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My name is Tom Zinnen. >> Tom Zinnen: Welcome, everyone, to Wednesday Nite at the Lab.
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.
night, 50 times a year. Tonight I'm delighted to be able We do this every Wednesday
She's been a registered nurse for 22 years and has worked at to introduce to you Beth Niblack-Sykes.
the bedside with the neuroscience population for
almost all of that time.
She has additional certifications as a critical
nurse. care nurse and as a neuroscience
at University Hospital Her current position is as a care team leader for the Neuroscience Intensive Care Unit
and Clinics. She has a bachelor's degree.
Both from UW Madison. One in animal science and another in nursing. SAnd 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
I am used to talking with small groups of people in circles sitting on chairs so do bear for having 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
The families take the brunt of even aware that they're there.
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
nurse's discretion for the interpretation to the nurse's discretion who's caring for the patient and for the charge
benefit of the whole unit. The charge nurse is also the
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
A lot of rules. One of the things that we think about when we loosen the rules More rules.
new they are to our unit. All these things get people in a is how sick the patient is, how
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
The things that will make us their life.
clamp down are 50 family members per patient.
People that are interfering with We don't have the room.
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.
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
planning which starts on day coordinate the discharge
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
therapists work with patients in very closely. The occupational and physical
starting their rehab process from day one. They'll be following, most of
our patients will be seen by
the hospital, not only in the occupational, ICU.ical therapy, and speech therapy probably daily throughout their stay at
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
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
Palliative care services are for available to everybody.
those who are dealing with advanced disease or devastating injury.
And we help people make decisions about treatment options and discharge options,
What to expect once you get into as well as emotional support.
the ICU. There's going to be a lot of
equipment. tubes, cords, wires, and
When I first stepped into an ICU as a brand new nursing
the patient on the bed because assistant, I couldn't even see
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
helps us drain spinal fluid if a small catheter that goes into the patient's head and measures the pressure in the head and
needed. The patient monitors are kind of ubiquitous throughout the
hospital but particularly in the
Not only are they visible at the ICU, and they measure blood pressure, heart rhythm, oxygenation.
patient bedside but we also have central monitors so when we're
staff can follow how the vital not directly in the room the
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.
What happens when someone is IVs are ubiquitous too. I don't think there's a patient in there that doesn't get an IV.
admitted and the family is waiting in the waiting room,
Well, they're transferred to an ICU bed, and all those wires and waiting and waiting?
If a patient needs a ventilator, cables are hooked up to the bedside monitor.
the respiratory therapist is assessing the patient's need and
The IVs are checked and checked again for patency to make sure setting up the ventilator.
checked and triple checked that they're working. And the medications are double
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
And that is compared to what was in greater detail later.
What happens next? given from the last report. Then a head to toe physical assessment is given.
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
leading to the admission. There's also a whole slew of them regarding the events
answer. And those are like, do you wear glasses, do you have dentures, enlist family members to help us
problems, diabetes, what's going do you have blood pressure
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
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.
on. There's a lot of people working routall at once.CU. There's a lot of things going
the hospital, pretty much the same thing will be happening but When you're on general care in
the moment. So things can move slower. it won't be as fast paced and usually people aren't as sick at
Did that answer your question? Okay.
In our patient population oftentimes if they come from an outside hospital or from another
been done at the outside. And that tells us how they facility, often a CT scan has
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
if not more often. the patient probably every hour
And that's 24/7. And the average length of stay
three weeks. for some of our patients is
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
rest until the next hour when we sleep and we want to let them
It seems to me that to prevent wake them up again. >> What about television? I don't see the real issue.
into each case. If somebody is awake enough that television... >> And that's what we take
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
differentiating what's happening television and have a hard time
on TV to what's real, we may have them turn off the TV.
shouldn't say most of our patients, a lot of our patients are in a comatose state of some Mdegree or another, and
oftentimes well we'll just have what we call the care channel on, which is very peaceful
music, which helps. [INAUDIBLE] >> It can be. musiIt can be too muchical
for the patient.
And a lot of our patients, that Like fits them right there.ed a nap and is the end of the day and they are just losing it.
