Wisconsin Public Television University Place Wednesday Nite at the Lab  Beth Niblack-Sykes Welcome to the Neuroscience Intensive Care Unit  August 10, 2011 UP611    cc >> Tom Zinnen: Welcome, everyone, to Wednesday Nite at the Lab. My name is Tom Zinnen. I work here at UW-Madison and I also work for UW Extension Cooperative Extension. On behalf of our other partners, Wisconsin Alumni Association, the Science Alliance at UW-Madison, and Wisconsin Public Television, thanks for coming to Wednesday Nite at the Lab. We do this every Wednesday night, 50 times a year. Tonight I'm delighted to be able to introduce to you Beth Niblack-Sykes. She's been a registered nurse for 22 years and has worked at the bedside with the neuroscience population for almost all of that time. She has additional certifications as a critical care nurse and as a neuroscience nurse. Her current position is as a care team leader for the Neuroscience Intensive Care Unit at University Hospital and Clinics. She has a bachelor's degree. 

She has two bachelors' degrees. Both from UW Madison. One in animal science and another in nursing. And she lives here in Madison with her husband and two children. Please join me in welcoming Beth to Wednesday Nite at the Lab. [APPLAUSE] >> Beth Niblack-Sykes: Thank you for coming today and thank you for having me. I am used to talking with small groups of people in circles sitting on chairs so do bear with me. Please ask questions as we go along, it makes me feel a whole lot more comfortable. So working in an ICU is a high stress environment, mostly for families and patients. A lot of our patients aren't even aware that they're there. 

The families take the brunt of it. So a lot of what I'm saying is going to be geared for educating family members. First of all, people are hit by a lot of rules. This is our strictest version. All of our rules are open to interpretation to the nurse's discretion who's caring for the patient and for the charge nurse's discretion for the benefit of the whole unit. The charge nurse is also the care team leader. It's an interchangeable term. So people get overwhelmed right off the bat before they've even made it out of the waiting room. More rules. And they still don't know what's going on. 

More rules. A lot of rules. One of the things that we think about when we loosen the rules is how sick the patient is, how new they are to our unit. All these things get people in a lot quicker. Unless they're truly very sick, then we need more time with them and you're going to be waiting a long time while we try to save their life. The things that will make us clamp down are 50 family members per patient. We don't have the room. People that are interfering with patient care. People that over stimulate the patient and slow down their recovery. Yeah. 

>> Can you use the computer and put it up on full screen. >> Okay, I don't know how to do that. Let's see. >> Does anybody know how to do that? [LAUGHTER] >> F5 usually starts a slide show >> Okay, I want to do it manually, though. >> Slide show, play from start, play from current slide. >> Current slide, I guess. But I want to have the control. That's full screen. Yeah, that's what I've been doing. Now it's not working, though. 

There we go. I put the night shift first because that's what I do. And the day shift. This is maybe a total of a third of our staff. Besides the bedside nursing, there's a lot of other people that you're going to meet. We all practice together in a collaborative interdisciplinary model. The team includes, of course, doctors and nurses. There's the primary nurse who's typically the nurse that admits the patient, and she'll oversee the nursing plan of care. The staff nurse is different from day-to-day but we do try to provide continuity. Then there's the nursing assistant, the nurse case manager, who you'll see intermittently and she helps coordinate the discharge planning which starts on day one. 

Advanced practice nurses you'll see intermittently. Depending on their expertise, you'll see them as well. The social worker assists in discharge planning, access to community resources, legal issues such as a POA, which we'll talk about more. Pharmacists. The respiratory therapist who you'll most likely work with very closely. The occupational and physical therapists work with patients in starting their rehab process from day one. They'll be following, most of our patients will be seen by occupational, physical therapy, and speech therapy probably daily throughout their stay at the hospital, not only in the ICU. The swallow therapist is key for most of our patient population. Most of our patient population has difficulty swallowing. Once we've established what the person is able to eat or drink, if at all, or whether they need tube feedings, we work with our dietician or nutritionist to develop a plan that will give them enough calories to heal. 

Health psychologist is there to help patients and families cope and adjust to disease, injury, and disability. Our spiritual care services are non-denominational and they're available to everybody. Palliative care services are for those who are dealing with advanced disease or devastating injury. And we help people make decisions about treatment options and discharge options, as well as emotional support. What to expect once you get into the ICU. There's going to be a lot of tubes, cords, wires, and equipment. When I first stepped into an ICU as a brand new nursing assistant, I couldn't even see the patient on the bed because of all the tubes. They were there, I just couldn't see it. I was freaked. This is the mainstay, a piece of equipment for our patient population. 

It's a ventriculostomy and it is a small catheter that goes into the patient's head and measures the pressure in the head and helps us drain spinal fluid if needed. The patient monitors are kind of ubiquitous throughout the hospital but particularly in the ICU, and they measure blood pressure, heart rhythm, oxygenation. Not only are they visible at the patient bedside but we also have central monitors so when we're not directly in the room the staff can follow how the vital signs are trending from various points in the ICU. So they're never not being observed. Ventilators assist with breathing for many of our ICU patients. They can have different adjustments so that it meets the patient's needs. This slide says only nursing and physicians can handle the ventilators but I need to add that respiratory therapists are the main people that work with the ventilators. IVs are ubiquitous too. I don't think there's a patient in there that doesn't get an IV. What happens when someone is admitted and the family is waiting in the waiting room, waiting and waiting? Well, they're transferred to an ICU bed, and all those wires and cables are hooked up to the bedside monitor. 

