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Medical Aspects of Lightning

 

How Big A Problem Is This? Statistics

Lightning has been the second largest storm killer in the U.S. for the last 40 years, exceeded only by floods. A lightning strike can result in a cardiac arrest (heart stopping) at the time of the injury, although some victims may appear to have a delayed death a few days later if they are resuscitated but have suffered irreversible brain damage.

According to Storm Data, a National Weather Service publication, the U.S. averages 73 reported lightning fatalities per year. Due to under reporting, the figures are more realistically about 100 deaths per year. Only about 10% of people who are struck by lightning are killed, leaving 90% with various degrees of disability.

ODDS OF BECOMING A LIGHTNING VICTIM
U.S. 2000 Census population 280,000,000
Odds of being struck by lightning in a given year
(reported deaths + injuries)
1/700,000
Odds of being struck by lightning in a given year
(estimated total deaths + injuries)
1/240,000
Odds of being struck in your lifetime (Est. 80 years) 1/3000
Odds you will be affected by someone being struck
(Ten people affected for every one struck)
1/300

 

 

 

 

 

 

Who Gets Injured

While about one third of all injuries occur during work, workers compensation companies are often reluctant to acknowledge the injury or pay related medical expenses. About another third of injuries occur during recreational or sports activities. The last third occurs in diverse situation, including injuries to those inside buildings.

How Do Lightning Injuries Affect People?

While any death is a blow to a family, eventually the family readjusts and goes on. However, for those who have a relative who suffers significant disability from lightning, life changes forever and the dreams of that family and the survivor may be markedly altered. The family income may be tremendously decreased if the survivor was one of the breadwinners, or the spouse or another family member may have to quit work to care for the survivor if the disability is great enough.

While about one third of all injuries occur during work, workers compensation companies are often reluctant to acknowledge the injury or pay their medical expenses. About another third of injuries occur during recreational or sports activities. The last third occurs in diverse situation, including injuries to those inside buildings.  Many injuries in each of these groups can be prevented with proper education, well conceived lightning protection systems that protect the people as well as the equipment being used or ‘shelters’ where the survivor may seek safety, and lightning safety plans for coaches, parents, and referees at sporting events. While lightning safety and injury prevention is an individual responsibility and decision for adults, adults are ALWAYS responsible for the children in their care, particularly if it is an outdoor sports activity such as soccer, t-ball, camping, etc.

Unlike high voltage electrical injuries where massive internal tissue damage may occur, lightning seldom causes substantial burns. In fact, most of the burns are caused by other objects (rainwater, sweat, metal coins and necklaces, etc) being heated up and causing the burn rather than caused by the lightning itself.

Lightning tends to be a nervous system injury and may affect any or all parts of the nervous system: the brain, the autonomic nervous system, and the peripheral nervous system.  When the brain is affected, the person often has difficulty with short-term memory, coding new information and accessing old information, multitasking, distractibility, irritability and personality change. A great quote sums it up perfectly:
"Patients have difficulty in all areas that require them to analyze more items of information than they can handle simultaneously. They present (appear) as slow because it takes longer for smaller than normal chunks of information to be processed. They present as distractible because they do not have the spare capacity to monitor irrelevant stimuli at the same time as they are attending to the relevant stimulus. They present as forgetful because while they are concentrating on point A, they do not have the processing space to think about point B simultaneously. They present as inattentive because when the amount of information that they are given exceeds their capacities, they cannot take it all in."
Early on, survivors may complain of intense headaches, tinnitus (ringing in the ears), dizziness, nausea, vomiting and other ‘post-concussion’ types of symptoms.  Survivors may also experience difficulty sleeping, sometimes sleeping excessively acutely after the injury but changing during the next few weeks to inability to sleep more than two or three hours at a time.  A few may develop persistent seizure-like activity several weeks to months after the injury.  Unfortunately, standard EEG’s do not always pick up injury in the areas that lightning most often affects leading to a diagnosis of ‘pseudoseizures’.  

Personality Changes / Self-Isolation

Many may suffer personality changes because of frontal lobe damage and become quite irritable and easy to anger. The person who ‘wakes up’ after the injury often does not have the ability to express what is wrong with them, may not recognize much of it or deny it, becomes embarrassed when they cannot carry on a conversation, work at their previous job, or do the same activities that they used to handle. As a result, many self-isolate, withdrawing from church, friends, family and other activities. Friends, family and co-workers who see the same external person, may not understand why the survivor is so different. Friends soon stop coming by or asking them to participate in activities. Families who are not committed to each other break up.

Obviously, depression becomes a big problem for people who have changed so much and lost so much.  Suicide is something that almost all severely injured people have thought about at one time or another.  Occasionally, those who do not have access to medical care or who do not understand what is happening may self-medicate with alcohol and other drugs, particularly those who have previously sought solace with these compounds.  It is very important that the family and friends of the survivor maintain supportive contact even though it requires an adjustment in their relationship with the survivor.  An injury such as this is an injury to the family, not just to the person hit.

Fatigue

Survivors often complain of easy fatigability, becoming exhausted after only a few hours of work. This may be because every task that they used to automatically do without thinking now requires intense concentration to accomplish. Many return to work but find that they cannot multitask and do all of the activities that are required at their job.