And the thing you got to do is just shut down and just have one
person dealing with them to help
exhibit. them calm down. There's a wide range of behaviors that our patients
We're very familiar with that Not the lpopulation.ulsivity, Did that answer your question? confusion.
Okay. >> I knew a stroke patient who >> No.
[INAUDIBLE] >> He was prevented from was prevented from watching television...
excited. watching C-SPAN and the news. >> Because it might get him
And I think... >> It could be if he was getting
and raising his blood pressure. And as a stroke patient, we're upset about what he was seeing
pressure issues. very cautious about blood
The nurse assessed that, hey, We when he watches C-SPAN andnd that might have been what was doing it.
I understand. >> Sometimes we have to keep starts getting mad about what's going on or whatever.
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.
the slide, when a person goes to So when a person, going back to
CT scan, the patient always goes on a bed with a monitor,
least one or two other staff accompanied by their RN and at
members. If they have a ventilator, the
with them, and everybody stays respiratory therapists will go
facility, getting ready for the wscan, getting to the scan, and scan. Oftentimes, at least in our
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
checks. in bedsThey happen a lot.f like that. So I've talked a lot about neuro
monitor the progression or This is a repeated neurologic assessment that's designed to
some key components. regression of symptoms. They're personalized to the patient but they all contain
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?
this, they're already fed up. It's also 3:00 in the morning Nand they haven't been asleep people are easily able to answer
But we still need them to answer yet.
It's important that the patient, us. We need to know that they can answer us because it can change.
not the family or friends, answer the question because we
how they're going to tell us. Just by those three stupid want to know what they know and
and participate. questions, we can tell how hard it is for the patient to wake up
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
We're going for a CAT scan. After that, we request them to Bill. Hey, something's different.
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
nor do we want to use them if we medications to take it away and
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
you need to go to surgery. the pain medication or because
So we're in a rock and a hard Other medicaspot. that aren't sedatSo we use ice bags.sk of 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.
how alert the patient is for us. This is the Glasgow Coma Scale. It's a commonly used scale that we use to get a rough idea of
exam. Anybody that scores about a Somseven, we're seriously a three for showing up for the
breathing tube. And less than that, they're getting one. considering giving them a
we look, let me go back here, we At the bottom of the scale when
look at the best motor response at the bottom. And it says abnormal flexion
posturing and extension posturing.
The first one, abnormal posturing is decorticate Those are some of the lower scoring things.
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
and everything like that. That is going closer and closer where there's brain stem damage, bottom includes a wrist rotation
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.
we specialize in, strokes, of which there's two types: The neurological conditions that
of blood flow usually due to ischemic and hemorrhagic. Ischemic means that there's loss
a clot, a blood clot or a plaque formation that has closed off a blood vessel.
Hemorrhagic can be from high
the blood vessel. blWe also see brain tumors,sm traumatic brain injury, and to a ruptures and blood leaks out of
injuries. They usually go to a different lesser extent spinal cord
unit than ours but we do see them occasionally.
If you don't walk away with anything else today, please know
Sudden weakness, numbness of the the signs and symptoms of a stroke.
face, arm, or leg, especially on one side of the body. Sudden confusion.
Trouble speaking or understanding.
Sudden trouble walking, dizziness, loss of balance, or Sudden trouble seeing in one or both eyes.
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
Or if you have some of these either have it or you don't?
You can just have one of them. symptoms... >> To have a stroke you don't have to have all of these.
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?
blood vessels in the brain like a garden hose and it gets pinched off, there's no water flowing through, there's noe
blood flowing through and everything downstream from where
If it's in a bigger vessel, say in the neck, it's going to that blockage is, that tissue dies.
If it's in a smaller, more affect half your brain. Half your brain will die.
affected. Hemorrhagic, it's a rupture of a brain, it will be a smaller amount of brain tissue that's
surrounding brain tissues. blood vessel interrupting blood flow and allowing blood into the
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,
and lipids, and heart disease. diabetes, elevated cholesterol
Those are things that can be managed but they never really go
I think my slides are out of away.
order. Anyway, the incidence of stroke.
death in the United States. It's the leading cause of serious long-term disability. IAnd it can occur in all ages.f
25% of strokes are younger than 65 years old. At one point in the last year on
third of our patients were in their 20s that had had strokes. >> Do they know what the cause our unit, I think probably a
people are? >> Part of our stroke work-up is of those strokes in younger
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
they're successful. Obesity. four or five times before
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
Excessive alcohol intake. doThere's help and resourcese and keep doing it and start building.
