Hospital (and carer) notes for M.E.
2006-10-31 18:00:56*please repost* *please repost* *please repost* *please repost* *please
repost* *please repost*
This is part one of the paper, part two is a form patients can print out and
fill in (or tick the appropriate boxes on) that goes into detail about their
symptoms of M.E. and their specific disabilities. I haven't included it here
because the formatting would be all over the place due to the plain text
format. An ability/disability scale is also included.
Here is part one:
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Hospital and carer notes for Myalgic Encephalomyelitis
Copyright © by Jodi Bassett, April 2008
Available: http://www.ahummingbirdsguide.com/hospitalandcarernotes.htm
Patients with Myalgic Encephalomyelitis have a variety of specific care
needs, some of which are well-known and common to a variety of other
illnesses and others which are unique to M.E. and with which hospital staff
or carers may be wholly unfamiliar.
Inappropriate care (even if well intentioned) can have serious consequences
for M.E. patients in the short term and the long term, or even permanently.
Knowledge of some of the basics about how M.E. affects the body is vital if
you are in the position of providing care for someone with M.E. in order to
avoid additional unnecessary suffering and disability. This paper provides a
brief overview of this topic for hospital staff and carers.
What is Myalgic Encephalomyelitis? How does it affect the body?
Myalgic Encephalomyelitis is a debilitating neurological (CNS) disease which
has been recognised by the World Health Organisation since 1969 as a
distinct organic neurological disorder with the code G.93.3. It can occur in
both epidemic and sporadic forms and over 60 outbreaks of M.E. have been
recorded worldwide since 1934.
M.E. is an acute onset neurological disease initiated by a virus (an
enterovirus) with multi system involvement which is characterised by post
encephalitic damage to the brain stem (hence the name 'Myalgic
Encephalomyelitis'). M.E. is similar in a number of significant ways to
diseases such as multiple sclerosis, Lupus and Polio. At least 25% of M.E.
sufferers are severely affected and are almost completely (or completely)
housebound and/or bedbound. Children as young as five can get M.E., as well
as adults of all ages. M.E. has a similar strike-rate to multiple sclerosis
and is a (potentially fatal) chronic/lifelong illness.
M.E. is primarily neurological, but because the brain controls all vital
bodily functions virtually every bodily system can be affected by M.E.
Although M.E. is primarily neurological it is also known that the vascular
and cardiac dysfunctions seen in M.E. are also the cause of many of the
symptoms and much of the disability associated with M.E. - and that the
well-documented mitochondrial abnormalities present in M.E. significantly
contribute to both of these pathologies. There is also multi-system
involvement of cardiac and skeletal muscle, liver, lymphoid and endocrine
organs in M.E. Some individuals also have damage to skeletal and heart
muscle.
Thus Myalgic Encephalomyelitis symptoms are manifested by virtually all
bodily systems including: cognitive, cardiac, cardiovascular, immunological,
endocrinological, respiratory, hormonal, gastrointestinal and
musculo-skeletal dysfunctions and damage. Myalgic Encephalomyelitis affects
the brain, the heart, almost every bodily system and every cell of the body.
One of the defining features of M.E. is an inability to maintain
homeostasis.
What all of this means in practice is that patients with M.E. have to be
very careful with or limit:
a.. Physical activity
b.. Cognitive activity
c.. Sensory input (exposure to light, noise, movement and vibration), and
d.. Orthostatic stress (maintaining an upright posture)
The main characteristics of the pattern of symptom exacerbations, relapses
and disease progression (and so on) in M.E. include:
1.. People with M.E. are unable to maintain their pre-illness activity
levels. This is an acute (sudden) change. M.E. patients can only achieve
50%, or less, of their pre-illness activity levels post-M.E.
2.. People with M.E. are limited in how physically active they can be but
they are also limited in similar way with; cognitive exertion, sensory input
and orthostatic stress.
3.. When a person with M.E. is active beyond their individual (physical,
cognitive, sensory or orthostatic) limits this causes a worsening of various
neurological, cognitive, cardiac, cardiovascular, immunological,
endocrinological, respiratory, hormonal, muscular, gastrointestinal and
other symptoms.
