Walking into the conference room, Joe waited until Roy and Joanne were seated before handing his notes off to Dr. Druthers.
"I need to make a quick call down to the rehab department so that someone can be here to help us figure out a basic plan. I'd also like to check on something at the nurse's desk," he let them know. "It shouldn't be too long."
Nodding, the DeSoto's sat back as Karl began reading over Dr. Early's evaluation notes and Joe left. Upon reaching the desk, as he picked up the phone and began dialing, Nurse Fitz handed Dr. Early the latest blood work results. Scanning them over as the phone began to ring, Joe smiled slightly.
"Rampart Rehabilitation Services, Jacob Landers speaking," was the greeting as the phone was answered.
"Hi, Jacob. This is Joe Early. I just completed the first evaluation on John Gage. I was hoping that you still had the time to come up to the ICU to listen over the evaluation and help us formulate a plan."
"Sure, give me a couple minutes to let someone know where I'll be and get up there," Jacob agreed.
"Thanks," Dr. Early said. "We'll be in Conference Room B. I just need to get some new medication orders filled out for John, so by the time I'm done, I should be there as well."
"Alright, I'll meet you there," Jacob acknowledged as he hung up.
Hanging up as well, Joe looked over the electrolyte levels once again. Sighing in relief at what he found, he looked around for John's day nurse.
Spotting her waiting nearby, he asked, "Maggie?"
"Yes, doctor?"
"Could you please set up an IV solution of dextrose 5% solution over three hours? I'd like his blood work repeated after every hour," Dr. Early ordered. "Also, reduce the Carbamazepine medication in half. Keep a close eye out just in case the seizures start up again, though I don't expect they will.."
Writing down the instructions, Nurse Fitz gave the chart to Joe to sign.
"I'll make sure of that personally."
"Thanks," Joe smiled at her and after adding his signature, went to meet Jacob who had been waiting by the conference room.
Entering first, Joe introduced the individual who had come in with him.
"This is Jacob Landers. He is one of the coordinators of the rehab services here. Jacob works with patients to find the right therapists and also is involved with helping out the therapists themselves when needed," Dr. Early explained.
A bit shocked as the man barely stood 5'5" and seemed even skinnier than Johnny was now, Roy tried swallowing his misgivings as he stood to greet him.
"Hi, I'm Roy," he said. "And this is my wife Joanne."
"Please, call me Jo," she said pleasantly, also a bit shocked. "It's nice to meet you."
Laughing a bit as they sat down, Jacob smiled at them.
"I know I don't look like I can handle adult patients, but I find my height actually has worked for me if patients are scared easily."
"That's why I thought Jacob might actually be one of the best coordinators and assistants to work with Johnny," Dr. Early explained. "With his mindset, we aren't sure if someone who is larger and who has more muscles that he could actually see would scare him. If Johnny was too scared around the therapist, then progress would be slow at best."
Nodding, Roy took Jo's hand and asked, "So, than what exactly is the plan? It sounds as though you have somewhat of an idea already."
"Yes and no," Joe replied. "I already know that John will benefit from having a physical and occupational therapist, possibly a speech therapist as well. That is why Jacob is here. He can better determine if a speech therapist is needed once I explain the results of the neuro exam. Jacob can also start planning on which therapists will work well with Johnny and what they will likely need to work on. It may very well change, but having an outline of a plan in place will be helpful. That way, when John is ready to begin rehab, we won't be left scrambling."
"The sooner we can begin helping him relearn skills, the better chance he has at relearning and recovering better," Jacob explained to them. "I'm glad that you and your family have begun seeing Dr. Druthers, as that will help a lot in this process. I do have to warn you, this is not going to be an easy road, nor a short road."
"I think we both realize that," Jo said as she looked towards Roy.
"I can vouch that the kids realize that things are different," Karl said. "Even though I haven't talked with them much, I know that even though they don't fully grasp what is happening, Chris and Jenny are willing to try because to them, Johnny has always been family."
"That's great!" Jacob said. "John is going to need a lot of support. But first, I need to know what you found through your first exam Dr. Early."
Sliding Joe's notes towards him, Dr. Early nodded in Karl's direction.
"Why don't I begin with some good news first?" seeing the hopeful looking on Roy and Joanne's faces, he smiled as well. "The EEG results have yet to show another seizure, which is a positive sign in and of itself in my opinion. What I found the most encouraging, however was that John's magnesium level was very low. That can actually cause seizures."
"But then, why didn't this show up sooner?" Roy interrupted.
