FIG Services, Inc. P.O. Box 1161 Hendersonville, NC (828) Ph (828) Fx FIGservices.com. July 22, 2013

Transcription

1 FIG Services, Inc. P.O. Box 1161 Hendersonville, NC (828) Ph (828) Fx FIGservices.com July 22, 2013 Mr. & Mrs. Stuart Sharpe 6090 Millwick Drive Alpharetta, GA P E stu788@comcast.net Re: Hannah Danielle Sharpe (DOB: 05/14/96) Dear Stu & Sandy, Thank you for the opportunity to assist with your daughter's case. It is understood you are requesting that I address the cost of Hannah's future medical care as discussed in the provided medical records and phone conversation on 07/15/13. The cost of future medical care is focused on Hannah's medical condition following the 06/16/12 incident and residual deficits related to the full thickness burns. Details of Hannah s medical care/symptoms/functioning are deferred to the medical records and providers. On 06/16/12, Hannah was involved in a golf cart accident resulting in friction and chemical (leaking battery acid) burns. She was initially seen at Oconee Medical Center for emergency triage, and then referred to Joseph M. Still Burn Center (JMSBC) in Augusta, GA for specialized burn care. JMSBC physicians noted a fairly significant partial and full thickness friction burn to Hannah's right side, left knee, and left foot. There were also scattered burn areas which appeared to be partial and full thickness. JMSBC physicians estimated a 10% total body surface area (TBSA) with 8% being full thickness. On 06/17/12, Hannah was admitted to JMSBC for specialized burn care. Her condition was critical and life threatening without immediate medical intervention. Hannah underwent emergent burn wound excision and application of cadaver to her left foot (14 x 5 sq cm), left great toe (2 x 2 sq cm), left knee (6 x 7 sq cm), right leg (41 x 22 sq cm plus 5 x 4 sq cm plus 9 x 3 sq cm), right thigh (40 x 27 sq cm), right great toe (2 x 2 sq cm), right second toe (1 x 1 sq cm), right third toe (1 x 1 sq cm), right fourth toe (1 x 1 sq cm), right fifth toe (1 x 1 sq cm), right forearm (12 x 5 sq cm), right hand (4 x 3 sq cm), and right flank (20 x 15 sq cm); debridement and simple closure of left foot on dorsal aspect (2 cm); and debridement and simple closure of right foot and ankle area (6 cm). While hospitalized, Hannah required sedation with medication, diagnostic studies and lab work, cardiac and pulmonary monitoring, nutritional support, wound excision/debridement, skin grafting, wound care, dressing changes, intravenous/oral/topical medications, pain management, occupational therapy, physical therapy, psychological support, and specialty physician consultations. On 06/20/12, Hannah's medical condition stabilized to undergo further surgery (burn wound excision and application of cadaver to left leg (21 x 14 sq cm), left thigh (8 x 11 sq cm), and dressing change to right arm, right flank, and left leg (5-10% TBSA)). She was also discharged home to continue her recovery with physician follow up and anticipated re-admission for further surgery.