If a patient needs a ventilator, the respiratory therapist is assessing the patient's need and setting up the ventilator. The IVs are checked and checked again for patency to make sure that they're working. And the medications are double checked and triple checked against the orders. The vital signs are obtained and treated right away if necessary. The physician and a nurse do a full neuro check or neurologic assessment which we'll go into in greater detail later. And that is compared to what was given from the last report. Then a head to toe physical assessment is given. What happens next? The physician views the records and scans that accompanied the patient and writes the orders. If the patient is capable of participating, both the doctor and the nurse will interview them regarding the events leading to the admission. There's also a whole slew of other questions that we may enlist family members to help us answer. 

And those are like, do you wear glasses, do you have dentures, do you have blood pressure problems, diabetes, what's going on in your world, anything else we need to know to help take care of you. The pharmacist, meanwhile, is reviewing all the home medications and verifying them against what was ordered if we have those records. Sometimes we have to take some away. Certainly we're going to be adding some more. Yeah. >> Outside of the fact that the intensive care is the internal and critical, what's the difference between the procedures for a regular ICU? >> This is regular ICU. I mean, ICUs are ICUs. I think this is pretty much the routine in any ICU. There's a lot of things going on. There's a lot of people working all at once. 

When you're on general care in the hospital, pretty much the same thing will be happening but it won't be as fast paced and usually people aren't as sick at the moment. So things can move slower. Did that answer your question? Okay. In our patient population oftentimes if they come from an outside hospital or from another facility, often a CT scan has been done at the outside. And that tells us how they looked at that time. When they come to us, they may look the same, they may look better in terms of neurologic exam or they may look worse. At any case, we're going to get another CAT scan to compare from point A to point B and see how fast things may be progressing. >> Question. >> Yeah. >> What exactly is meant by avoiding stimulation? >> Avoid stimulation. 

That's a good question. It's different for every patient. >> Like what? >> Sometimes what we're going to be doing is we're going to be doing neuro checks and assessing the patient probably every hour if not more often. And that's 24/7. And the average length of stay for some of our patients is three weeks. So they're not getting much sleep. So we try to coordinate with the family if you want to talk and interact with them come on in after I'm doing my neuro check real quick while I've got them awake and you can say I love you and everything like that but the rest of the time they need their sleep and we want to let them rest until the next hour when we wake them up again. >> What about television? I don't see the real issue. It seems to me that to prevent someone from watching television... >> And that's what we take into each case. 

If somebody is awake enough that wants to watch television, usually not a problem. If they're agitated and confused and they sort of feed into what's going on in the television and have a hard time differentiating what's happening on TV to what's real, we may have them turn off the TV. Most of our patients, I shouldn't say most of our patients, a lot of our patients are in a comatose state of some degree or another, and oftentimes well we'll just have what we call the care channel on, which is very peaceful music, sometimes classical music, which helps. [INAUDIBLE] >> It can be. It can be too much for the patient. Like a toddler that's skipped a nap and is the end of the day and they are just losing it. And a lot of our patients, that fits them right there. And the thing you got to do is just shut down and just have one person dealing with them to help them calm down. There's a wide range of behaviors that our patients exhibit. Not the least is impulsivity, agitation, combativeness, and confusion. 

We're very familiar with that population. Did that answer your question? >> No. >> Okay. >> I knew a stroke patient who was prevented from watching television... [INAUDIBLE] >> He was prevented from watching C-SPAN and the news. >> Because it might get him excited. And I think... >> It could be if he was getting upset about what he was seeing and raising his blood pressure. And as a stroke patient, we're very cautious about blood pressure issues. We have very tight controls and that might have been what was doing it. 

The nurse assessed that, hey, when he watches C-SPAN and starts getting mad about what's going on or whatever. >> I understand. >> Sometimes we have to keep blood pressure in a range of say 120 to 140. That's 20 points at any given moment. And we're titrating medications through the IV to keep that fluctuation as minimal as possible. So we have to get snippy. But like I said, we assess each patient's needs and what will work with one person won't work with the next. So when a person, going back to the slide, when a person goes to CT scan, the patient always goes on a bed with a monitor, accompanied by their RN and at least one or two other staff members. If they have a ventilator, the respiratory therapists will go with them, and everybody stays with the patient throughout the scan. Oftentimes, at least in our facility, getting ready for the scan, getting to the scan, and getting back and getting set back up in the room is probably about 99%. 

The scan is about three to five minutes. Everything else takes about half an hour. It's a lot of work. And a lot of stimulation for the patient feeling the movement going down the hall, the changes in beds and cots and stuff like that. So I've talked a lot about neuro checks. They happen a lot. This is a repeated neurologic assessment that's designed to monitor the progression or regression of symptoms. They're personalized to the patient but they all contain some key components. They're performed as frequently as every 15 minutes to every two hours, all day and all night until they leave the ICU. Once they move to general care, it's every four to eight hours. 

