A fall into an industrial spice grinder led to multiple complex injuries for a 32-year-old patient, treated initially at an outside hospital and transferred to NYU Langone’s Rusk Rehabilitation.
Teamwork: A Patient with Medically Complex Injuries Regains Function
Trapped in the industrial grinder for an hour as firefighters and police officers extricated his left arm and right leg from the machine’s augur, the patient required a tourniquet at the scene, followed by an immediate amputation of the left forearm and a massive blood transfusion. The patient suffered a degloving injury of the perineal area, a comminuted fracture of the right tibia midshaft, and a deep posterior thigh–gluteal laceration. A left orchiectomy was performed immediately, and the right testicle was placed in a pocket in the thigh to preserve it in anticipation of further scrotal surgery. The patient’s left lower extremity was stabilized with an external fixator, and the laceration was closed.
Almost two weeks later, the patient underwent penile reconstruction with a split-thickness skin graft, followed two weeks later by exploration of the thigh wound, seroma drainage, and closer, with skin grafting to preserve the perineum. The penis and pelvic wound were regrafted 10 days later. Hyperbaric treatment was continued until the grafts closed and healed. At six weeks post-incident, the patient was admitted for acute inpatient rehabilitation care at Rusk Rehabilitation’s Comprehensive Integrated Inpatient Rehabilitation Program.
Clinical Expertise, Advanced Research, and Patient-Centered Care
An extensive multidisciplinary team, encompassing physical and occupational therapists, psychologists, vocational counselors, recreational therapists, and integrative health counselors, was assembled to address the patient’s multiple physical and psychological needs.
The goal of physical therapy was focused on strengthening his extremities and core, as well as improving his balance and gait. The occupational therapy plan of care focused on increasing upper extremity range of motion and strength, activities of daily living retraining, as well as education on desensitization exercises for his left elbow below the amputation site, and preparation for an upper extremity prosthesis.
To support the patient’s mental health, he received close psychological support to assist him in dealing with his difficult emotional experiences and to facilitate his coping with limb loss. He was introduced to a peer volunteer from the Amputee Coalition of America, who readily discussed his experiences, as well as the community resources available. Integrative Health Services at NYU Langone provided a treatment plan consisting of guided meditation, guided imagery, progressive muscle relaxation, and focused relaxation breathing. The patient was also monitored by the wound surgery team to provide recommendations on managing his multiple wounds.
To assist this patient in overcoming the many challenges associated with his injuries, he received a body-powered prosthesis for his left upper extremity, in addition to a myoelectric hand. Psychological counseling was initiated, and planning began for post-discharge reconstructive pelvic surgery. Social workers at NYU Langone coordinated follow-up care and the transition to outpatient therapy. Prosthetic specialists provided the training and education necessary to avoid post-operative complications, setting goals to move the patient toward greater independence and mobility. Overall, the patient received emotional support from a compassionate team, which helped him develop the coping skills necessary after loss of a limb.
A Team Approach to Pain Management
The patient faced ongoing challenges coping with his pain, which included acute pain in the right arm, groin, and right ankle, as well as phantom limb pain. To address those issues, multiple therapeutic modalities were introduced. Cognitive and behavioral therapies included relaxation exercises and imagery training. In addition, desensitization techniques and mirror therapy were used to decrease his phantom limb pain.
The patient readily acknowledged a history of substance abuse, and multiple rehabilitation hospitalizations without successful abstinence. However, he indicated that this accident made him take a step back and realize the “bad decisions” he had been making. He noted that “sometimes it takes a life-changing incident for you to re-evaluate your life.” Positive reinforcement was provided to him for his willingness to engage in outpatient substance abuse treatment and his agreement to return to active participation in Narcotics Anonymous. Continued close contact between Rusk Rehabilitation social workers and the patient’s Workers’ Compensation case worker, as well as the involvement of his supportive family, were instrumental in helping the patient ultimately achieve a successful abstinence from substance abuse.
A Smooth Transition to Outpatient Care and Return to Work
A month after admission, the patient was discharged from acute rehabilitation care and continues his recovery at outpatient rehabilitation. After a recent follow-up visit, Jeffrey M. Cohen, MD, professor in the Department of Rehabilitation Medicine and medical director of Medically Complex Rehabilitation Services at Rusk Rehabilitation, who oversaw the multidisciplinary team for this case, noted: “Psychologically and physiologically, he is doing well. He has returned to the work force.”
The patient continues psychological treatment twice monthly, and sees an addiction psychiatrist monthly for his history of substance abuse. In the months following the incident, he received targeted muscle reinnervation surgery to successfully control his neuroma pain. Pelvic reconstruction surgery has restored his sexual function to near normal.