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Orientation and Awareness

July 20, 2016

Orientation and Awareness

Basic Implications for Independence and Brain Injury Rehabilitation

I

“More line!”

I was humping hose as fast as I could, but – don’t let anybody tell you different – it’s pretty hard to bend those charged 1 ¾ inch hose lengths into loops,  once you’ve done three of them. And your partner is waiting for you to finish, and join him at the bottom of the basement steps. And you’re there to fight a basement fire.

“How deep are you, Jim?,” I called down, my voice muffled by my SCBA mask.

Maybe he had advanced a little beyond the steps and run out of slack. No answer.

I called out again, and received no reply, so I kept making my loops.

“Joe! Feed me more hose!,” I yelled to our man outside.

Shouting uses precious air, and the smoke made it impossible for me to read the gauge on my shoulder strap in order to see just how much air (and time) I had left.

As more light broke through the door behind me and another section of hose came through, a bit of the smoke dissipated, a cool breeze followed, and I realized that there were two loops done, lying there in front of me against the wall. Not three. Had I miscounted?

Had I made two loops, or had Jimmy dragged one of the three into the basement with him, leaving two behind?

“More line!,” cried the muffled voice from the darkness below. “I need more line!”

If he was at the bottom step, he should be able to assume a defensive position there if necessary, or haul tail back up to me if conditions at basement-level were completely unbearable. I called out, yet again, in an effort to figure out what was going on. Nothing.

My heart was pounding, my breathing labored. The hose was heavy, it was twisted. There was some intermittent light, but the sweat got into my eyes.

I stopped making loops amidst his renewed shouting, and shoveled what hose I had down into the darkness.

“Here it comes, Jim!”

His shouting continued, and I kept pushing hose – this time, just as soon as it came to me through the door. Then there came a tug on the line. He couldn’t have used up all the slack so quickly! Was there a kink in the hose? Had it turned around on itself? Was he pulling on the line as a reference point, trying to find his way out of the building? I needed to get down into that basement ASAP and figure out what was going on!

As I turned around and reached for a length of hose to guide myself down the steps, feet-first, a sudden jerk on the line pulled the hose and me down into the blackness…

II

“When are we eating?”

“We just had breakfast, sir.”

“No, we didn’t,” insisted the elderly gentleman to his nurse, glaring at her, suspiciously.

If he had been still seated in the dining room, it might have been a bigger issue but, as the food carts with their empty trays had just been rolled out of sight and down the hall, and the other patients were continuing with their post-breakfast morning routines, the exchange didn’t escalate any further.

“Where am I going next?”

“To class, ma’am – straight down the hall; see where everybody’s waiting in line by the door?”

“Yeah. I see. That’s where I need to go? Are you sure? You came out with that answer pretty quick!”

Her snappy, humorous tone concealed the realization that, till she saw it for herself, she did not remember where to go – even though she attended the same class at the same time and location every day.

“Yup. Go ahead, and have a good time!”

“Where’s the elevator?,” asked the lanky, middle-aged man, supporting himself on his rollator, in a low tone.

“See those doors at the end of the hall?”

He turned slowly. “Yeah.”

“Go through those doors and make a left. Then go straight ahead until you see the elevator on your right-hand side… Where are you headed?”

“I’m going to get my car in the parking lot. I want to go home.”

“Do you know where you are?”

“No.”

“You’ve suffered a brain injury. You are at a brain injury rehabilitation center, trying to get better.”

“No, I’m not. I need to find my car and go home.”

III

Orientation is a pretty big deal. We take for granted that our peers know who they are, where they are, how they got there, and what day and time it is. When I know and appreciate the answers to these basic questions about myself and my real-world setting, I can say that I am fully oriented. When each party involved in an interaction shares this quality of being oriented, we can proceed with meaningful and productive communication.  We are, as we say, “on the same page.” Yet, the same cannot be taken for granted when we interact with patients who are recovering from brain injury – a population for whom meaningful and productive communication plays a key role in the rehabilitation process.

First arriving EMS units in the field will assess the orientation of the conscious or semi-conscious patient (someone with anything but, “U” on the AVPU Scale). By means of on-going interaction during on-scene assessments and on the rig during transport, he or she will be continuously monitored for perceptible changes to that baseline determination. See where meaningful and productive communication fits into the Continuum of Care right from the get-go? That same type of back and forth exchange between the conscious patient and professionals can be employed in both acute and sub-acute stages of the rehabilitation process. Armed with knowledge of the patient’s baseline level of orientation, such on-going cognitive triage can almost become second nature in the professional setting.

If we can say that we are oriented, we may then start to access our environment – becoming more aware of who and what is around us – more effectively.  I can find myself within my environment and appreciate myself in a world of other people who are trying to do the very same thing. Ordinarily, I do that without knowing it. It is, more or less, my responsibility, and I make it through my days with varying rates of success and accomplishment. The same cannot always be expected of the brain-injured patient.

However well the brain-injured person’s memory serves to help him or her perform tasks, proprioceptive awareness – that awareness of the self, one’s body and its functions moving about in the time and space around them – needs to be monitored for change by professionals and loved ones alike. A good indication of solid proprioceptive awareness might be one’s ability to make sound observations about his or her own condition. How am I feeling? What do I need or want? What is wrong and what might make it better?  Can you hand that remote control over there?… I can’t reach it from my wheelchair. Meaningful and productive communication makes its appearance, yet again!

As it turns out, Jimmy managed to shelter himself in a part of the basement just beyond the bottom of the stairs. In the absence of a smoke condition and in the daylight, I would have easily seen him from my position on the landing above him, near the door. Anyway, as Jimmy felt things heat up down there, he lost track of time. He figured that the first phase of our operation – making those loops of extra hose – was taking longer than it actually was; maybe we’d run out of air before we put the fire out! So, he decided that he needed to help me and speed things along by pulling more hose down to basement level on his own. That happened to be just when I grabbed the hose and started to follow it down to his location. So… down I went, alright! Down I fell, that is.

It was necessary, once we found each other in the basement, that Jimmy and I become reoriented – and quickly. Thus reoriented, awareness of our position in the evolving fire environment was a must. It was at that point that we were able to proceed, making the best of a bad situation and get the job done.

It is just as necessary that our brain-injured patients be oriented and re-oriented as soon as possible, and as often as needed. Oriented correctly to reality, communication with loved ones and with professionals providing care becomes a more positive and beneficial experience all around. Exposure to the environment becomes less fear-inducing and an opportunity for greater freedom.

Awareness, as it develops within the injured brain, can be used to better effect by the rightly-oriented person.   Pre-morbid tools like one’s memories and relationships, one’s personal and professional skill sets, along with post-morbid tools like one’s means of mobility,  brain injury education, therapeutic modalities, recreation activities and the like can be more fully accessible to a mind that is ready and willing and able to use them. Utilizing them, more effective and diversified compensatory strategies can be developed. These represent more tools in the patient’s toolbox. Ultimately, functional gains are more likely to be made and sustained by the patient who is oriented and aware, on route to the ultimate goal:

Get better.  Move on. Achieve the highest degree of independence possible.

Lacking full orientation and awareness, unable to benefit from meaningful and productive  communication, the patient with the injured brain may become, at best, a spectator at his or her own life’s contest or, at worst, trapped in the basement with no means of success or escape.

 

 

Mark W. Ingoglio, BA, FF-II/EMT-B, CBIS

 

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