2 On 06/27/12, Hannah was re-admitted to JMSBC for continued specialized burn care. Initial diagnosis was 10% total body surface area (TBSA) of full thickness burn injuries to the both lower extremities including both feet, trunk/flank, and right upper extremity including hand. That same day, she underwent burn wound excision and split thickness skin grafting to both feet, both legs, right hand, right forearm, and right flank. Split thickness skin grafting measurements included: right foot (3 x 3 sq cm), right lower leg (32 x 18 sq cm plus 4 x 2 sq cm), right thigh (42 x 26 sq cm), left foot (13 x 5 sq cm), left great toe (3 x 3 sq cm), left knee (5 x 4 sq cm), right hand (4 x 2 sq cm), right forearm (13 x 5 sq cm plus 4 x 3 sq cm), and right flank (11 x 5 sq cm). Donor sites were taken from both of her thighs. On 07/02/12, Hannah underwent debridement and dressing changes to 10% TBSA (including both lower extremities, right arm, and flank) as well as staple removal under anesthesia. Hannah was then discharged home to continue her healing, recovery, and rehabilitation. Over the next several months, Hannah attended frequent follow up visits with the JMSBC team. Her care included specialty physician care, medications (prescription & over-the-counter), topical creams/ointments/ medications, dressing changes/wound care, interim wrappings, silicone gel sheets, scar cream, and customized compression garments. Hannah and her parents were educated on scar management (moisturizer, sunscreen, and scar massage). Unfortunately, Hannah has developed complications of hypertrophic scarring, keloid scarring, hyper vascular scarring, hyper-pigmented scarring, pruritic scarring, and fragile skin/breakdown/ulcerations (especially on the right forearm and left foot). JMSBC physicians noted a diagnosis of scar condition, fibrosis of skin, and late effect burn injury to lower extremities, right upper extremity, and right flank. Hannah underwent a series of Kenalog injections (1/14/13, 2/25/13, & 4/1/13) with minimal improvement of her scarring condition. She has also initiated laser treatment (05/03/13 & 07/25/13) for scarring to her legs and right hip. JMSBC physicians indicated this scarring was too excessive for reconstructive surgery and would require several sessions of laser treatment. On 07/19/13, Hannah underwent reconstructive surgery with scar excision to her right flank area and left foot. JMSBC physicians indicated additional reconstructive surgeries will be scheduled. Physicians have recommended continued scar management (moisturizer, sunscreen, scar massage, and limited sun exposure), climate controlled environment, and symptom management (Benadryl, Atarax, and Prudoxin medications). During a telephone conversation on 07/15/13, Hannah and her family shared chronic symptoms of itching, discomfort/ tightness in the scars, and self-consciousness of the disfigurement/scarring. While she has no functional limitations, Hannah restricts her activities due to being self-conscious of the scarring, unable to tolerate sun exposure and warm/hot temperature environments, and symptoms. Hannah can no longer wear shoes of choice. She wears supportive shoes that do not have straps or restriction across her feet. The anterior pressure on her feet is bothersome. She is able to wear a select style of sandals and flip-flops. Symptoms are brought on by the pressure and friction across the scarring. She no longer wears skirts or shorts exposing her legs. She has concerns of sun exposure as well as others viewing the disfigurement/ scarring. For example, Hannah wore blue jeans during the family vacation for two weeks. She also wore sweat pants and leggings during high school activities to avoid others seeing her disfigurement/scarring. Hannah has not shown her disfigurement/scarring to her closest friends. She avoids conversation surrounding the accident, medical care, and disfigurement/scarring. Her family has concerns of her emotional well-being given her behavior and extreme self-consciousness. Her family describes "up and down days" with Hannah's emotions and discussed resources (such as psychological counseling, burn support group, networking with burn survivors, and involvement with teenage girl burn survivors). Page 2 of 8 Hannah Sharpe prepared by Shelene Giles