This is what a quick neuro check is. Starts with three stupid questions. Who are you? Where are you? And what day is it? Now, after about six hours if people are easily able to answer this, they're already fed up. It's also 3:00 in the morning and they haven't been asleep yet. But we still need them to answer us. We need to know that they can answer us because it can change. It's important that the patient, not the family or friends, answer the question because we want to know what they know and how they're going to tell us. Just by those three stupid questions, we can tell how hard it is for the patient to wake up and participate. When they got here, hey, it was easy it was me talking to you. Hey, who are you? What day is it? Not a problem. 

But after a while it's, hey, I'm shaking you, wake up, wake up. What's your name? Takes me five minutes to get Bill. Hey, something's different. We're going for a CAT scan. After that, we request them to do simple one- to three-step commands. Usually we say hold up your hands. Close your eyes. Wiggle your toes. If they can do those three steps without being reminded, that tells me a lot. They're processing pretty good. 

Their hand stays up, it doesn't go flopping down. They're not getting weak on one side. Have them wiggle their toes. Their legs are working. Bend up your knee. I learn a lot. We also check frequently for the level of pain and the quality of pain. How's your headache, I know you got one. Is it better? Worse? Are you feeling queasy? Have you been throwing up? Unfortunately, with all that headache pain, we don't have the medications to take it away and nor do we want to use them if we did. We'll try to keep you comfortable but it's sedating, and then I have a hard time figuring out whether you're not answering my questions because the pain medication or because you need to go to surgery. 

Other medications that aren't sedating increase the risk of bleeding. So we're in a rock and a hard spot. So we use ice bags. We reposition. We keep the head of the bed up. We try everything. And hopefully it makes a small difference. But people in our unit hurt. This is the Glasgow Coma Scale. It's a commonly used scale that we use to get a rough idea of how alert the patient is for us. 

You and I score a 15. Somebody that's dead gets a three for showing up for the exam. Anybody that scores about a seven, we're seriously considering giving them a breathing tube. And less than that, they're getting one. At the bottom of the scale when we look, let me go back here, we look at the best motor response at the bottom. And it says abnormal flexion posturing and extension posturing. Those are some of the lower scoring things. The first one, abnormal posturing is decorticate posturing and that's flexion posturing. And this is something that a patient is not awake, they're not conscious when they do this. It's very stereotypical, you can't break them out of it if you wanted to. 

Their muscles are contracted and tight, like that. And they may relax periodically but with a light touch or a noise or from some internal stimuli they will start doing these postures of contracting up. The extension posturing on the bottom includes a wrist rotation and everything like that. That is going closer and closer where there's brain stem damage, and we are very concerned for these patients. That's not to say that people that are exhibiting these posturings won't make some sort of recovery. Most likely not a full one however. The neurological conditions that we specialize in, strokes, of which there's two types: ischemic and hemorrhagic. Ischemic means that there's loss of blood flow usually due to a clot, a blood clot or a plaque formation that has closed off a blood vessel. Hemorrhagic can be from high blood pressure or an aneurysm which is where a blood vessel ruptures and blood leaks out of the blood vessel. We also see brain tumors, traumatic brain injury, and to a lesser extent spinal cord injuries. 

They usually go to a different unit than ours but we do see them occasionally. If you don't walk away with anything else today, please know the signs and symptoms of a stroke. Sudden weakness, numbness of the face, arm, or leg, especially on one side of the body. Sudden confusion. Trouble speaking or understanding. Sudden trouble seeing in one or both eyes. Sudden trouble walking, dizziness, loss of balance, or coordination, or a sudden, severe and unusual headache. Often those headaches are described as the worst headache of my life or it was like a thunder clap for those that are there to describe it. >> Is there such a thing as having some of these symptoms and that's... >> Any of these symptom. 

>> And that's a partial stroke? I mean, if you have a stroke you either have it or you don't? Or if you have some of these symptoms... >> To have a stroke you don't have to have all of these. You can just have one of them. That being said, it doesn't mean that you've had a stroke if you have one of these symptoms, but it does mean it needs to get checked out. If it's something that is new and distressing and you don't feel right, call 911, it's an emergency. We would rather see you in the ER getting evaluated and sending you home because it was a false alarm any of day of the week. It's inconvenient, it's embarrassing but it will save your life or your livelihood. A stroke is a brain attack. Ischemic, like I said, is blockage of the blood vessel down in the brain. No flow downstream. 

And that's 80% of all strokes. >> What does that mean, no flow downstream? What does that mean? >> No flow. It means if you think of the blood vessels in the brain like a garden hose and it gets pinched off, there's no water flowing through, there's no blood flowing through and everything downstream from where that blockage is, that tissue dies. If it's in a bigger vessel, say in the neck, it's going to affect half your brain. Half your brain will die. If it's in a smaller, more distal vessel farther up in the brain, it will be a smaller amount of brain tissue that's affected. Hemorrhagic, it's a rupture of a blood vessel interrupting blood flow and allowing blood into the surrounding brain tissues. Let me go back. That's 20% of all strokes. The stroke risk factors. 