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
They have stronger incidence of high blood pressure. Americans have higher risk.
increases your risk, therefore Just having a strong family history for blood vessel disease
pick good parents and you'll be halfway ahead of the game. Ischemic stroke, it's a blockage
of the blood vessel, either with
The affected brain tissue dies a blood clot or plaque, and there's no flow from that blood vessel down stream.
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
pressure is to limit the sodium or salt intake, but that's very difficult to do. the way to reduce high blood
Because salt is in all foods, all canned foods, prepared >> It sure is.
movement to get the food supply free of salt so that you can add foods, how do you get salt-free foods and why isn't there a big
it at the table or in your own cooking?
Salt, people like salt. [LAUGHTER]
And food manufacturers want us to buy their product and they're going to put salt in it. the table.
It also allows them to put less flavor in because the salt It's also a preservative.
contributes to the flavor. It's up to us.
There's an increasing movement. There's more and more availability all the time.
can get low sodium versions of a I know, like chicken broth, you
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,
The best thing to do is to like you said.
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
It's frustrating. It's very frustrating. things. >> I just am puzzled.
>> 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
can make a big difference. the symptoms are acted on
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
symptoms to use that drug to window, I believe, right now is six hours from the onset of
can go a little farther out, but help break up the blood clot. In some cases the doctors may evaluate the patient and say we
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
reverse the stroke. >> How does it work? six hours, we may not be able to
actively clotting. >> What it does is it breaks up activating clots that are
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.
clot so completely that you don't get fragments blocking Yeah. >> Does the tPA break up the
smaller vessels? >> Right.
Because as soon as it opens up
that blood vessel, and even if there were to be small clots
right behind them working on going downstream, it's following
in that had a clot in her neck. It was affecting the whole side I've seen of her body.s happen. We had a young woman that came
She was going to be severely She had a one-year-old at home.
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.
There can be and that's where you get a TIA is what we call it. >>It's a transient ischemice?
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
a few minutes and then it gets or difficulty speaking for maybe
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
now for that. sBut we can hopefully give them we can't do as much about that. There's no miracle drug right
supportive treatment, let them recover from the stroke, and
then if they have plaques in
remove those fatty deposits of their arteries, there's a surgery we can do a few weeks down the line that will help
plaque from the carotid arteries in the neck.
damage that has already occurred, it's used to prevent This does not correct any stroke
strokes in those that are at risk for them.
Intracerebral hemorrhage, these have different names because
more deadly than the ischemic strokes. they sort of have different mechanisms, but these are much
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
hemorrhages and those are caused devastating are the subarachnoid
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
This is where you have that sudden thunder clap headache. The worst headache of my life. once they get worked up for one.
nausea and vomiting and rapid loss of consciousness. Often associated with sudden
Most people don't make it to the hospital.
Those that do, 50% die in the first month.
a nurse with us after her aneurysm. Hemorrhagic stroke treatment. wUsually we try to evaluate thew
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
vessels and they can see the beautiful three-dimensional image that they can spin around and it'll look at all the blood
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
us drain off spinal fluid. monitors the pressure and helps
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.
If they can find the aneurysm. Usually that's within 24 hours.
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
this is an option, people have aneurysm, it all depends on the shape and the location whether
very good results from that. That's only the beginning.
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.
again, and it can cause further strokes, ischemic strokes. What's that like? That's like a crimped off hose
So we keep these patients in our ICU for about three weeks,
if not longer.
population that we see a lot of. Every hour, neuro checks, 24/7. They're cranky. Brain tumors is another patient
tumors that are cancers that There's a wide variety of brain tumors. We see a lot of metastatic brain
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
little bits that can't be seen. And they do not spread to other parts of the body but they can can see, but oftentimes there's
Then there's nonmalignant brain tumors which won't spread and they don't spread to other parts spread and regrow in the brain.
seriousness depends on where of the body, but their
usually like a morning headache, they are in the brain and how big they are. The symptoms of brain tumors is
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
And I want to specify in an adult because children have seizures regularly for many ononlethal reasons, fevers and.
such. Traumatic brain injury. The causes vary by gender, race,
Motor vehicle crashes, cars, age, and geographic location.
