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A True Shock to the System

Like peeling away the layers of an onion, research into electrical injuries is revealing more all
the time. In work spearheaded by the Chicago Electrical Trauma Research Institute (CETRI),
researchers are finding that electrical shock can be as much a stealthy, progressive disrupter
to the body as a silent immediate killer. Chicago-area physicians, therapists, and scientists
working under the CETRI umbrella are growing more convinced every day that electrical
shock causes much more than devastating burns and other physical injuries. As this article
shows, theyre finding it can also trigger a chain of events that leads to potentially disabling
changes in mood, personality, emotions, and cognitive functioning.

A True Shock to the System


May 20, 2014Tom Zind | Electrical Construction and Maintenance

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What is in this article?:

A True Shock to the System

SIDEBAR 1: Rare but Deadly

SIDEBAR 2: Aftermath of an Electrical Accident


Research into electrical injuries at the Chicago Electrical Trauma Research Institute is exposing
injuries that go beyond the physical, including changes in mood, personality, emotions, and
cognitive functioning.
Advertisement

Like peeling away the layers of an onion, research into electrical injuries is revealing
more all the time. Its enough to bring a tear to the eye when the full extent of the
potential damage to unfortunate victims most from the workplace is completely
grasped.
In work spearheaded by the Chicago Electrical Trauma Research Institute (CETRI), a
group that coalesced in 2009 to centralize more than two decades of scattered but
intensive research into electrical injury and its treatment, researchers are finding
that electrical shock can be as much a stealthy, progressive disrupter to the body as a
silent immediate killer.
Chicago-area physicians, therapists, and scientists working under the CETRI
umbrella are growing more convinced every day that electrical shock causes much
more than devastating burns and other physical injuries (see Rare but Deadly).

Theyre finding it can trigger a chain of events that leads to potentially disabling
changes in mood, personality, emotions, and cognitive functioning.

Most of us are well aware of the physical effects of an electrical shock, such as this heat injury.

But the good news, as CETRIs work and research is revealing, is that the prognosis
for recovery is good and improving. Addressed early in the treatment process, these
non-physical injuries can be mitigated to the point where the victim can function in
daily life. The key is timely, aggressive, and focused therapy.
Armed with an expanding view into the full range of damage electric shock can
produce, a core of about a dozen affiliated clinical investigators is helping
CETRI pioneer new treatment strategies. In addition to treating the injurys physical
toll, the CETRI regimen is incorporating an expanding focus on its less understood
mind/body component. In the course of pursuing new avenues of treatment for the
patients who come through a comprehensive treatment and rehabilitation program
that feeds its research efforts, the institutes work is becoming a model for other
caregivers to purse a more comprehensive, multi-faceted approach to diagnosis and
treatment.
RELATED

After Shock: Inside Electrical Trauma


Anatomy of an Electrical Accident

Were banging the drum about electrical injury not being just a physical injury,
says CETRIs Assistant Director Kristina Adams, Ph.D. Were out doing seminars at
meetings of groups like the Construction Safety Council, trying to take any and every
opportunity we get to help everyone better understand electrical injury and know
what to look for.

Beyond skin deep


By themselves, serious electrical burns and tissue damage are a challenging enough
condition to address. But CETRI research is revealing that greater, but often less
obvious, damage may be born by the bodys intricate neural structure. Its wiring, in
essence, can be changed through disruptions the shock causes in the nervous system
and musculoskeletal complex. With the brain and spinal cord deeply involved in
pain, motor impairment and mental dysfunction loom as probable byproducts of
electricity coursing through the body, producing a complex web of ailments and
symptoms that can be hard to untangle.
Researchers have grown more interested in the phenomenon of alterations in mood,
emotions, and cognition because they can be as dangerous as physical damage.
Considering the impact on social interaction, job performance, sleep, quality of life,
and a host of other routine day-to-day functions, these are potentially costly
consequential injuries.
Numerous studies, many based on actual cases handled by CETRI, have found a
strong correlation between electrical shock and the development of worsened mental
states over time. Years of research have convinced Neil Pliskin, Ph.D., professor of
psychiatry and neurology at the University of Illinois at Chicago, that electrical injury
victims are at high risk of developing emotion regulation challenges.
A longstanding CETRI clinical investigator and the first neuropsychologist to join the
formal study of electrical injury pathology in the early 1990s, Pliskin points to one
recent study involving 185 electrical injury victims. It found that 75% of subjects
developed at least one, and, in some cases, two or more, diagnosable mood-related
changes post-injury, including depression. Notably, only 3% of that sample had prior
contact with a psychiatrist or other mental health services provider.
Rock-solid, emotionally stable individuals go through an electrical injury
experience, and theyre different, Pliskin insists. Theyre more anxious, dont want