Medical conditions that are chronic and often increase risk are high blood pressure, diabetes, elevated cholesterol and lipids, and heart disease. Those are things that can be managed but they never really go away. I think my slides are out of order. Anyway, the incidence of stroke. It's the third leading cause of death in the United States. It's the leading cause of serious long-term disability. And it can occur in all ages. 25% of strokes are younger than 65 years old. At one point in the last year on our unit, I think probably a third of our patients were in their 20s that had had strokes. >> Do they know what the cause of those strokes in younger people are? >> Part of our stroke work-up is to evaluate for the cause, and oftentimes it's a clotting disorder. 

For women, it's oral contraceptive pills in combination, oftentimes. It's an occult thing. You don't know you have a clotting disorder until something happens. For women of childbearing age, sometimes a clue is frequent miscarriages. But that's still being worked at to find out if that's a true link or not. There's controllable risk factors, otherwise known as lifestyle choices. Smoking. Quit. You got to keep trying. It's going to take multiple attempts. 

I think the average person tries four or five times before they're successful. Obesity. Help is available too. There's lots of resources out there. Elevated cholesterol and lipids. Diet changes. Medications. Inactivity. First get the okay from your physician, start small, figure out what you like to do, and have fun doing it so you'll keep doing it and do what you love and keep doing it and start building. Excessive alcohol intake. 

There's help and resources available for that. Illegal drug use. Get help, resources are available for that. We see all of that in our unit. The uncontrollable risk factors are increasing age, being male, heredity and ethnicity. African Americans and Hispanic Americans have higher risk. They have stronger incidence of high blood pressure. Just having a strong family history for blood vessel disease increases your risk, therefore pick good parents and you'll be halfway ahead of the game. Ischemic stroke, it's a blockage of the blood vessel, either with a blood clot or plaque, and there's no flow from that blood vessel down stream. The affected brain tissue dies and the surrounding brain tissue is damaged. 

That causes swelling which then furthers the damage. We have many ICU interventions to try to minimize that damage. >> Question. >> Yeah. >> Since high blood pressure is a risk factor for stroke and the way to reduce high blood pressure is to limit the sodium or salt intake, but that's very difficult to do. >> It sure is. >> Because salt is in all foods, all canned foods, prepared foods, how do you get salt-free foods and why isn't there a big movement to get the food supply free of salt so that you can add it at the table or in your own cooking? >> Salt, people like salt. [LAUGHTER] >> They can add it at the table. >> And food manufacturers want us to buy their product and they're going to put salt in it. It's also a preservative. 

It also allows them to put less flavor in because the salt contributes to the flavor. It's up to us. There's an increasing movement. There's more and more availability all the time. I know, like chicken broth, you can get low sodium versions of a lot of soups and broths and stuff like that. But again, the more processed foods that you buy are going to have more salt. And it is hidden everywhere, like you said. The best thing to do is to prepare your own foods from fresh and to choose high potassium foods as well. And those help counteract that and help lower blood pressure as well. >> Choose what? >> Potassium rich foods, such as potatoes, prunes, all sorts of things. 

>> I just am puzzled. >> It's frustrating. It's very frustrating. >> I'm pursuing this question. >> A nutritionist would be a very good resource to help go through that mine field. >> I just question why there isn't a public outcry. >> There should be. >> Back to the downstream brain dying. >> Yep. >> What's the time factor we're talking about here? >> Minutes, hours. 

>> That's pretty general. >> It is. Well, depending on how big the clot is, where it is, how fast the symptoms are acted on can make a big difference. It's also individual. When we go to what our treatments are, such as the tPA if it's indeed a blood clot that's caused the problem, our window, I believe, right now is six hours from the onset of symptoms to use that drug to help break up the blood clot. In some cases the doctors may evaluate the patient and say we can go a little farther out, but we really need people to activate the 911 system and get help early so that the sooner we use that drug, the better it works. If we're closer to the six hours, we may not be able to reverse the stroke. >> How does it work? >> What it does is it breaks up activating clots that are actively clotting. I don't even pretend to know the whole biochemical reaction, but basically what it does is it breaks up the clot right away. It thins the blood so quickly that the patients that are a candidate for this, they have to be screened very carefully for recent surgery, recent gastrointestinal bleeding because that could be a killer for them in itself if we use it on them. 

Yeah. >> Does the tPA break up the clot so completely that you don't get fragments blocking smaller vessels? >> Right. Because as soon as it opens up that blood vessel, and even if there were to be small clots going downstream, it's following right behind them working on them. I've seen some miracles happen. We had a young woman that came in that had a clot in her neck. It was affecting the whole side of her body. She had a one-year-old at home. She was going to be severely disabled. We got that drug into her within about three minutes of the helicopter landing with her and by the time she got back from her scan she could move fully freely again. Other times we're not as lucky. 

Sometimes we get some of it back. But the earlier we get to them, the better. >> Is there partial blockage? >> It was a full blockage. >> Is there partial blockage? >> There can be and that's where you get a TIA is what we call it. It's a transient ischemic attack. And that's like a mini stroke is what it's also called. And it's sort of a warning sign that a big one is coming. People will have, like, arm weakness or one-sided weakness or difficulty speaking for maybe a few minutes and then it gets better. Human nature being what it is, we're all guilty of it. Oh, wow if I just wait a minute, I'll feel better. 