3 Hannah is now a high school senior. This summer has been stressful with the environmental limitations and disfigurement/scarring. She has not gone to the pool, swimming, white water rafting, and sun bathing since the accident which was a favorite pastime with her girlfriends. She recently went to her high school prom in May which created unwarranted emotions surrounding the disfigurement/scarring. Hannah's activity limitations leave her behind causing sadness - when she should be enjoying life with her girlfriends. Hannah's future plans are to graduate from high school and attend college. Her specific major is uncertain. She planned on living on campus in the dormitories. However, Hannah now questions her college plans for fear of living in the dorm with others. She is extremely self-conscious and apprehensive of others seeing the disfigurement/scarring, especially when showering or dressing. Hannah's parents are concerned with this traumatic incident and residual disfigurement/scarring altering their daughter's pathway in life and her ability (self confident) to achieve her dreams. Hannah's parents expressed concerns of the reconstructive surgeries/procedures interfering with Hannah's high school activities and social setting. They also shared concerns of the long term disfigurement/scarring as well as ongoing medical management throughout Hannah's life. It is anticipated Hannah will have chronic symptoms and residual disabilities resulting from the burn accident. JMSBC physicians have recommended additional medical treatment and surgical interventions to improve Hannah's quality of life, functioning, and provide symptom management. The following narrative sections are recommendations to assist in Hannah's medical/psychological/rehabilitation needs: Medical Care Given the severity of Hannah's burns/scarring, ongoing symptoms, residual disability, recommendations of future surgery, and likelihood of complications/secondary diagnosis, it is anticipated she will continue life time treatment with specialty physicians. These specialties could include burn care, plastic surgery, and dermatology. Appointments have been recommended on a periodic basis for reassessment, treatment recommendations, prescription refills, and early identification of complications/secondary diagnosis. Reconstructive Surgeries/Procedures Physicians have noted complications of hypertrophic scarring, keloid scarring, hyper vascular scarring, hyperpigmented scarring, pruritic scarring, fragile skin/breakdown/ulcerations, and fibrosis of skin. Reconstructive surgeries and laser procedures have recommended to reduce these complications. Costs of the surgeries and procedures are considered in the following tables. These costs include physician/anesthesia/hospital charges as well as associated costs. Associated costs will likely include preoperative clearance (appointment, lab work, and diagnostic studies), physician follow-up, postoperative diagnostic studies, postoperative lab work, home health assistance, physical therapy, occupational therapy, medications, ointments/creams, compression garments, medical supplies for dressing changes, and mileage reimbursement. Therapeutic Modalities Hannah's emotional well being is crucial to her recovery/rehabilitation of future medical treatment. Hannah will likely continue to experience psychological symptoms and exacerbations related to the burn accident. For these reasons, a psychological intervention is recommended to address these chronic symptoms and lifestyle changes. These counseling sessions will focus on coping with disfigurement/changes in body image, identify behaviors and problem solving during an exacerbation of symptoms, addressing altered lifestyle related to the burns/scarring, addressing physiological changes, adjustments to physiological changes, chronic symptoms, extensive and life-long medical treatment, and anticipated complications. Page 3 of 8 Hannah Sharpe prepared by Shelene Giles

4 Medications JMSBC physicians have recommended medications (prescription and over-the-counter) for symptom management. It is understandable Hannah will likely have symptoms on a long term basis, and will likely experience a flare-up/exacerbation of symptoms in the future. It is anticipated these prescription and overthe-counter medications, or similar medications, will likely be recommended/received over the years. When Hannah receives cuts/scraps over the burn/graft scars, these areas will take longer to heal due to the compromised skin. For these reasons, antibiotic ointments (prescription and over-the-counter) are recommended to assist with the healing process and prevent infection. Also, Hannah's ability to produce vitamin D from the sun is limited due to the hypertrophic scarring. A supplement is recommended to prevent complications related to vitamin D deficiency. Scar Management Hannah suffered 2 nd and 3 rd degree burns to 10% TBSA. These burns required surgical procedures to provide wound excision/debridement and skin grafting. Due to the severity of burns, Hannah developed significant scarring. Medical research indicates the necessity of long term skin protection and scar management. Presently, Hannah uses a sunscreen and moisturizer on a regular basis. Skin protection should include daily use of sunscreen, lubricants/moisturizer, and scar massage. There are certain lotions and sunscreens (ex., Elta, Lubriderm) which are preferred by other burn patients. Also, standard band-aids can cause blistering/irritation when applied to the scars/skin grafts. Alternative bandages (ex., Mepilex) which are designed for sensitive/compromised skin have been recommended. Given the severity of Hannah's burns/scarring, protective clothing is recommended for protection against sun exposure and assistance with temperature regulation. Due to impaired body temperature control, it is necessary that Hannah have air conditioning in her automobile and home. Other A Nurse Case Manager is recommended to assist in coordinating Hannah's medical care and associated services during the reconstructive surgeries, especially during her high school and college years. A Nurse Case Manager has experience in coordinating medical treatment among multiple providers, educating Hannah regarding her medical care, and assessing for complications. Complications JMSBC and this Nurse Life Care Planner s further medical research have yielded the following complications resulting from Hannah's severe burns: hypertrophic scarring, pigmentation changes, altered sensations, tenderness at burn/graft sites, heat/cold intolerance, at higher risk for sunburn, at higher risk for skin cancer (Basal cell carcinoma), allergic reactions/sensitivity to products (soap, laundry detergent, lubricants, perfumes, etc.), at higher risk for infection with future surgeries, at risk for injury to skin grafts/donor sites, unstable scarring leading to future graft revisions, psychological factors related to disfigurement/psychosocial aspects, continued psychological diagnoses (anxiety, depression, adjustment disorder, acute stress disorder, and post traumatic stress disorder), epidermal inclusion cysts, Marjolin s ulcers, and educational/vocational barriers related to visible differences and medical condition. Recommendations have been provided to help prevent/lessen these complications. Page 4 of 8 Hannah Sharpe prepared by Shelene Giles