to be around other people, some become very tearful or upset, or cant tolerate stress.
And the change the level of disruption is traumatic. These are people who
havent been utilizers of psychiatric services now going through significant
psychiatric changes.
And the problems often dont end there. Research has also found that some victims
are prone to developing cognitive deficits. They seem to develop over a course of
several years following the incident and likely spring from emotional changes. While
generally not disabling, problems with memory and task completion are nevertheless
disruptive.
What happens, in studies where we compare these victims with others of their same
age, they think more slowly and have a more difficult time paying attention, says
Pliskin. Things that were once automatic are no longer automatic for some of these
people. What they say is, its not that I cant do things, its just that I have to work so
much harder to be able to do the things I could do before.

The mystery of how


For all the progress in discovering this predictable pattern in victims, researchers are
still struggling to understand the mechanism. Numerous theories have been
advanced, but the unique circumstances surrounding many electrical injuries
complicate the effort to pinpoint cause and effect.
One of the most confounding mysteries is the onset of these problems without clear
evidence of physical trauma that might be expected to lead to changes in behavior
and thinking. While survivable electrical shocks can be violent, they only rarely
involve head injuries of a severity likely to affect the brain; electrical current passing
directly through the brain can cause traumatic brain injury. After years of studying
electrical shock victims exhibiting psychiatric symptoms, Pliskin flatly rules out the
idea that typical brain trauma is in play because the classical markers arent there.
What we do know is that electrical injury isnt traumatic brain injury (TBI), he
says. Only a third of patients lose consciousness as a consequence of their injury.
While there may be confusion and disorientation after the shock, its not a given
theyll lose consciousness. Others do develop head injuries where an explosion
throws them back, and they hit their head. But others dont.

Thats left investigators searching for other possible causes. One theory is that its not
physical; its that victims are wrestling with the unique emotional trauma of having
been shocked. Memories of the incident, the suddenness and randomness of the
event, along with the powerful realization that they could have died, might
overwhelm victims. Left to linger without treatment, those symptoms can worsen
and result in an experience approximating post-traumatic stress disorder.
This can be very complex, an element of this thats tied up in the circumstances of
what happened and the nature of the injury, says Pliskin.

A re-set theory
Then theres the notion that something more inexplicable is at work. Some point to
the still-common practice of using electro-convulsive shock therapy (ECT) to treat
the hardest-to-treat depressive patients. While the exact mode of action in ECT was
never reliably established, use of ECT does lead to mood changes, leading
researchers to draw parallels. Essentially, the same thinking that led psychiatry to
ECT at one time could provide at least some clue to whats happening with shock
survivors.
Im not equating the two, but the concept of being advertently exposed to an
electrical field and that having an impact on functional brain systems so that it
changes someones ability to regulate their emotions its just not that far-fetched,
says Pliskin.
Another theory invokes the mind/body connection concept. It holds that the
electrical shock itself, independent of any serious tissue burn, fundamentally
damages the bodys muscle and peripheral nerve complex and that the trauma gets
coded into the central nervous system. The resulting pain, sensory changes, and
effect on motor functions lead to physical changes in the brains circuitry that can
produce changes in mood, behavior, and cognition.
The idea has a basis in the study of pain treatment and therapy, says Raphael Lee,
M.D., professor of surgery and medicine at the University of Chicago, whose
pioneering work in electrical injuries set the stage for the eventual establishment of
CETRI.
Pain management specialists, he says, are convinced that peripheral nerve injury can
lead to changes in the brain. That leads to changes not only in the experience of pain,

but also emotional and cognitive expression. The fact that so many electrical shock
victims exhibit these problems even in cases where serious burns arent involved
leads researchers to conclude that the shock itself can actually damage nerves.
Someone gets a brief electrical shock, there can be substantial damage to peripheral
nerves and muscle that is not caused by generalized heating, where severe tissue
injury would be expected to cause nerve damage, says Lee. Exactly how it happens
that electrical forces themselves could, in a brief moment, cause significant injury to
muscles and nerves, is not clear. That was a controversial idea at one time, but today
that controversy is gone.

