What a pain!
July 21, 2013 2:50 PM   Subscribe

My 79 year old dad fell and hit his head on the metal bathtub door runner 3 weeks ago. He was outside of the bathtub, fell backward, and hit the base of his skull on the right side. It is continuing to hurt at a level that makes him not want to take care of his basic needs beyond getting to the bathroom. I am working on getting home nursing and custodial services set up, though he's convinced that if he could just get the headache to go away, he wont need any of those services. What's the cause, what's the treatment?

Initially, his headache was tolerable, but got progressively worse after a couple days until he got worried enough to take a cab to the emergency room. They did a CT scan, didn't find any spinal injury, concussion, on anything else they could treat, so sent him home with instructions to take Advil and rest. When he laid still the pain was tolerable, but when he would try to stand up, he would get explosive shooting pain from the right side base of his scull that he thinks was the point of impact. It continued to get worse, so he went back to the emergency room where they prescribed Tramadol and Diazepam and sent him home. My sisters and I all live out of town and he doesn't have any friends close enough for him to feel like he can bother so nobody knew about any of this until one of my sisters phoned and found him fairly incoherent, and not having eaten anything for 3 days. I live closest so called and told him I'd be flying down. He emphatically told me not to come, he was fine so long as he didn't move and would eat when he was hungry. We told him to stop taking the medicine and I was on the next plane. We have since been to a pain specialist, his primary care physician, had a visit by a home health care nurse, and an evaluation from a physical therapist. An appt. with the neurologist is tomorrow morning. They have ruled out whiplash, muscle injury, prescribed Cymbalta, Lymbrol, and a topical concoction. We have done ice, and recently switched to heat. They have stressed the importance of getting out of bed even though it's uncomfortable. The pain is its most acute when he's in the process of getting up or getting down, though bad any time he is upright. He still won't get out of bed voluntarily except to go to the bathroom. I am getting him up for meals and trying to keep him but am met with resistance. He is not interested in going to a rehab facility or considering assisted living, and again, is convinced all will be fine when the pain goes away. I won't go home until I know his medical and custodial needs are being met (have been in contact with OneGeneration and waiting on a call back from Jewish Family Services - he lives in Tarzana and these were suggested by neighbors with elderly parents). I should also note, he's fiercely independent, private, has lived alone for 45 years, is a hoarder, and has never had any of his neighbors in his house, though they have offered to check in on him. He does have a lifeline bracelet. I realize as I have been writing this, this is about so much more than the pain question, but that's HIS immediate need and concern, so if you have any ideas on that or have experienced and remedied a similar localized pain, let me know. But don't feel like you have to stop there.
posted by ms_rasclark to Health & Fitness (12 answers total) 1 user marked this as a favorite
Has anything helped? You describe a lot of different interventions, but I'm not sure if anything has eased his pain... How much Advil did they tell him to take? The dosage recommended for severe pain from strains/sprains/etc. is quite high compared to what it says on the bottle that you buy at Target or whatever. Has no one prescribed a narcotic at any point?

I am so, so far from being a doctor, but I have parents that will be like this when they are old enough and I try to keep on top of information that will help them. If he is convinced that he will be fine when the pain goes away, and there are things that you could still try to make the pain go away, I would go in that direction. Rest, Ice, Compression, Elevation, as I'm sure you know, are the ways to go in a mildish trauma kind of situation. You say you have "done ice" but has it been enough? I have had foot injuries that still benefited from periodic icing (hours at a time) 6-8 months later.

It sounds complicated; I feel for you. I'm sure other posters will have better plans for your specific situation.
posted by slenderloris at 3:07 PM on July 21, 2013

How was his blood pressure? One of my coworkers had a problem with a massive headache where the pain made her blood pressure go up to scary levels, which made the headache worse, which kept her blood pressure up, etc. The doctor gave her narcotics to keep the pain down so they could get the blood pressure down, and she had to stay on the painkillers for a while even once the headache went away (if she stopped, the pain came back and the blood pressure shot back up).
posted by Blue Jello Elf at 3:24 PM on July 21, 2013

Best answer: Really sounds like a subdural hematoma, but they should have seen that on the CT scan.