>> What's the difference between neuroscience and neurology? >> Neuroscience is a broader scope. We do both neurology and neurosurgery. If a patient has an ischemic stroke that's caused by plaque, we can't do as much about that. There's no miracle drug right now for that. But we can hopefully give them supportive treatment, let them recover from the stroke, and then if they have plaques in their arteries, there's a surgery we can do a few weeks down the line that will help remove those fatty deposits of plaque from the carotid arteries in the neck. This does not correct any stroke damage that has already occurred, it's used to prevent strokes in those that are at risk for them. Intracerebral hemorrhage, these have different names because they sort of have different mechanisms, but these are much more deadly than the ischemic strokes. They happen fast and they do a lot of damage fast. One type is also called an intraparenchymal hemorrhage. And this is bleeding into the tissue deep within the brain. 

And it's often called a high blood pressure kind of stroke. The ones that are really devastating are the subarachnoid hemorrhages and those are caused by aneurysms. The cause of the aneurysms are not well-known, and they can occur in infants through adults. Often people have multiple aneurysms which are discovered once they get worked up for one. This is where you have that sudden thunder clap headache. The worst headache of my life. Often associated with sudden nausea and vomiting and rapid loss of consciousness. Most people don't make it to the hospital. Those that do, 50% die in the first month. One of the nurses on our unit was, I think, 19, and she is now a nurse with us after her aneurysm. 

Hemorrhagic stroke treatment. Usually we try to evaluate the source of bleeding. Once we've gotten them all admitted to the ICU and hooked up to the monitors and treated blood pressure, we rush them off to CAT scan or CTA which is a CAT scan that specializes in looking at the blood vessels. They've got computer programming now where they can look at the blood vessels in 3-D version, taking away all the rest of the space and then you have this beautiful three-dimensional image that they can spin around and it'll look at all the blood vessels and they can see the aneurysm. We also manage the increased pressure in the head or ICP. Usually putting in a ventriculostomy, which is that catheter in the head, that monitors the pressure and helps us drain off spinal fluid. We manage the symptoms by doing those frequent neuro exams that I talked about and watching the vital signs and treating blood pressure every few minutes. They treat the source of the bleeding, if possible, with surgery or endovascular interventions. Usually that's within 24 hours. If they can find the aneurysm. 

The endovascular interventions are things like coils that goes in, instead of like a surgery where they cut into the brain, they go in through the groin like with a heart catheterization and they thread a catheter up to the head and inject little coils into the aneurysm which cause the aneurysm to clot off and die. It's much less invasive and depending on the type of aneurysm, it all depends on the shape and the location whether this is an option, people have very good results from that. That's only the beginning. Once somebody has had an aneurysm, they're at risk for something called vasospasms because of the blood that's leaked all around into the spinal fluid and throughout the brain. What's that like? That's like a crimped off hose again, and it can cause further strokes, ischemic strokes. So we keep these patients in our ICU for about three weeks, if not longer. Every hour, neuro checks, 24/7. They're cranky. Brain tumors is another patient population that we see a lot of. There's a wide variety of brain tumors. 

We see a lot of metastatic brain tumors that are cancers that have spread from other areas of the body to the brain. Occasionally they bleed so they come in looking like they've had a bleeding kind of stroke but really it's a tumor that bled. Then there's primary brain tumors which are often hard to remove completely. The doctors always get what they can see, but oftentimes there's little bits that can't be seen. And they do not spread to other parts of the body but they can spread and regrow in the brain. Then there's nonmalignant brain tumors which won't spread and they don't spread to other parts of the body, but their seriousness depends on where they are in the brain and how big they are. The symptoms of brain tumors is usually like a morning headache, often with nausea and vomiting, that improves throughout the day. Or friends and families notice mental status changes, behavior and personality changes. Angry outbursts over nothing. Strange things. 

I don't know. The most common thing is a new onset of a seizure in an adult. And I want to specify in an adult because children have seizures regularly for many nonlethal reasons, fevers and such. Traumatic brain injury. The causes vary by gender, race, age, and geographic location. Motor vehicle crashes, cars, motorcycles, all-terrain vehicles. Typically they're young, male and thrill-seeking personalities. A long-term disability in somebody that's injured severely at 20 is devastating both socially and financially. Falls are the most common reason for traumatic brain injury in the very old and the very young. A certain amount are work-related, a certain amount are caused by fire arms: violence, hunting, suicide. 

Alcohol use is a common denominator in all of these. Falls in the elderly. These are somewhat preventable. The risk of falling increases with age. It's affecting women more than men. Two-thirds who fall will fall again in six months. Failure to exercise regularly, which is one way to prevent falls, leads to decreased strength, decreased muscle tone, decreased flexibility, decreased bone mass. One-third of all falls in the elderly involve environmental hazards in the home. It's the leading cause of death from injury in the 65 and older age group. The most profound nonlethal effect is the loss of independence, in part due to fear of falling. 

People start restricting their activities because they're afraid they're going to fall. 50% of the elderly who sustain a fall-related injury will be discharged to a nursing home, hopefully just for rehab for a few weeks. Yeah. >> I think this is a question. I'm thinking of a situation where the initial fall causes problems with maintaining balance. So that would seem to just make the problem worse. >> Absolutely. >> Than what you're talking about. >> Right. They fall, they hurt themselves, they didn't have good balance to begin with. 