Adding insult to injury


While the shock event may last only milliseconds, its effects can not only persist, but
also worsen over time. An ensuing cascade of pain not to mention emotional and
cognitive disruptions can take root.
In the course of following victims over an extended period of time, CETRI
researchers have seen a pattern of regression from fewer and milder symptoms
right after the event to more acute symptoms months later.
The explanation, Lee says, lies partly in what pain researchers have learned about
how the brain reacts to nerve trauma and processes pain signals. Rather than the
body becoming more inured to the resulting pain, it can actually become more hyperaware of it, resulting in a heightened sensitivity to pain. The same mechanism may
be at work with mental functioning.
That delay is a progressive change due to maladaptive behavior, where a person gets
an injury and the complex neurophysiology isnt working the way it used to because
of the injury, says Lee. Over time, it affects the centers in the brain responsible for
emotion and memory, and it doesnt improve them it makes it worse.
Understanding how and why electrical shock produces such an array of changes is
important. But what may matter more is the ability to recognize symptoms and find
an effective way to treat victims. In that regard, CETRI is leading the way.

Spotting trouble signs

While treatment and rehabilitation encompasses a mix of approaches, the emphasis


is increasingly on the importance of early intervention, followed by focused and
aggressive treatment targeting symptoms that can produce long-term emotional and
physical disability (see Aftermath of an Electrical Accident). Unfortunately,
thats complicated by uncertainty.
In a clinical setting, says Pliskin, its hard to reliably identify who will develop
psychosocial difficulties. And its still not known what factors and variables make
them more likely to take root. But, he says, a simple awareness of the potential and
an understanding of the havoc they can produce in a victims life means the earlier
that you can sensitize people and recognize those who might be in trouble, the
better.
Thus, heading the list of best practices advised by CETRI is thoroughly evaluating
patients on intake and being able to quickly bring mental health professionals into
the picture. It is a strategy CETRI is uniquely able to employ, given its access to a full
range of experts and one it says should be adopted by other caregivers to the
extent possible.
Its important to know the nature of the beast when a person starts out on a
treatment plan after an electrical injury, says CETRIs Adams. With early detection
of problems and a prognosis from a cognitive standpoint, people are in a position to
get better, more focused treatment.
A treatment regimen along the lines of that used to help victims regain physical
capabilities that the shock impaired can be effective. By incorporating therapies that
encourage victims to confront feelings and emotions and help them maintain or
improve memory and cognition, treatment professionals will be directly targeting
symptoms that are likely to fester and worsen if left untreated.

Forestalling decline
That can be critically important, given the high stakes for the victim, their families,
and their gainful employment. The average age of a patient who goes through the
CETRI program is 35, Adams says, which means many more working years where
theyll need their full physical and mental faculties to thrive.
Plus, victims not fully treated likely wont be as productive. And employers, many
still largely unaware of the full nature and complexity of electrical injuries, may lack

the skills and patience to deal with chronically afflicted workers. In addition,
treatment delays or detours due to inaccurate or incomplete diagnoses will also add
costs and extend the recovery period.
Given what researchers now know, Lee concludes, electrical injury generally
warrants aggressive, thoughtful, and
comprehensive treatment. That marks a departure from the long-held belief that
victims of shock and other physical trauma that dont show visible injuries can
simply get up, dust themselves off, and get back to work.
Electric injury in the workplace is a common cause of long-term disability, and one
of the most common outcomes of individuals who have a disabling problem is that
they become disabled in a permanent sense, he says. So Im convinced that early
intervention, early aggressive monitoring, and rehabilitation approaches are
helpful.
Zind is a freelance writer based in Lees Summit, Mo. He can be reached
attomzind@att.net.

A True Shock to the System


May 20, 2014Tom Zind | Electrical Construction and Maintenance

EMAIL
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What is in this article?:

A True Shock to the System

SIDEBAR 1: Rare but Deadly

SIDEBAR 2: Aftermath of an Electrical Accident


Research into electrical injuries at the Chicago Electrical Trauma Research Institute is exposing
injuries that go beyond the physical, including changes in mood, personality, emotions, and
cognitive functioning.
Advertisement

SIDEBAR 1: Rare but Deadly


Workplace electrical injuries are getting rarer thanks to improved safety practices,
rules, and equipment. Thats something to celebrate when the toll of those injuries is
tallied.
Compiling U.S. Bureau of Labor Statistics data, the Electrical Safety Foundation
International, Arlington, Va. a 501(c)(3) organization dedicated exclusively to
promoting electrical safety in the home, school, and workplace, says fatal electrical
injuries were cut in half between 1992 and 2010, with the pace accelerating since
2006. Fatalities fell by one-third from 2006 to 2010 alone.