Despite the CT, I would ask your neurologist to absolutely rule out a subdural hematoma.
posted by jamjam at 4:18 PM on July 21, 2013 [2 favorites]

Response by poster: When he was doing Advil, it was 4 at a time. Nothing we've tried has made any lasting impact. Blood pressure was high at the dr. appt. then low when it was taken by the visiting home healthcare nurse and was lying down (thus low pain). Will ask about the subdural hematoma tomorrow. That feels about right, though not the acute kind or I'd probably be writing a different kind of post.
posted by ms_rasclark at 5:01 PM on July 21, 2013

I would get a really detailed description of the headache from your dad and keep a headache journal for him with ALL the detail you can on meds, pain and movement or activity. Precisely what brings it on (like angle of incline, light, is it associated with movement or just being upright?) and write it down. Bring that to every appointment.

As someone who has had a number of concussions this does happen although not normally for so long to me anyway. He may, however have a strained tendon or muscle in his neck (presumably the neurologist will do this) and his instinct that it will heal up with rest could very well be spot on. Also be aware that small fractured sometimes don't show up on xray, although I'm sure your doctor has explored that thoroughly, all I'm saying is that they may ask him back again.

One other thing is to see a dentist in case it's his jaw. You can crack a back tooth falling like that and tooth pain is weird.

Finally consider rebound headaches from the nsaids. These can be brutal for some people.
posted by fshgrl at 5:16 PM on July 21, 2013 [3 favorites]

That sounds remarkably like the subdural hematoma my dad suffered from after his fall. It showed as being quite small on the initial scan, but when he became incoherent a fee weeks later it has grown to a size that they needed to do a craniotomy.

I would just suggest you continue getting CAT scans and/or MRIs.

Good luck.
posted by waterisfinite at 6:05 PM on July 21, 2013 [2 favorites]

Nthing the headache journal and getting the neurologist to do all the testing, etc., over again (that you can get done, obviously.) Especially because subdural hematomas can take a while to show up, per Wikipedia anyway.

Also, make sure those folks at OneGeneration do the full client assessment. He may be a candidate for a guardianship given his near-total inability to care for himself (especially with the psychiatric issues on top of this situation, and his advanced age.)
posted by SMPA at 6:10 PM on July 21, 2013

I had a head injury about 18 months ago. I had to get two follow-up CTs in addition to the first one I had in the emergency room, just to make sure I didn't have a subdural hematoma that had been missed.

The impact also strained the muscles in my neck, which was painful for a while afterward. The only thing that really helped was hydrocodone, which I hated.

I hope your dad can get some answers and starts feeling better really soon - debilitating pain sucks.
posted by easy, lucky, free at 7:01 PM on July 21, 2013

Best answer: Something's wrong here and it's not being diagnosed. He could definitely have a slowly leaking subdural that wasn't apparent on the initial CT scan, but whether that's the story or not, he needs someone to actually take notice and examine him neurologically and from a vascular standpoint at once. It's possible that a vascular problem in his heart or neck could have actually caused the fall in the first place, particularly since there are changes with movement. What's happening now could even be a reaction to the pain meds he's been given. Old people in particular are known for dementia-type reactions to medications and sometimes they end up in nursing homes when the real problem is they need a change in their medicine.

You're doing a great job and I know he's cranky and uncooperative, but that's really most likely due to the unrelenting, blinding pain, and he honestly can't even consider moving to a different living arrangement when he can't bear to move at all. He's probably 100% right when he says that everything will be fine if the pain just goes away.

Get as loud and stubborn as you have to as you advocate for him with the doctors; they're good guys, but they're not gods, and they can miss things sometimes. Also, new doctors base most of what they do on what they're told by the referring physician - you might need to make it clear that he needs a whole new approach to this problem - and stand on that. Pay no attention when they tell you that Medicare won't pay for this or that - they usually do anyway, and that should never be a reason to deny medical workup or care.

Good luck to you both - I hope he gets relief very soon.
posted by aryma at 7:08 PM on July 21, 2013 [5 favorites]

He may be a candidate for a guardianship given his near-total inability to care for himself (especially with the psychiatric issues on top of this situation, and his advanced age.)

Pay NO attention to this kind of crap until you KNOW that all the physical problems have been identified and resolved as best they possibly can.
posted by aryma at 7:10 PM on July 21, 2013 [4 favorites]

Something is wrong and he should go back to the E.D.

Also- he should stop taking ibuprofen for now. It thins the blood and will exacerbate any bleeding he may have.
posted by brevator at 4:12 AM on July 22, 2013

Response by poster: Neurologist visited, MRI scheduled, nursing and custodial services lined up until resolved one way or another, excellent and specific MeFi support appreciated!
posted by ms_rasclark at 2:41 PM on July 22, 2013 [1 favorite]

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