4.. The level of physical activity, cognitive exertion, sensory input or
orthostatic stress needed to cause a significant or severe worsening of
symptoms varies from patient to patient, but is often trivial compared to a
patient's pre-illness tolerances and abilities.
5.. The severity of M.E. waxes and wanes throughout the hour/day/week and
month.
6.. The worsening of the illness caused by overexertion often does not
peak until 24 - 48 hours (or more) later.
7.. The effects of overexertion can accumulate over longer periods of time
and lead to disease progression, or death.
8.. The activity limits of M.E. are not short term, a gradual (or sudden)
increase in activity levels beyond a patient's individual limits can only
cause relapse, disease progression or death in patients with M.E.
9.. The symptoms of M.E. do not resolve with rest. The symptoms and
disability of M.E. are not just caused by overexertion, there is also a base
level of illness which can be quite severe even at rest.
10.. Repeated overexertion can harm your chances for future improvement in
M.E. M.E. patients who are able to avoid overexertion have repeatedly been
shown to have the most positive long-term prognosis.
11.. Not every M.E. sufferer has 'safe' activity limits within which they
will not exacerbate their illness, this is not the case for the very
severely affected.
In short, if patients with M.E. exceed their individual post-illness
physical, cognitive, orthostatic and other limits, they will experience some
combination of the following:
a.. A mild-severe (acute or delayed) worsening of one or more symptoms for
hours, days or longer afterward
b.. A mild-severe (acute or delayed) worsening of virtually every symptom
for hours, days or longer afterward
c.. A severe (acute or delayed) worsening of the base level of
illness/disability for hours/ weeks/ months or even years afterward, or
d.. A permanent worsening of the base level of illness/disability (i.e.
permanent physical damage is caused and chances for significant recovery are
adversely affected or taken entirely)
It is also important to be aware that repeated or severe overexertion can
also result in the death of the M.E. patient. (Death in M.E. is most often
caused by heart failure or multiple organ failure.)
So what are the top 10 most obvious things you need to be aware of in
providing care to a M.E. patient?
a.. Reduce exposure to light
b.. Reduce exposure to noise
c.. Reduce/eliminate all non-essential visitors
d.. Do not encourage patients to be more physically active (or upright
longer) than they can easily tolerate
e.. Try to schedule demanding tasks for the patient's best time of day as
much as is possible
f.. Try to reduce the patient's levels of cognitive exertion and sensory
input
g.. Be aware of any special dietary requirements
h.. Be aware of the likelihood of negative drug reactions
i.. Be aware of the need for extensive rest and problems with sleep
j.. Be aware that these aforementioned relapses can be delayed, and that
they can be very serious and prolonged
1. Reduce exposure to light
-Some patients will require the room to be completely dark (or very close to
it), some will be fine so long as blinds and doors are kept closed, while
other patients will fit somewhere in-between these two extremes.
2. Reduce exposure to noise
-At a minimum, doors and windows must be kept closed to reduce noise. Anyone
entering the room must also take care to reduce or eliminate noise as much
as possible, particularly if a patient has severe noise sensitivity.
-Open wards such as in emergency rooms are a DISASTER for M.E. patients.
They WILL without exception cause months or more of severe relapse in the
severely affected and may also cause a more immediate worsening of the
overall condition and should be avoided if at all possible. (Moderately
affected patients may also relapse severely in an open ward.) Sharing a room
with another patient is also inappropriate for the severely affected M.E.
patient and will also cause a high level of increased pain and suffering and
long term relapse.
-The problem here is not merely pain in the ears and painful or burning
eyes. Even low levels of noise or light (and other sensory input) can cause
a significant and prolonged worsening of the severity of the condition
overall, as well as symptoms including seizures, severe mental confusion and
inability to process even very simple information, episodes of paralysis,
problems with proprioception, balance and so on. Pain levels can quickly
soar to a 10/10 level even with moderate or brief noise or light exposure,
and recovery can be prolonged.
3. Reduce/eliminate all non-essential visitors
-As well as reacting badly to the extra noise and light exposure caused by
visitors, patients can also be made sicker by watching the movement of
someone in the room, and by the extra demands made on the brain when talking
and listening to speech is required.