Nonfatal electrical injuries as a percentage of the total for the two largest categories of electrical accidents
remained relatively unchanged from 1992-2010, even though the total number of nonfatal electrical
accidents declined by more than 60%.

Meanwhile, non-fatal injuries fell 60% in that 18-year span (Figure). Injuries were
highest in the construction and electric utility industries, where injury rates were 0.6

and 0.2 per 10,000 workers between 2003 and 2010. Contact with current from
machines, tools, appliances, etc., and contact with transformers, wiring, and similar
components caused the most injuries.
But what electrical injuries lack in incidence they make up for in consequence. The
Chicago Electrical Trauma Research Institute (CETRI) has compiled data that
measure the toll these injuries may be exacting.
Citing figures from the Electric Power Research Institute, Palo Alto, Calif. an
independent, non-profit organization that conducts research, development and
demonstrations for the electric utility industry CETRI says electrical injuries cost
to employers has been estimated at $15.75 million per case in direct and indirect
costs. It also cites data that puts the average cost of just treating burns from electrical
injury at about $14,000.
Another statistic cited by CETRI shows one-quarter to two-thirds of injuries caused
by contact with overhead power lines resulted in more than 31 days away from work.
The range for other occupational injuries and illnesses was between 18% and 20%.
The bigger costs, though, likely stem from treating the non-physical component of
the injuries the emotional and cognitive issues that often accompany the injuries.
That quest often involves heading down blind alleys and arranging consultations
with multiple specialists. CETRI cites one study in which 31 patients participated in
83 separate consultations, but 80% of those visits yielded no clinical diagnosis.
Statistics show non-physical problems are prevalent. CETRI says half of all victims
experience anxiety, and 25% endure chronic pain. In many victims, weight gain,
fatigue, depression, poor concentration, and post-traumatic stress disorder show up
one to six months after the event, and physical symptoms like numbness, tingling,
and weakness, can appear within two months.

A True Shock to the System


May 20, 2014Tom Zind | Electrical Construction and Maintenance

EMAIL
INSHARE

COMMENTS 0
What is in this article?:

A True Shock to the System

SIDEBAR 1: Rare but Deadly

SIDEBAR 2: Aftermath of an Electrical Accident


Research into electrical injuries at the Chicago Electrical Trauma Research Institute is exposing
injuries that go beyond the physical, including changes in mood, personality, emotions, and
cognitive functioning.
Advertisement

SIDEBAR 2: Aftermath of an Electrical Accident


Electrical injuries the most common form of work-related burn injuries and a
major cause of work-related deaths result in approximately 1,850 emergency
department visits every year in Ontario, according to the Electrical Safety Authority.
The staff at St. Johns Rehab, part of Sunnybrook Health Sciences Centre in Toronto,
is helping patients combat the adverse and often invisible effects of such injuries.
Canadas only dedicated electrical injury rehabilitation program, St. Johns has been
providing customized, comprehensive assessment and care to people suffering the
long-term effects of electrical trauma since 2003.

Electrical injury survivors may experience muscle weakness, fatigue, and have difficulties doing everyday
tasks. With the help of an occupational therapist, Ted does work conditioning exercises, such as lifting, to
help restore his strength, endurance, movement, and flexibility (Courtesy of Sunnybrook Health Sciences
Centre).

According to the experts at St. Johns, not all electrical injuries are created equal
each patient presents different symptoms at different times. They may experience
neurological symptoms such as numbness, weakness, memory problems, paresthesia
(paralysis of the tongue), fatigue, and chronic pain, as well as psychological
symptoms, such as anxiety, nightmares, insomnia, and flashbacks of the event.
Because these symptoms often arise unpredictably, electrical injury survivors are
often challenged or misunderstood by family, co-workers, insurers, and employers.
Ted (an assumed name) is one such survivor.
After 600V of electricity radiated throughout his body, Ted showed no visible signs
of trauma. He even continued to work for months following the accident until the
after-effects began to reveal themselves below the surface. Today, Teds recovery is
ongoing. He works with a multi-disciplinary team of nurses, physiotherapists,
occupational therapists, neuropsychologists, and other health professionals at St.
Johns Rehab to address needs specific to his condition. He suffers from severe posttraumatic stress disorder, with lack of sleep being one of the most problematic postaccident conditions. With the help of his customized rehabilitation program, his
attention, concentration, and memory have improved. His anxiety and depression
have also decreased, and he is finally able to get some sleep.
I was completely dysfunctional, says Ted. I started having nightmares every night.
I couldnt sleep. My muscles were weak, and I kept losing my balance. I still hear
ringing in my ears. St. Johns Rehab gave me my life back.