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
the very old and the very young. for traumatic brain injury in
A certain amount are work-related, a certain amount
violence, hunting, suicide. Alcohol use is a common denominator in all of these. are caused by fire arms:
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,
bone mass. decreased flexibility, decreased
It's the leading cause of death from injury in the 65 and older elderly inage group.ronmental hazards in the home.
effect is the loss of independence, in part due to The most profound nonlethal
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
balance is even worse, and begin with. Now they're injured and recovering from that so their
they're more at risk for falling.
Osteoporosis increases the It's a cycle.
calcium, vitamin D, and chaweight-bearing exercise.l. Starting now, if you're 18, 15, 11, make sure you get enough
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.
Use color and contrast to define Get regular vision exams.
denote change of level. And, the thing I always forget, Uclean your eyeglasses often to the first and last stairs so
Medications. improve visibility.
You want to make sure that Have your doctor and pharmacist review your medications regularly.
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
falling. or you can go with a lower dose that might decrease your risk of
People who take multiple medications are at a greater
Like I said, there's side effects that affect mental risk of falling.
you get up suddenly. alertness, balance and gait, or drop your blood pressure when
Environmental hazards. Sometimes the side effects of a couple medications will combine to increase the effect.
The most common is tripping over objects on the floor. Loose throw rugs, tape down the
edges of the large throw rugs,
Use stronger bulbs, night lights get rid of the little ones. Get rid of clutter. Improve your lighting.
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
furniture, that family heirloom that's kind of wobbly. sturdy or get them installed. Get rid of the unsteady
Be sure electrical and phone cords are out of the way, and
use non-skid mats in the
to summarize. Now we're moving on to There's lots of other suggestions, too, but I'm trying
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.
the blood vessels, it's got the brain tissue, and it's got an accumulation of cerebrospinal It's gotfluid or CSF.g through
Anytime something changes in
tumor or a collection of blood, it starts building up pressure. After the pressure starts sbuilding, the pressure itself a
starts squeezing on the brain tissue and causing more damage. And again you're in that cycle
Then it starts blocking the cerebrospinal fluid flow and of trouble.
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
center where that's a space where there's a collection of skull dospinal fluid.tricles, That tube will measure the ICP,
which we can read on the
As the pressure goes up we can monitor, and it allows us a way to reduce the pressure in the head.
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
that's the monitoring device and pole. It's not the best picture but
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
This could be somebody that fell serious problems. The signs and symptoms of increased ICP.
on the ice, got back into the house, has a headache, and a little while later they start
feeling sick to their stomach,
Somebody should already be vomiting. They start seeing blurry or double, sensitivity to light.
calling 911. Eventually there will be
irritability. If they were at the doctor and drowsiness, confusion,
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
Traumatic brain injury or TBI. which is bleeding between the dura mater and the next layer down, the subarachnoid.
Intracranial hematomas, like what we just saw, form after a
to accumulate. blow to the head and cause blood
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
swelling, and that causes increased ICP which then causes part omore damage.cell. The brain cells die, causing
can do about that. There's nothing surgical that we
Oftentimes we can do surgery for the hematomas to relieve the
As with all head injuries, injury.
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
Large hematomas press on the minutes.
brain causing swelling and sometimes herniation, which is
The symptoms include confusion, loss of consciousness, paralysis definitely life threatening.
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
It's time to get checked out by your primary care physician. what they were a month ago.
It's often associated with a This is a CAT scan view of an epidural hematoma.
temporal bone fracture, and if you look at about 10:00 on the
there is some sort of fracture head there you can see that
to the bone there. The bleeding is rapid because it's arterial.
Severe headache develops rapidly
recover, only to later rapidly or after several hours. A person may initially lose consciousness then appear to
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
bleeding below the dural CT. The subdural hematoma is
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
to turn off the stove after cabineyou're done cooking. even remember doing it and after a few weeks you're forgetting how
Concussions. These are often sports-related,
soccer, football. And these are more common in
induced alteration in mental younger people. It's defined as an injury
status without obvious damage to the brain structures when you look at a CAT scan or an
MRI.