"With a head injury, especially one this severe, electrolytes are affected and it can sometimes take a while to happen. We will have to keep a close eye on his electrolytes until his brain heals," Joe cautioned. "But, this should be correctable. I've just started Johnny on an IV solution of dextrose 5% solution that'll be given over three hours. We'll complete blood work every hour and if his magnesium levels are stabilizing after three hours, I'll put Johnny on what is called a maintenance dose. I did cut the Carbamazepine that I had initially put him on in case he was experiencing seizures due to the head injury. I am very hopeful that once his electrolytes are finally balanced, he can be taken off of that."
"So, why did you reduce that medication now?" Joanne asked.
"With everything going on, I don't want to risk using unneeded medications that may be needed later. John's body could develop a tolerance or an allergy-like response to medications that are used unnecessarily," seeing the worry on both Roy and Jo's faces, Joe held up a hand before either could speak. "I don't think that Johnny will have problems with seizures in the future, but there is still a small chance it could happen. Based on past research, it seems that during the first year is when it could possibly could happen and even then, the chance is very small."
Sighing, Roy took a minute to go over everything they had been told so far.
"So basically, we just need to wait until his magnesium levels are stabilized and hopefully, that will end the seizures?"
"Yes," Joe assured him. "I honestly don't know how long he will need to be on magnesium, but quite honestly, it is a fairly easy fix and something that is easy to watch for. At worst, he may end up taking a pill form of it for a long time."
"Well, that's not so bad," Jo said, relief evident in her voice.
"No, not at all," Joe smiled slightly. "Are you two ready to go on and hear about what I found in the exam?"
Glancing at one another, Jo and Roy again reached for one another.
"I think so," Roy said, with a tremor in his voice.
"Might as well," Jo said, breathing deeply.
"I'm sure you two are both aware that Johnny is having memory problems," Joe stated to Roy and Joanne. "It could be that because he is still medicated fairly heavily or due to the brain swelling that he is having trouble with recalling simple information from a short time ago. Quite honestly however, I have to question if that is the case since Johnny also has a hard time identifying objects that any seven year old should. He also couldn't figure out how to put the three picture story together. That, though, I wonder about if it is simply a case of not knowing how to tying his shoes or if it is a cultural problem."
"What do you mean by that?" Jo asked, her voice laced with confusion.
"One thing Roy does know about John's childhood is that he grew up on a reservation," Dr. Druthers explained. "It could be possible that due to economical factor or the fact his parents preferred to carry on the tradition of their heritage so that what we think of as normal shoes weren't worn."
"So, he wouldn't recognize shoes, or even if he did, he wouldn't necessarily know how to tie them?" Joanne asked in amazement.
"You have to remember, he grew up in the 1950's. It may have been quite common where he grew up," Karl said.
Shaking her head, Joanne couldn't believe her ears.
If that is the case, I wonder what else Johnny has never heard of or knows about, she wondered. Does he even know about the things we take for granted today?
Roy must have been thinking along those same lines, as he voiced out loud, "We really have got to figure out what it was like for him growing up. I mean, we have no clue what is normal for him and things we think nothing of might overwhelm him."
"That's why I'm here," Dr. Druthers said. "Hopefully, we can help Johnny feel more at ease in a foreign world with people who he doesn't know. As I've said before, it wouldn't be easy."
"It doesn't matter," Jo declared. "As long as our kids are on board, so are we. Right, Hun?"
"Right," Roy agreed. "So, besides the memory issues, what else is going on doc?"
Moving on, Joe explained that the reason he had Johnny drawing simple shapes was to test not only his memory, but also his coordination and muscle tone.
"Unfortunately, as you can see by these drawings," he said pulling them out. "John had a very difficult time with figuring out how to move his hand and his muscle tone."
"How did you figure out the muscle tone from that?" Roy asked.
"And what is muscle tone?" Jo wanted to know.
"Muscle tone helps a person control their body. Basically, it is the little muscle movements that make up the whole. The fact that John's hands were loose and floppy like while doing so indicates that his muscle tone is lower than before the accident. Also, his coordination, or ability to do a task such as holding the paper while holding the paper and drawing the shape, was obviously affected. By observing him, I saw Johnny struggling to hold the pencil and the paper at the same time frequently."
"Anything else?" Roy sighed, wondering what else could have gone wrong.
Hating to go on, but knowing the couple needed all the information, Dr. Early sadly told him, "Yes. I am not sure if you and Jo noticed, but Johnny has been having some trouble with his speech. He is having difficultly processing what is said to him and it takes him longer than it should. Also, John stutters a bit and stumbles on his words.
"Lastly," taking a deep breath, Joe let it out. "I find when I check his reflexes and grip, it is nowhere near where it should be. They are both slow and weak. Again, all this could be partly due to the medications, but I have a feeling a lot of it is due to the damage his brain has suffered. You have to remember however, it hasn't been that long since the injury and there is hope that Johnny can at least have some recovery, if not a full recovery. We just don't know at this point."