Medical Testing

There are two kinds of medical tests:  

Sometimes function can be ascribed to the anatomic tests but often it cannot so that it is often fallacious on the basis of a normal static picture to ascribe normal function.  The mental changes that the lightning survivor has are functional (how the brain works) changes, not anatomic ones so that anatomic tests such as the CT scan and MRI are usually normal. More functional scans such as PET and SPECT may show changes but are hard to obtain due to their relative infrequency in medical centers. To use an analogy:  if an electric shock were sent through a computer, the outside case would probably look ok (similar to a photo or x-rays of the person), the computer boards on the inside would probably look ok and not be fused nor melted (CT, MRI for the person), but when you boot up the computer it would have difficulty accessing files, making calculations, printing, etc. similar to a person with brain injury who has short term memory problems, difficulty accessing and coding information, difficulty organizing output,

A functional test of how a person’s brain is working that is seldom thought of by most non-neurologists is called neurocognitive or neuropsychological testing.  These tests are administered by a qualified neuropsychologist familiar with the literature in this area, not by a psychiatrist, and consist of a 6-8 hour battery of pen and paper tests including memory, IQ, organizational ability, and other ‘how the parts of the brain are working’ kinds of tests.  Survivors of lightning and electrical injury usually have a characteristic pattern of deficits.  This type of testing is expensive and not necessary for most but can sometimes be helpful when litigation is involved and there is a doubt about the cause of a person’s injury.

Delayed Problems

Another common, often delayed problem for some survivors is pain, also a difficult problem to quantify and manage and one that does not always present initially in the full-blown pattern that it may have later. The pain may not only present as the chronic intense headaches mentioned above but may be in the back (perhaps from compression and disc injury from the intense muscle contractions which may throw a person several yards at the time of the injury), or in an extremity. Many may have nerve entrapment syndromes. A small number may eventually develop classic RSD. (Reflex Sympathetic Dystrophy, Sympathetically Mediated Pain Syndrome, causalgia)

Sometimes the functional tests that are ordered are testing the wrong thing an electromyogram (EMG) measures only the largest nerve fibers, the motor fibers, which are seldom affected by lightning injury.  Smaller pain-carrying nerve fibers are not tested by EMG so that a ‘normal EMG’ means little when ordered for someone with pain.  Likewise, the standard EEG does primarily surface readings of the brain and misses seizure activity in several deeper regions.  EEG’s may not pick up only 50% of temporal lobe seizures (some personality, organizing ability) and miss 120% of hypothalamic seizures.4

Lack of libido and impotence are often reported. Other common and not so common complaints involve the digestive system, the endocrine (hormonal) system, and the immune system, some of which are currently being studied. It is not clear if these are directly due to lightning injury, to medication side effects, or to other incidental causes unrelated to lightning.

Help Exists - Lightning Strike and Electric Shock Survivors, International, Support Group

An organization that has been of tremendous help to survivors, their families, their physicians and other professionals is Lightning Strike and Electric Shock Survivors, International (LSESSI), a support group formed in 1989 by a gentleman who was injured in 1969 who became tired of no one recognizing or knowing what to do for those with lightning injury. LSESSI has printed materials, offers tremendous support, networks survivors with others in their area, and provides an annual meeting where survivors come together for support as well as for lectures from professionals who work with lightning and electrical survivors and their families. LSESSI can be reached at 912-346-4708, Lightnin@nternet.net, http://www.lightning-strike.org/index.html, or at P.O. Box 1156, Jacksonville, North Carolina 28541-1156.

Four Factors Necessary for Recovery

The four most important factors in overcoming disability from lightning injury (or from any illness or major injury for that matter) are:

a.        A supportive family/friends network.
b.       The person or family becoming their own best advocate and learning as much as they can about their disability.
c.        A physician (regardless of specialty) who is willing to listen, read, learn and work with the survivor and their family.
d.       A sense of humor.
 

Prevention

Far more important than treating survivors is preventing lightning injury.

National Lightning Safety Awareness Week
Prevention is the KEY.
 

  REFERENCES

 

1.        Holle RL, Lopez RE, Curran EB:  Distributions of Lightning-Caused Casualties and Damages Since 1959 in the United States, 11 Conference on Applied Climatology, American Meteorological Society, January 1999
2.        Cooper MA: Lightning Injuries: Prognostic Signs for Death, Ann Emerg Med 9:134, 1980
3.        Lopez RE, Holle RL, Heitkamp TA, Boyson M, Cherington M, Langford K:  The Underreporting of Lightning Lnjuries and Deaths in Colorado. Bull Amer Meteor Soc, 74:2171-78, 1993.
4.        Cooper MA, Andrews CJ, Holle RL, Lopez RE:  Lightning Injuries, Ch 3, Auerbach P (Ed):  Wilderness Medicine, 4th Edition, CV Mosby, 2001.
5.        Cherington Paper
6.        Life After Shock I, Life After Shock II, collections of stories of lightning and electric shock survivors and how it has changed their lives, Lightning Strike and Electric Shock Survivors, Intntl, Morris Publishing, Nebraska,1996/2000.
7.  Heitkamp, Holle, Lopez
8.         Holle, R.L., R.E. López, and C. Zimmermann, 1999: Updated Recommendations for Lightning Safety-1998.  Bull Amer Meteor Soc, 80:2035-2041
9.        Cherington M, Cooper MA:  eds, Seminars in Neurology, Vols 3&4, 1995, two issues on electrical and lightning injuries
12.  Primeau M, Engelstetter G, Bares K: Behavioral Consequences of Lightning and Electrical Injury, Sem Neurol, 15(3):279-285, 1995.
11. Pliskin NH, Capelli-Schelpfeffer M, Law RT, Malina AC et al:  Neuropsychological Symptom Presentation after Electrical Injury, J Trauma 44(4):709-15, 1998
12.  Heilbronner RL, Pliskin NH:  Psychological issues in the neurorehabilitation of electrical injuries, NeuroRehabilitation 13:127-32, 1999.
13.  Groenwald D:  Cumulative and Persisting Effects of Concussion on Attention and Cognition, 154 (sorry, no further info on this reference is available to us)

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