Introduction
Approximately 22.6 million patients per year suffer from various neurological disorders or injuries requiring interventions. 1 Neurosurgical conditions have high challenges and sequalae thereby increasing the risk of associated damage and poor quality of life 2 with one-third of ICU admissions having a risk of poor outcome and long term disability. 3 In a country like ours, large number of patients are admitted to government hospital emergency settings without the provision of any personal, familial or any other details under the name of Unknown. Their names remain the same until a proper and validated identity gets established either during or after treatment making it a tough call for the clinician under the legal, ethical, and financial aspects. With the little information provided, they are referred to the Psychiatric Social Work (PSW) Team for the further information collection, reintegration with the family or rehabilitation of the patient in the community. With this background, we present two cases of unknown cases admitted in the Neurosurgery Emergency Services in a tertiary care centre in South India during January 2019 (Pre-COVID) and March, 2020 (during COVID) referred to PSW Team for psychosocial interventions.
Case Vignettes
Case 1
Mr. J, 50 years old, married man, illiterate, from rural domicile, lower socio-economic status, working as a daily wage laborer in marriage tent business with the owner and the family in different states with regular daily up-down travel. He was found on the road by police authorities of nearby police station and was admitted as Unknown on 5th January 2019 at Neurosurgery Emergency services with a written consent by the police authorities and the medical superintendent. The patient being a case of Traumatic Brain Injury underwent immediate surgical intervention and was referred post 1 week of care to the PSW Team. With the referral note, the team constantly engaged the patient in the sessions to get the socio-demographic details with the possibility of reintegrating the patient. Post 4 days of constant collection and validation of details- the name, place of work, family constellation, domicile, and details of employer was collected. Though the contact numbers provided by the patient were not valid, the details of the employer turned out to be valid.
After three weeks, with the information gathered, the police authorities of the town were contacted, and the details of the patient and his family were also given with the requested of verification of the same. Within 3 days, the family members were identified who then came to the hospital and took the patient with them. Prior to discharge, the details of the injury and a thorough pre-discharge counseling, Psychoeducation, Treatment adherence and importance of follow-up was explained to the family members. And as the case already had been recommended by the PSW Team for the waiver off post the income assessment, the patient did not have to pay the hospital treatment charges with the caregiver being informed the fact to bring the income certificate in the next follow-up date for the welfare benefits.
Case 2
Mr. S, a 35 years old, unmarried male, educated up to 10th standard, working at metro station as swachatha worker on contract basis from urban domicile, belonging to lower socio-economic status, was admitted in March 2020 to the male neurosurgical ward by the medical team with complaints of severe headache, vomiting, seizure, and weakness in lower and upper limbs. Post the surgery, the family members were not to be found in the hospital premises. The PSW team was referred the case for contacting and tracing the family members.
The team tried to do an initial assessment but due to the cognitive deficits and speech difficulties of the patient, assessment and detailed session could not be done thereby leaving the team with nil details. On the other hand, contact number of the patient’s brother written in the hospital file was found to be futile with no response. To explore further, details of the neighbor who had accompanied the patient’s caregiver during admission were collected. COVID-period made home visits difficult, hence police intimation through the Resident Medical Officer was sent. A complaint in the nearest police station was filed regarding the unknown making police visit his house. But it was found locked with neighbors stating that family hasn’t been staying here for months. Parallelly, the PSW team was trying to contact the brother but had no response.
The team then made a home visit to the patient’s house where he was staying before the incident where his occupation as a daily wager in a metro station was understood. Though network with colleagues and distant relatives was established, due to pandemic they refused to provide support.
Back in the hospital, the team waited for patient’s recovery. After a week, home visit was made to another brother’s house to discuss regarding the unknown, who though agreed first, didn’t come to take him.
In repeated discussion with the larger team, it was a decided to seek police help for the reintegration. Post a week with the Sub-Inspector, the patient was reintegrated successfully post 5 months.
Discussion
The cases conceptualized from Ecological Model4 focused on assessing available resources and integrating the same through Social Diagnosis.5 There are many points to consider, the police authorities being proactive helping in faster management; the tertiary care center having a standard operating procedure helping in care management and the public though being afraid, trying to cooperate.6
It is important to note that unknown cases with neurosurgical complications have difficulty in memory, speech, and mobility making it difficult to comprehend, remember or stay conscious affecting the therapeutic rapport. PSW Interventions involve contact tracing, community resource utilization, coordination with departments, liasoning with the police, and family education to ensure care management, treatment adherence and regular follow-up.
Conclusion
There is a need for established multidisciplinary team with structured guidelines and better cooperation from micro, meso and macro levels to ensure better care and management of unknown cases, which could also incorporate the DAMA and LAMA situations.7 Psychiatric Social workers working from a Rights-Based Approach8 help in ensuring care and quality of life for them by amending their status from unknown to known.
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