A person may feel dazed, They usually last less than six hours but can have longer lasting effects.
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
hitting their head in a game life for Parkinson's disease, dementia or depression. If somebody comes home after
they should avoid ibuprofen, they should avoid aspirin, which
bleeding. But Tylenol is okay. all increase the risk of
concussion will experience a Rest is the best treatment. Oftentimes people that have a
concentrate, are dizzy, have post-concussion syndrome. They later have trouble thinking, an inability to
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
players, boxers. such and those who repeatedly have concussions, football
>> Okay. I hadn't heard that that was
That's great. That would be very encouraging. [INAUDIBLE] b>> They could be.t.
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.
question that we've answered The one thing about brain research in the 20 years, we've come a long way, but for every
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
There is changes even though people have a harder time.
they look fine on the outside. Going on to further types of
There's contusions and traumatic brain injury.
lacerations. Contusions is a fancy word for a
Lacerations are tears in the bruise on the brain tissue.
brain tissue caused by foreign objects or skull bone fragments.
deceleration of the head after a They form from sudden
blow like hitting your head on the windshield. There's the first impact, your
skull hits the windshield.
Then your head snaps back and your brain sloshes back and hits and hits the inside of your skull.
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
To that person, there is no left of the body.
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
issues, oh, my god who's arm is that in my bed. They will truly not be aware god, I've got right and left
They typically have poor that that's their own arm.
They can get up and walk to the bathroom just fine if I'd only They're not aware that the left side of their body doesn't work.
what is going on with them. They're impulsive. let them. They have no insight at all into
milk the cows. They don't need help. They're going to get up and go
They have a short attention span and slow learning.
want to cut back on the television watching. These are the people we might
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
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.
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
It's difficulty with the mouth which is different from not being able to understand or express yourself.
making the word right. The impacts also depend on the
or the blood vessel involved. But that's starting to get down deep into neurology. brain lobe or the part involved
frontal lobe, which is in the forehead, it's involved with But just as a general rule, the
personality. movement, intelligence, reasoning, behavior, memory, and
riding your bike but down over It makes you who you are. That's way the helmets should not be up here when you're
The temporal lobe is involved ywith hearing, language, word protecting that crucial frontal lobe.
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
Language, sensation, and damage when I had my concussion because I have a real hard time with right and left.
reading. The occipital lobes, the
they're down in the back right cerebellum and the brain stem,
vision and perception of vision. area there, close to the bottom of the brain. The occipital lobe controls
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.
sitting here to draw a line in I try to encourage people now
There's as many as there are the sand, think about what is your definition of quality of life.
end and the brain stem begin? >> It starts going, the spinal Go ahead. >> Where does the spinal cord
cord ends around C1. It's not like a distinct cut
off.
It starts going into the brain stem, the pons, the medulla, and
So it starts coordinating everything there that it's midbrain and so on and so forth.
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
gateway. where it starts, it's like a
It starts sending out messages to the different lobes. [INAUDIBLE]
It's the top
equipment. of the spinal cord. It's fuzzy. It's all one beautiful piece of
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.
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
Ask questions of the nursing and overwhelmed by fear, anxiety, and too much new information. Take notes.
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
Write down your questions and the answers because they're hard we'll get you to the physician.
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?
Is there any hope for continued improvement after discharge? Or is it needing a nursing home forever to be cared for?
These will help guide your And improvement to what point over what period of time?
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
The healthcare power of or stiff attorney. pressure Talk to your family, make your Advanced directives.
It may be somewhat difficult now wishes known.
but will save much distress when they're trying to guess what you
Appoint someone to carry out wanted while full of grief.
your wishes. This may not be the most obvious
Be sure that that appointee is person.
nontraditional relationships willing and able. Especially this is important to have this legal document in
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
schedule. But I believe it will be online for viewing later this week. don't remember the rest of the
couple of healthcare power of attorney forms with me. Otherwise, you can go online and If you need some, I've got a
And you can Google search Wisconsin healthcare POA for download them.
further resources. And that's it.
Thank you.
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