Now they're injured and recovering from that so their balance is even worse, and they're more at risk for falling. It's a cycle. Osteoporosis increases the chance of injury with a fall. Starting now, if you're 18, 15, 11, make sure you get enough calcium, vitamin D, and weight-bearing exercise. It's never too soon or too late. The lack of regular exercise, it improves bone mass, strength, and flexibility, but always check with your doctor before starting a program of exercise and always wear supportive, well-fitting, low-heeled shoes. Impaired vision. Get regular vision exams. Use color and contrast to define balance aids such as grab bars. Use contrasting color strips on the first and last stairs so denote change of level. 

And, the thing I always forget, clean your eyeglasses often to improve visibility. Medications. Have your doctor and pharmacist review your medications regularly. You want to make sure that you're not taking too much and that they're the right drug for you. Oftentimes there may be another drug that has fewer side effects or you can go with a lower dose that might decrease your risk of falling. People who take multiple medications are at a greater risk of falling. Like I said, there's side effects that affect mental alertness, balance and gait, or drop your blood pressure when you get up suddenly. Sometimes the side effects of a couple medications will combine to increase the effect. Environmental hazards. The most common is tripping over objects on the floor. 

Loose throw rugs, tape down the edges of the large throw rugs, get rid of the little ones. Get rid of clutter. Improve your lighting. Use stronger bulbs, night lights at night and then touch lamps that are easy to turn on and off. Make sure, if you have grab bars, fix them so that they're sturdy or get them installed. Get rid of the unsteady furniture, that family heirloom that's kind of wobbly. Be sure electrical and phone cords are out of the way, and use non-skid mats in the bathroom. There's lots of other suggestions, too, but I'm trying to summarize. Now we're moving on to intracranial pressure. This is what happens when there's trauma to the brain. 

The brain is a closed box. It's got three things in it. It's got blood flowing through the blood vessels, it's got the brain tissue, and it's got an accumulation of cerebrospinal fluid or CSF. Anytime something changes in that balance of those three things, such as a space-occupying lesion such as a tumor or a collection of blood, it starts building up pressure. After the pressure starts building, the pressure itself starts squeezing on the brain tissue and causing more damage. And again you're in that cycle of trouble. Then it starts blocking the cerebrospinal fluid flow and you're getting more trouble. Here's a cross-section of the head showing the ventricles and the CSF space. A person that gets a ventriculostomy has a thin flexible tube that's inserted through a small burr hole in the skull down to the ventricles, which is the blue area in the center where that's a space where there's a collection of spinal fluid. That tube will measure the ICP, which we can read on the monitor, and it allows us a way to reduce the pressure in the head. 

As the pressure goes up we can open up the drainage system, let out a little bit and reduce the pressure. This is what the outside of the part that's hanging on an IV pole. It's not the best picture but that's the monitoring device and the collection bag for the spinal fluid. It's real important that when the nurse adjusts the head of the bed that nobody else adjusts the head of the bed, because that can change how the drainage system works and can cause serious problems. The signs and symptoms of increased ICP. This could be somebody that fell on the ice, got back into the house, has a headache, and a little while later they start feeling sick to their stomach, vomiting. They start seeing blurry or double, sensitivity to light. Somebody should already be calling 911. Eventually there will be drowsiness, confusion, irritability. If they were at the doctor and the doctor checked the back of their eye, they'd see a swollen optic nerve. 

The late signs are losing consciousness and changes in the sizes of the pupils. Here's a cross-section of the brain. It's got a lot of small print up there. But the top small box picture shows an epidural hematoma which is the bleeding between the dura mater and the skull. And then a subdural hematoma which is bleeding between the dura mater and the next layer down, the subarachnoid. Traumatic brain injury or TBI. Intracranial hematomas, like what we just saw, form after a blow to the head and cause blood to accumulate. Intracerebral hematomas are within the brain tissue. Subdural hematomas are between the dura and the arachnoid layer. Those are usually from venous bleeding. 

Epidural hematomas form between the skull and the outer layer, and those are usually arterial bleeding. A traumatic subarachnoid hemorrhage, which looks a lot like an aneurysm in terms of the CAT scan, it occurs in the middle layer, the arachnoid area, and in the inner layer. So the spinal fluid becomes bloody looking. Normal spinal fluid looks like water. Another type of brain injury is diffuse axonal injury or DAI. And that's pinpoint areas of widespread damage to axons, a part of the nerve cell. The brain cells die, causing swelling, and that causes increased ICP which then causes more damage. There's nothing surgical that we can do about that. Oftentimes we can do surgery for the hematomas to relieve the injury. As with all head injuries, people taking aspirin, Plavix, Coumadin, fish oil or other medications may be at increased risk for bleeding after even a seemingly minor head injury like a bump on a cabinet door or a headbutt by a small child sitting on your lap. 