5 Costs associated with these recommendations are presented in the attached tables. These costs are based on usual/customary charges in today s dollars at the 70-80th%ile of usual/customary & reasonable charges. The National Vital Statistics Report, Vol. 61, No. 3, September 24, 2012, Table 1 yields an average life expectancy of a 17 year old to be 61.9 additional years. Therefore, a life expectancy of 61 additional years was used in determining frequency and cost of Hannah's future medical and non-medical needs related to the burn accident dated 06/16/12. Thank you for the opportunity to assist with Hannah's case. Shelene Giles, MS, BSN, BA, RN, CRC, CNLCP, CLCP, MSCC, LNCC Nurse Life Care Planner Page 5 of 8 Hannah Sharpe prepared by Shelene Giles

6 RECOMMENDATIONS DURATION FREQUENCY COST FREQ TOTAL MEDICAL CARE Visits, JMSBC (allow 10 visits over next 12 months) Allow for 10 $ $1, Specialty consults (burn care, plastic surgery, dermatology) (allow for 25 visits over life expectancy) Allow for 25 $ $4, RECONSTRUCTIVE SURGERIES/PROCEDURES Reconstructive surgeries (allow for 3 over next 18 months) Reconstructive surgeries (allow for 3 in later years) Laser procedures (allow for 5 treatments per body part - upper leg, lower leg, & feet) Allow for 3 $35, $105, Allow for 3 $35, $105, Allow for 5 $21, $106, THERAPEUTIC MODALITIES Psychological counseling Allow for 20 sessions $ $3, MEDICATIONS Over the counter anti-itching relief (oral & topical) (ex - Benadryl, Claritin) Allowance every 6 months $ $3,

7 RECOMMENDATIONS DURATION FREQUENCY COST FREQ TOTAL Prescription anti-itching relief (oral & topical) (ex - Atarax, Prudoxin) Allowance every 6 months $ $9, Over the counter antibiotic ointment Allowance every 6 months $ $3, Prescription Bactroban ointment Allowance every 6 months $ $9, Vitamin D Allowance every 6 months $ $1, SCAR MANAGEMENT Moisturizer Every 6 months $ $2, Sunscreen Every 6 months $ $2, UV protectant clothing Yearly allowance $ $30, Thermo regulated clothing/accessories Yearly allowance $ $15, Scar massage Allow 20 sessions $ $2, OTHER Mileage to/from medical appointment Ongoing $0.24 3,500 $

8 RECOMMENDATIONS DURATION FREQUENCY COST FREQ TOTAL Burn support group Ongoing $ $0.00 Angel Faces retreat Once $7, $7, Case manager Allow 50 hours $ $3, TOTAL $416,