-In the case of cleaners, these should be cancelled for the duration of the
hospital stay, both for the reasons outlines above, and because many M.E.
patients have sensitivities to many common chemicals used in cleaning
products. (Exposure to these chemicals may merely trigger headaches but in
some cases they can cause extremely severe relapse.)
-It is counter-productive and ill-advised to do hourly 'obs' (pulse and
blood pressure checks etc.) on a patient with severe M.E. as this will soon
cause them to deteriorate in both the short and the long term (or even
permanently).
4. Do not encourage patients to be more physically active (or upright
longer) than their bodies and hearts can easily tolerate
-Even sitting up in bed propped up by a few pillows counts as 'being
upright'
when someone is severely affected, and even 30 seconds or a few minutes of
being fully upright may be long enough to cause problems.
-Physical activity doesn't just include strenuous activity, but any
movement. Even simple movements or stretching of the muscles can cause a
worsening of the condition in the severely affected. Physical tasks may need
to be broken up into many smaller tasks with long rest periods in-between.
5. Try to schedule demanding tasks for the patients best time of day as much
as is possible
-Find out when the patient's best time of day is, and try to fit tasks in to
that window as much as possible.
-Don't expect that a patient will necessarily be able to do the same things
at different times of the day. Some tasks may only be possible at certain
times of day, or after a long period of rest. Making a patient do difficult
tasks at the time of day when they are at their most ill, can not only make
the task much harder or impossible, but also cause a far worse relapse than
if attempted at their most well time of day.
6. Try to reduce the patient's levels of cognitive exertion and sensory
input
-Sensory input includes; light, noise, movement, touch and also vibration.
(The vibration felt when by travelling by car can be excruciating. Even
being lifted from one bed to another can be unbearable.)
-Cognitive exertion includes talking and listening to speech, reading and
writing, watching TV, listening to music and so on. Talking as well as
listening to speech can be very difficult or impossible. Cognitive tasks may
need to be simplified and broken up into many smaller tasks with long rest
periods in-between.
-Some severely affected patients are unable to maintain consciousness for
more than short periods at a time. Some may only be properly conscious for a
few hours a day or less. Sometimes consciousness cannot be maintained for
more than 10 minutes or so consecutively (or less). Trying to force these
patients into consciousness for longer periods can only be
counter-productive, unfortunately. It can quickly make the problem even
worse. (Aside from certain medications and other treatments, what will help
improve this condition most is rest.)
-Some patients will require wheelchairs, but those who also have severe
orthostatic problems (problems with being upright, including sitting) must
not be put in wheelchairs at all and will need to be moved lying flat in bed
(or lying flat on the back seat of a car) at all times.
7. Be aware of any special dietary requirements
-Patients will often be intolerant of a large variety of foods. Some may
also have food allergies.
-There may also be strict requirements - due to the metabolic problems seen
in M.E. - that a patient eat every 2 or 3 hours (or even more often) and
that meals or snacks be high in protein and low in sugar and carbohydrate to
prevent relapse. (High sugar or high carbohydrate foods are often very
poorly tolerated by M.E. patients).
-Some patients will require assistance from a carer to eat (or tube feeding
in severe cases). Problems with swallowing can also make eating or drinking
difficult or impossible for the M.E. patient.
8. Be aware of the likelihood of negative drug reactions
-M.E. patients can react badly to almost every type of drug; particularly
those which act upon the CNS. Some severely affected patients are unable to
tolerate any drugs or over the counter vitamins and other supplements at
all, although many will have found a small number of products that they can
tolerate through much trial and error.
-Negative effects from taking certain medications can range from headaches
and feelings of being poisoned, to a severe worsening of the overall
condition, and so on. The relapse caused by medications can also sometimes
be semi-permanent; the patient does not regain the level of health they had
before they tried the new medication.
-All new medications should be started one at a time and at very low doses
(eg. 1/10th of a standard dose)
- If a M.E. patient is in hospital for surgery, please be aware that certain
precautions must be taken with anaesthesia for the safety and wellbeing of
the patient. Please read: Anaesthesia and M.E.