"That is why I am here now," Jacob interjected. "The sooner we can start on therapy, the better the chance of a more meaningful recovery."
"And you can't tell us what a meaningful recovery will be?" Jo asked, already knowing the answer.
"No, I'm sorry," Jacob said. "Usually it takes a year or so before we know for sure how much a person is able to recover from a head injury. But like I said, the sooner we get started, the better."
"So, where do we begin?" Roy asked.
"Well, first of all, I will take my notes and find a physical therapist, occupation therapist, and a speech therapist. They will each conduct their own evaluation once Johnny is out of the ICU and in the Neuro step-down unit. That will probably be taking place in, what? Twelve more days?" he asked, looking towards Joe for the answer.
"About nine actually, it depends on how well he is doing," Dr. Early acknowledged.
Continuing to explain, Jacob told them, "After each of them finish their evaluations, I will get together will all three of them and together, along with Dr. Early, will work out a plan tailored to John. Once we have that sorted out, we will let you know what is involved in the plan. We will be starting slowly at first of course, taking into account John's other injuries. As they heal, the therapists and I will add in more. I don't believe that John will need speech therapy for long, maybe a month or so at the most. The physical therapist will have to concentrate on his upper body until his cast is removed in five weeks. After that, I'd like to get him into the pool as it will help him with a wide range of things, from muscle strength to coordination to balance to physical strength. Plus, I find a lot of patients, especially the younger ones, find the pool soothing."
"Wow," Jo said impressed. "You sound as if you have a fairly good idea what to do already."
"Somewhat," Jacob acknowledged. "It could change over the course of the next nine to twelve days, or after the main evaluations, but this will at least give us a starting point. I will send up a physical therapist to start working on moving Johns limbs when he is moved down to the step-down unit."
"Thanks," Roy said, shaking his hand.
"No problem. If there isn't anything else, I'll go and get started on looking for people," Jacob said standing.
Also standing, the remaining four shook their heads no.
"Again, thank you so much," Jo said gratefully. "We can't tell you how much we appreciate it."
"I've heard wonderful things about John, so it's really my pleasure," Jacob admitted as he left.
Before Jo or Roy could say anything else, he had exited the room, leaving them stunned that once again, Johnny's kindness was so well known.
Clearing his throat, Karl began, "Well, I know you two are probably anxious to check on Johnny, but if you don't mind, I'd like to tell you and Dr. Early what I observed during the last part of the exam."
Seeing them both nod, he continued, "I noticed that John was experiencing mood swings, and I also saw that Dr. Early noted that down as well. Mood swings are actually not unusual after a head injury and is something we will all keep an eye on. I will be the main one who will do so. If they continue to fluctuate after a few weeks, I can always prescribe a mild anti-anxiety and anti-depressant medication for him. However, I'd prefer to try to work with him to manage his moods. I do want you to realize though, that I may need to add a medication on for a short while until things even out and I can help Johnny work through his emotions, help him balance himself out without medication."
"Yeah, I noticed that," Roy admitted. "I mean, he's also been, I don't know, hyper and then kind of crashes, but this is a lot different."
"One thing I did notice that is positive is that even though John says he isn't sure of you two, when upset, frustrated, or is dealing with any strong emotion really," Karl told them. "I found that he leaned towards you both, especially you Roy. John seemed to look towards you for help and guidance, almost as if he knew you would protect him and sort out the confusion for him. That is an excellent sign. It means that subconsciously, he does trust you even if he doesn't know you."
Smiling, Jo nudged her shoulder into her husband, "I've always thought those two were brothers in a past life."
"Yeah, yeah," Roy mumbled as he blushed.
Laughing along with Joe, Karl said, "Whatever bond it is, I'm glad it's there. It's also there with you too Joanne, although not as strong. Just keep being there for him. When he's awake, tell him about yourselves, about your kids, family, life, anything and everything you can think of. He may not remember it the next day and you likely will have to repeat it again, but that's okay. Ask him questions, but if he doesn't answer, just move on. I think if you guys do that, it will help him out."
"Thanks," Roy and Jo answered together.
"Do you two have any questions?" Dr. Early asked, seeing that Karl was finished.
"No, I don't think so," Jo said slowly as she looked at her husband.
"No, thank you guys, this has helped a lot," Roy acknowledged.
"You're welcome," Joe said. "I'll follow you back to Johnny's room. I'd like to check on him myself."
"Same here," Karl agreed.
With that, the four of them made their way to John's cubicle to find him still resting peacefully.