patient was discharged from Marianjoy on September 30, 2021, to her parents’ home with home health care consisting of nursing, occupational therapy, physical therapy and speech-language pathology for several months until her home (which was destroyed by the tornado) could be rebuilt.

Q: How did you continue to follow the patient?

I have continued to follow her in Marianjoy’s outpatient rehabilitation medicine clinic. Since discharge, the patient’s gastrostomy tube was removed. Her discharge was also complicated by a urinary tract infection that required hospitalization for three days in October 2021. The patient underwent a neuro-ophthalmology evaluation on November 18, 2021, with recommendations of right eye prism lens which is improved diplopia.

The patient had a neurosurgical evaluation with recommendations of no neurosurgical intervention for management of left brachial plexus injury. However, the patient and her family wanted a second opinion. The patient had continued motor recovery to left upper extremity. A second opinion plastic surgery evaluation with Jason Ko, MD, MBA, FACS, of Northwestern Medicine on January 24, 2022, recommended no surgical intervention, with orders for EMG of left brachial plexus and follow-up in two to three months.

Marianjoy outpatient occupational therapy, physical therapy and speech-language pathology services started on November 4, 2021, after home health ended. The patient received her custom manual wheelchair at that time. She reported that the neuropathic pain to her left upper extremity had resolved. She continues to progress in therapies. A repeat head CT and a neurosurgical follow up were completed.

An electrodiagnostic study of the patient’s left upper extremity on March 7, 2022, essentially revealed chronic denervation with early signs of reinnervation of left upper extremity proximal muscles. Distal intrinsic muscles of left hand remain denervated with no signs of reinnervation at that time, consistent with C8 root/inferior trunk involvement being most severe.

Physical and occupational therapy outpatient services were discontinued on April 7, 2022, with home exercise program and aquatic treatment referral. Additionally, the patient was seen by a neurosurgeon with a follow-up brain MRI unremarkable for ventriculomegaly. The patient had neuropsychology testing in the areas of visual spatial abilities, memory and executive functioning on April 18, 2022. It was felt that the patient was safe to be alone and did not have any cognitive impairments that would limit her return to work as long as her physical skills allowed that.

A follow-up office visit on June 6, 2022, noted continued spontaneous left upper extremity proximal to distal motor recovery along with improved trunk control with decrease ataxia on sit-to-stand transfers and ambulation. Occupational and physical therapy evaluation and treatment orders were placed to resume outpatient rehabilitation services.

Q: What is the latest update on the patient?

The patient is very motivated and has remarkable, inspirational willpower which has propelled her recovery. She has returned to her rebuilt home and is living with her husband and young child. She is modified independent in mobility from a wheelchair level in home, a powered wheelchair in community, and she is ambulating with a platform walker in home environment without assist.

Her self-care is modified independent in areas of feeding, grooming, dressing, bathing, toileting, toilet transfers, cooking complex meals using stove and oven, cleaning, grocery shopping from a power wheelchair level. The patient is independent with financial management and medication management.

With decreased truncal ataxia and continued therapies, the patient continues to make improvements in her mobility. She has started to ambulate using a narrow-base quad cane without AFOs with contact guard assist. She has active movement against gravity and resistance in her left upper extremity at shoulder, elbow and wrist. She is also demonstrating motor recovery in her hand and she is continuing to receive therapies.

As of late 2022, the patient is independently walking with a straight cane, driving her daughter to school, walking a half a mile on a track several days a week and continuing with therapies to work on improved function.