Diagnosis is made by a CAT scan. >> What has fish oil to do with that? >> Fish oil has a property of thinning the blood. There's a lot of supplements that have side effects that people might not always be aware of. So it's always important to talk with your doctor when you choose to add a supplement to discuss it with them before you do so to make sure that it doesn't interact with other medications you may be taking. Just because something is natural doesn't mean that it doesn't have side effects that might not be so good. Intracerebral hematomas occur rapidly, causing symptoms within minutes. Large hematomas press on the brain causing swelling and sometimes herniation, which is definitely life threatening. The symptoms include confusion, loss of consciousness, paralysis on one side of the body, problems with breathing or heart rate, and death. Subdural hematomas sometimes develop more slowly over days and weeks causing gradual memory loss and confusion. It's often mistaken for dementia in older people. 

The injury itself may have been so minor that it's not remembered and people just say they're getting old, they're not what they were a month ago. It's time to get checked out by your primary care physician. This is a CAT scan view of an epidural hematoma. It's often associated with a temporal bone fracture, and if you look at about 10:00 on the head there you can see that there is some sort of fracture to the bone there. The bleeding is rapid because it's arterial. Severe headache develops rapidly or after several hours. A person may initially lose consciousness then appear to recover, only to later rapidly deteriorate. This is one possibility for the talk and die syndrome. If you remember the actress Natasha Richardson a few years ago. This is one possibility of what might have happened to her. 

The diagnosis is again made by CT. The subdural hematoma is bleeding below the dural membrane and that surrounds the brain. The venous vessels bleed, which is slower than arterial, and there's slower rate of decline in mental status. These can be acute or chronic. Like I said, the bump on the cabinet door and you don't even remember doing it and after a few weeks you're forgetting how to turn off the stove after you're done cooking. Concussions. These are often sports-related, soccer, football. And these are more common in younger people. It's defined as an injury induced alteration in mental status without obvious damage to the brain structures when you look at a CAT scan or an MRI. They usually last less than six hours but can have longer lasting effects. 

A person may feel dazed, confused, or unable to recall events surrounding the injury. But the effects of concussion can be cumulative, especially for football players or soccer players that hit the ball with their head, or boxers. It increases the risk in later life for Parkinson's disease, dementia or depression. If somebody comes home after hitting their head in a game they should avoid ibuprofen, they should avoid aspirin, which all increase the risk of bleeding. But Tylenol is okay. Rest is the best treatment. Oftentimes people that have a concussion will experience a post-concussion syndrome. They later have trouble thinking, an inability to concentrate, are dizzy, have chronic headaches, irritability, depression, or anxiety. They have a hard time in school if they're kids. And this may last weeks or months. 

Just a little cartoon. >> Question. >> Yeah.  >> Being that there's now more attention being brought to concussions and they're repeated in football and soccer, and we have one doctor from here who's gone now to Boston and studying them, are you guys encouraged in the neuroscience division for for patients that do pass that kind of fit the mold to donate their brains to that study. >> I'm sorry, I'm not following the question. >> There's this study where they're studying the brains after they die of athletes and such and those who repeatedly have concussions, football players, boxers. >> Okay. I hadn't heard that that was becoming a movement. That's great. That would be very encouraging. 

[INAUDIBLE] >> They could be. I'm not aware of that but I know there's a lot of research going on and any research anywhere I'd be really thrilled with. We need to learn more. The one thing about brain research in the 20 years, we've come a long way, but for every question that we've answered we've come up with a slew more. The more we know the more we don't know. So anyway, these kids and we got to make sure the coach doesn't let them back in. This is just an interesting little thing. This is a functional MRI where they can do an MRI scan of someone and have them do tasks during the scan. And for people without a concussion on the left, you see all these highlighted activity areas, and after a concussion it looks a lot messier. It's not focused as much and people have a harder time. 

 There is changes even though they look fine on the outside. Going on to further types of traumatic brain injury. There's contusions and lacerations. Contusions is a fancy word for a bruise on the brain tissue. Lacerations are tears in the brain tissue caused by foreign objects or skull bone fragments. They form from sudden deceleration of the head after a blow like hitting your head on the windshield. There's the first impact, your skull hits the windshield. Then your brain sloshes forward and hits the inside of your skull. Then your head snaps back and your brain sloshes back and hits the back of your skull. And right there you've got two brain injuries. 

It's called coupe-contrecoup. Symptoms can be mild or severe. Oftentimes we'll have people come in and just watch for overnight or a couple of days and make sure that their lesions don't blossom and that they become truly sick. They often do. The location of a stroke or brain injury impacts the problems that are seen. The effects vary depending on the right or left side of the brain. Right side, an injury affects the left side of the body. But there's also other functions that each side of the brain are in charge of. A right-sided injury would make a person neglect the left side of the body. To that person, there is no left side. 

They are whole straight down the middle. If they wake up and happen to notice an arm laying across their body they'll say, oh, my god, I've got right and left issues, oh, my god who's arm is that in my bed. They will truly not be aware that that's their own arm. They typically have poor decision-making skills. They're not aware that the left side of their body doesn't work. They can get up and walk to the bathroom just fine if I'd only let them. They have no insight at all into what is going on with them. They're impulsive. They don't need help. They're going to get up and go milk the cows. 

