We’ve had a few sad cases in the last couple of months. Both resulted from patients just not taking the medication that they were prescribed. One had already lost an appendage due to Peripheral Vascular Disease (PVD), where circulation is quite impaired due to hypertension, smoking, etc. He was on a potent blood-thinner to save his other leg. He ran out of the drug, didn’t get it refilled, and ended up in the hospital on an even more potent blood-thinner to try to save his leg. He ended up dying due to complications from this.

Another patient was admitted with a large head bleed because he had not been taking his blood pressure medicine. He thought he could control it with herbs. I’m not for or against “alternative medicine” because I don’t know enough about it. I’m sure in some cases, it works, and in some, it doesn’t. The key to any treatment is frequently checking the efficacy, and altering dosage/medication as needed. His bleed is inoperable due to its’ location, and he’s left with a searing headache that is difficult to control… We don’t want him to have pain, but most strong pain relievers are narcotics.

Narcotics alter your level of conciousness. For “neuro” patients in ICU, we do “neuro checks” as often as every hour. For DAYS! We ask for the patient to grasp our fingers with their hands and squeeze… in this way, we assess strength for both its’ presence and equality on both sides. We ask them to lift their legs off the bed, smile, stick out their tongue, tell us their name, the month, the year, and who the president is. All at the same time. (Kidding!)

I once took care of a patient that was very alert and oriented but required frequent neuro checks to be done to assess for a very potential change in her condition. She would merely see me at the door to her room and start rattling off “My name is Alma, this is March 1999, and Clinton is president.” Then proceeded to smile, stick out her tongue, raise one leg off the bed and then the other, then raise her arms one by one. All this without me having to say a word :) I’d say she was well trained!

Frequent neuro checks suck because we even have to do them while the patient is sleeping. After a day or so, the MD might write to skip them if the patient is asleep, but the first 24 hours or so are really awful for the patient. Imagine spending a day or two in a strange environment that never seems to calm down much, and having to be disturbed every single hour! Changes happen very quickly, but they can also happen subtley. A patient might start with slurred speech, but be otherwise normal. Is this because it’s 2am and they’re dreaming, or is their stroke extending?

Anyway, giving narcotics to relieve pain is a huge tightrope walk that we nurses balance along with the neurologists/neurosurgeons. Too much (or even an adequate dose) of narcotic can alter the response to neuro checks and make us worried enough to send the patient back for a cat scan. An expensive test just to confirm that it’s the morphine, ya know? But it’s too risky to chance it. Sometimes it isn’t the morphine. Regardless, it’s very dissatisfying to a nurse to not be able to provide adequate pain relief. Sometimes non-narcs work, but for that kind of pain, that’s a rare thing.

Moral of the story: take your meds. If you are on medication, make sure that you are updated on your refills, or at least call and ask your doctor what would happen if you skipped it for a few days. A mildly depressed person missing 3 days of Prozac isn’t going to be catastrophic. A bipolar person missing their Lithium for 3 days might be. If you feel better taking your medication, that’s a good thing and does not mean that you will feel better without it. Always check with your MD before you go changing your med habits. (This also means NOT buying into the “If one is good, two is better, and three will cure it!” mentality. Most of the time, one is good, two will land you in the hospital, and three will kill you.)

The head-bleed guy, if his stroke does not extend, will end up going home and probably doing fine. He’ll have to withstand a debilitating headache, nausea, and vomiting for at least a few days, but the blood will eventually be reabsorbed by his body. He’s lucky… his stroke occured in an area that did not affect his speech, thought process, or motor function. That does not happen often. I hope he decides to control his blood pressure now… Although he was a very nice man, I’d hate to see him back.