-Patients may also react badly to the chemicals contained in many personal
care products. If this sensitivity is very severe, visitors must avoid
wearing these products as much as possible before visiting.
9. Be aware of the need for extensive rest and problems with sleep
-Patients with M.E. need a lot of rest, but often find it impossible to get
much sleep or find initiating sleep very difficult, or can only achieve a
very low quality of sleep or sleep only for short periods at a time.
-It may take some patients 4 or more hours to initiate sleep. Being
interrupted with noise or light or visitors during this time may make that
period even longer, or prevent the initiation of sleep altogether. Even low
level noise can sometimes wake M.E. patients who cannot achieve normal deep
sleep and so are very light sleepers.
-Some patients cannot ever sleep for more than a few hours a time post-M.E.,
and so they need to be left alone as much as possible in order that they get
these much needed sleep periods. (Sleep doesn't necessarily help M.E.
symptoms much - often patients feel just as ill or even much worse on waking
than they did before they went to sleep - but missed sleep causes severe
worsening of symptoms/disability. The way it feels to have M.E. and not to
have slept much the night before is indescribably horrific, particularly
when M.E. is severe.)
10. Be aware that these aforementioned relapses can be significantly delayed
(and so they are not always visible on superficial examination), and that
they can be very serious and prolonged - or even fatal in a minority of
cases
-Don't make superficial (i.e. wrong!) judgements of a patient's ability
levels. If you want to know how a patient is feeling or if they can or can't
do a certain task, just ASK THEM!
- People with M.E. are very highly motivated to be as active as they
possibly can be (as anyone would be with so many restriction on their
lives), but they know that if they push themselves to do more than their
bodies can handle, the end result will be a huge LOSS of ability levels, and
a higher level of suffering, and so this is not in their best interests.
(The way people with M.E. get to be as active as possible is by carefully
staying within their post-M.E. limits. This also gives the patient the best
chance for their best possible long-term prognosis.)
-Do take the risk of relapse, and the patient's unwillingness to
unnecessarily become far more ill for days, weeks or longer - very
seriously. Many M.E. patients are suffering in a fairly extreme way already,
and their lives are so painful and limited as to almost be unbearable
already, without any additional worsening of the condition.
In conclusion
Just do your honest best. Achieving all of these tasks perfectly all the
time may not be possible, it's a lot to take in and a lot to think about all
at once, but everything that you can do to reduce the relapse from a
hospital stay will make a real difference and be much appreciated. There is
a huge difference between a 2 month long relapse and a 6 month relapse and
between symptoms worsening during this time to a 7/10 level rather than a
9/10 or 10/10 level... or between a relapse that merely lasts weeks or
months, or is semi-permanent or permanent.
(We appreciate what a hassle it is to accommodate the demands of M.E. only
too well. M.E. is an acute onset disease. We went from being normal and
healthy one day to having to cope with all these limits and disabilities the
next. Or from one hour to the next even. We get it that M.E. is very
unforgiving, overwhelming and just a huge hassle to deal with on just about
every level. We think so too. But this doesn't change the reality,
unfortunately.)
Following this text are some additional forms about specific symptoms and
disabilities etc. that patients may or not want to (or be well enough to)
fill out in order to give you more information about their needs, where this
is appropriate. Thank you for taking the time to read this paper.
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Constructive criticism and suggestions welcomed.
If you would like to link to this paper, please do so by using the links to
my site provided rather than a reposting of this text on a third-party
website as only the version on my site has live links and will continue to
be updated.
Available: http://www.ahummingbirdsguide.com/hospitalandcarernotes.htm
To download or print copies of this text in Word or PDF formats, click on
the link above. A large text version is also available.
Best wishes everyone,
Jodi
--
A Hummingbirds Guide to Myalgic Encephalomyelitis:
www.ahummingbirdsguide.com
--
In all M.E. epidemic or endemic patients the patients represent acute onset
illnesses. The fatigue criteria listed here [in the CFS definitions] can be
found in hundreds of chronic illnesses and clearly defines nothing. Dr Byron
Hyde MD 2006