They have a short attention span and slow learning. These are the people we might want to cut back on the television watching. They often have speech and swallowing problems, facial weakness and they have a hard time judging distance, size, speed, and position of objects they're reaching for. Left-sided injury creates a different set of problems. It affects the right side of the body, but it also affects language. People have a tremendous difficulty understanding or making speech. Some people have no problem understanding what's being told to them but they cannot for the life of them say what they mean or want to say. And they are tremendously frustrated. Other people can say what they mean but they can't understand a word we're trying to tell them. Some people are totally alone. 

They don't understand anything coming in, and they can't express themselves either. As they make progress and they're in rehab, they're very slow and careful. It would probably take them maybe two hours to get dressed. They've got to check and recheck and be sure. They're also not able to see things on the right side of their body, which is a little different from neglect. It's more of a vision thing. They might bump into walls more. If their motor skills are okay and they're able to walk, they're going to crashing into walls and doorways on the right. They also may have problems swallowing or unclear speech which is different from not being able to understand or express yourself. It's difficulty with the mouth making the word right. 

The impacts also depend on the brain lobe or the part involved or the blood vessel involved. But that's starting to get down deep into neurology. But just as a general rule, the frontal lobe, which is in the forehead, it's involved with movement, intelligence, reasoning, behavior, memory, and personality. It makes you who you are. That's way the helmets should not be up here when you're riding your bike but down over your brow to make sure you're protecting that crucial frontal lobe. The temporal lobe is involved with hearing, language, word recognition, smell, memory and emotions. The parietal lobe has a lot to do with intelligence and reasoning, telling your right from left. I always think I must have had damage when I had my concussion because I have a real hard time with right and left. Language, sensation, and reading. The occipital lobes, the cerebellum and the brain stem, they're down in the back right area there, close to the bottom of the brain. 

The occipital lobe controls vision and perception of vision. The cerebellum is all about balance, coordination, and eye movement. If your cerebellum is damaged with stroke or brain injury you're going to be nauseated, you're going to be dizzy, and the world is going to be spinning eternally. The brain stem controls your basic primitive functions, your heart rate, your breathing, and your blood pressure. Brain stem strokes are devastating. With all that being said, quality of life is something we deal with every day on our unit. I try to encourage people now sitting here to draw a line in the sand, think about what is your definition of quality of life. There's as many as there are people. Go ahead. >> Where does the spinal cord end and the brain stem begin? >> It starts going, the spinal cord ends around C1. 

It's not like a distinct cut off. It starts going into the brain stem, the pons, the medulla, and midbrain and so on and so forth. So it starts coordinating everything there that it's picking up from the outside of your nerves and your fingers and stuff like that. It goes through the brain stem and into the core of the brain where it starts, it's like a gateway. It starts sending out messages to the different lobes. [INAUDIBLE] >> It's the top of the spinal cord. It's fuzzy. It's all one beautiful piece of equipment. But anyway, think about your own definition about quality of life. There is no right or wrong position. 

For some, a spark of life is all that's needed. For others, you might want to be everything of who you are today or not at all. For most of us, the line is somewhere in the middle. Think about where your line in the sand is. Yeah. >> And I would suggest that be prepared to find that that line moves when you're in that position. >> Absolutely. That's a very good point. Talk about outcomes and expectations with the doctor. Early on most people are overwhelmed by fear, anxiety, and too much new information. 

Take notes. Ask questions of the nursing and medical staff. If the nurse who's at the bedside 24/7, you'll see the doctors maybe 10 minutes a day, if she can't answer it, she'll try to find the answer or we'll get you to the physician. Write down your questions and the answers because they're hard to hold onto in your head when you're under stress. Certain questions to the ask the doctor. When the doctor talks of survival, ask for specifics. What does he mean by survival, or she? Is that going home to be a parent and back to work? Or is that being in a coma, living on a machine? Or is it needing a nursing home forever to be cared for? Is there any hope for continued improvement after discharge? And improvement to what point over what period of time? These will help guide your decisions. How does the answer you get fit with that person's line in the sand? Some complications of long-term immobility. Pneumonia, other infections, blood clots that are called DVTs, or deep vein thrombosis. These can move through the blood stream causing respiratory distress or stroke, contractures or stiff limbs and pressure ulcers. 

Advanced directives. The healthcare power of attorney. Talk to your family, make your wishes known. It may be somewhat difficult now but will save much distress when they're trying to guess what you wanted while full of grief. Appoint someone to carry out your wishes. This may not be the most obvious person. Be sure that that appointee is willing and able. Especially this is important to have this legal document in nontraditional relationships that are not legally recognized so that we don't have to go down the next of kin line which may not be what that person intended. Parting thoughts. Quit smoking. 

Wear a helmet. Complete your advanced directives. Discuss with your family what matters to you in matters of life and death. Practice moderation in all things. And take good care of your body. And then there's some resources this week. Actually at 9:00 tonight there's Consider the Question, a documentary about preparing for the end of life. It's on the Wisconsin Channel at 9:00pm, and it runs various other times later this week. I think tomorrow at 2:00 and I don't remember the rest of the schedule. But I believe it will be online for viewing later this week. 

If you need some, I've got a couple of healthcare power of attorney forms with me. Otherwise, you can go online and download them. And you can Google search Wisconsin healthcare POA for further resources. And that's it. Thank you. [APPLAUSE]