Hassan Moinzadeh, MD, Medical Director, Paradigm Catastrophic Care Management Steven Moskowitz, MD, Senior Medical Director, Paradigm Catastrophic Care Management

One of the most challenging parts of treating a catastrophic injury is helping injured workers adjust to major physical and emotional changes. How can they overcome the trauma, continue to be productive, and integrate back into their family and community to lead a full life?

It takes on average, about 18 months for a person to incorporate the bodily changes involved in a catastrophic injury. Even a healthy person who has limited psychosocial history coming into the accident is going to be having a hard time in those first 18 months.

Oftentimes, if you listen to the dreams they have, they will see themselves as walking or using their hands, and they then wake up and they realize they can’t and it’s a recurrent grief and mourning and anger and bargaining related to the process of having had a catastrophic injury.

So, it’s important to recognize that it takes a long period of time for a person to really come to terms with what it means to actually be a different person at the end of an injury than they were before. The only way is to really just ride through the difference and see who they become rather than just grieve and be nostalgic about the person they were, and the losses they’ve had.

In a biomedical approach, you are looking for a cure or a diagnosis that then you can treat: If you stubbed your toe and you have an infection and then you go the doctor and they take a look at it and maybe they culture it and they say, “Yep, it’s infected. You have cellulitis.” And they give you antibiotics and then you’re fine.

But we also forget that if you go back to the 19th century, most doctors were going to go see the patients in their homes. They actually were seeing the psychosocial elements as part of their diagnostic evaluation. And it’s only as we’ve become more and more specialized that this piece of treatment has gone away. So we don’t get access to information about their lifestyles and families and spiritual beliefs.

In the biopsychosocial model, you look at the symptoms not only in terms of the medical challenges that you might have to deal with, but also in terms of how a symptom might serve a combination of things coming together including a person’s beliefs, their fears, self-limitations, behaviors, various secondary gains and losses.

Early life experiences also lead to a series of beliefs, some of which are actually somatic beliefs, meaning that they are held not as conscious memories but as implicit memories occurring before the age of six. You can see how these beliefs can play out in a catastrophic injury. Does the injured worker believe

• they can be taken care of?
• things are going to turn out all right?
• they deserve to have success or not?
• the world is a dangerous place and it’s best not to trust people?

A person who is, for example, going to be released back to work and they’re doing so well and all of a sudden they start to regress and they start to get worse and you wonder, “Well what happened, they were just doing such a wonderful job.” And then you start to realize, that perhaps there’s an enormous anxiety about that sense of independence, that they haven’t actually come to terms with.

A few things that everyone involved with an injured worker can do:

• Remember that the injured worker is a whole person beyond their injury. Recognize and address their biopsychosocial recovery.
• Humanize the communication. A lot of worker’s comp is very technical, appointment setting up, benefits, but just remembering there is somebody who might have trouble coping on the other end.
• Assist with processes that to us are pretty rote and very simple, but may not be so simple for them.
• Clarify the expectations back and forth.
• Harmonize contradictory messages. There are so many contradictory messages in the healthcare system. Just be attuned to signals that they’re getting mixed messages or an unclear message.

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