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blood clots coming out of my nose

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  • blood clots coming out of my nose

    With the recent swelling of my right ankle, I've been thinking about blood clots alot. Over the past 2 or 3 years, I've had blood clots coming out of my nose, and I'm wondering if this is normal. I asked my doctor's nurse once, and she didn't think it was a big deal, BUT she screws up all the time. My doctor is great, but I don't trust her nurse.

    Background: I hate having boogers in my nose. I don't pick boogers out with my finger, but I do roll up a kleenex and shove it way up there, usually at least once a day. Sometimes, like maybe a few times a month, the kleenex pulls out a really big blood clot. It always comes from way up there, and it continues to bleed until I get every little and/or big blood clot out.

    I just did an internet search, and didn't find anything, which leads me to believe that maybe this is normal??? I've never heard anyone else talk about blood clots coming out of their nose, but I guess it wouldn't be a commonly talked about subject.

    I'll be calling my doc tomorrow about the ankle, and I'll ask about the nose clots as well. I bring it up here because I like the opinions of many, not just one. TIA.

  • #2
    Shannon, I don't remember now but are you taking aspirin (or other COX inhibitors) or anticoagulants? Wise.


    • #3
      I usually get blood clots in my nose during the winter months. They are worse if I need to blow my nose a lot, but even without blowing much I still have clots. I always thought it must be due to the colder temperature - my nose is perpetually cold in winter. As the weather picks up, the clots seem to fade away.
      Do you get them all year round? Do you have actual nosebleeds? Perhaps your nasal capillaries are just very thinly lined and so easily ruptured. Can't imagine it is something to worry about too much, but maybe a nurse can better inform you.


      • #4
        No, I am not Wise.

        Thanks Carbar, I guess maybe it's normal. It seems like it does happen most often in the winter months. I know regular nose bleeds are common, but I wasn't sure about the blood clots. Usually it starts out as a bleed and it doesn't stop till I get a blood clot out. Once the clot is out, it immediately stops bleeding.


        • #5

          The first thing that your doctor (an otolaryngologist) would do is to identify the site of the bleed. It can be either anterior (in which case the nose can simply be packed) or posterior (which is more difficult to deal with).

          The second is to ascertain the cause of the bleed. It can be the result of a combination of factors, e.g. dry weather increases the tendency for mucosal drying and surface rupture of blood vessels, episodes of hypertension (high blood pressure due to autonomic dysreflexia, for example), and arteriovenous malformations or heriditary telangiectasia (Wehner, et al., 2006), anemia (Damrose & Maddalozzo, 2006; Mahoney & Shapshay, 2006) or anticoagulation. In your case, because of your spinal cord injury, hypertension associated with autonomic dysreflexia is likely to be a risk factor.

          According to Viehweg, et al. (2006), 60% of the population has at least one episode of epistaxis per year. A recent study in China (Wang, et al., 2006) indicate that the most common cause of repeated epistaxis (nose bleeds) was failure to locate the bleeding site. The nasal bleed site should be identifiable through nasal endoscopy (Almeida, et al. 2005). Lund, et al. (2006) carried out a large study of 1297 women aged 50-64, finding that 70% of the subjects had at least one epistaxis episode per year with a mean of 1.88 per subject. There was a high correlation with the presence of passive smoke.

          Many different methods are used to treat recurrent epistaxis. The most common is nasal packing but this needs to be carefully done (Aneeshkumar, et al., 2005). Some doctors even use a foley catheter, presumably blowing up the balloon in the nose (Pellard, et al., 2005). Endoscopic ligation of the sphenopalatine artery turns out to the most effective and has the least complications (Umapthy, et al. 2006; Feusi, et al., 2005; Loughran, et al., 2005). Embolization is another option (Christensen, et al. 2005). One new approach is to use a hemosatic ointment (Passali, 2005). In Germany, Shlegel-Wagner, at al. (2006) recently described a new approach to treating posterior epistaxis with hot water irrigation.

          I hope that this is helpful.


          References Cited
          • Wehner LE, Folz BJ, Argyriou L, Twelkemeyer S, Teske U, Geisthoff UW, Werner JA, Engel W and Nayernia K (2006). Mutation analysis in hereditary haemorrhagic telangiectasia in Germany reveals 11 novel ENG and 12 novel ACVRL1/ALK1 mutations. Clin Genet 69: 239-45. Hereditary haemorrhagic telangiectasia (HHT) is an autosomal-dominant disease characterized by recurrent epistaxis, mucocutaneous telangiectasias and visceral arteriovenous malformations. Mutations in endoglin (ENG) and activin A receptor type II-like kinase 1 (ACVRL1 or ALK1) have been found in patients with HHT. We have screened a total of 51 unselected German index cases with the suspected diagnosis of HHT. We identified 30 different mutations in 32 cases (62.7%) by direct sequencing. Among these mutations, 11 of 13 ENG mutations and 12 of 17 ACVRL1 mutations were not previously reported in the literature. Two of the ACVRL1 mutations were each shared by two families. An analysis of the genotype-phenotype correlation is consistent with a more common frequency of pulmonary arteriovenous malformations in patients with ENG mutations than in patients with ACVRL1 mutations in our collective. Institute of Human Genetics, Georg-August University, Gottingen, Sweden.
          • Mahoney EJ and Shapshay SM (2006). New classification of nasal vasculature patterns in hereditary hemorrhagic telangiectasia. Am J Rhinol 20: 87-90. BACKGROUND: Hereditary hemorrhagic telangiectasia (HHT) is a disorder characterized by the triad of recurrent epistaxis, telangiectasia, and a family history of the disease. Management of recalcitrant epistaxis in HHT remains a challenging problem for otolaryngologists. The precise coagulation of telangiectasias with the Nd-YAG laser has shown efficacy in the treatmentf HHT-associated epistaxis, but results can be variable and patient selection is critical in ensuring a successful outcome. We propose a new classification of nasal vasculature patterns in HHT as a means for selecting the Nd-YAG laser for photocoagulation treatment. METHODS: The records of 40 patients who underwent Nd-YAG laser photocoagulation for HHT were reviewed retrospectively. Outcomes after Nd-YAG laser treatment were correlated with three observed nasal vasculature patterns: (I) isolated punctate telangiectasias or individual small arteriovenous malformation; (II) diffuse interconnecting vasculature with "feeder" vessels; and (III) large solitary arteriovenous malformation, which may be associated with scattered telangiectasia. RESULTS: Types I and II were the most common vasculature patterns seen in this patient population. Patients with patterns I and III showed greater improvement in epistaxis after Nd-YAG laser photocoagulation. Patients with pattern II fared better with septodermoplasty. CONCLUSION: These findings suggest that analysis of nasal vasculature patterns can improve therapeutic stratification of.patients with HHT. Proper patient selection using this new classification scheme may improve the management of epistaxis in patients with HHT. Department of Otolaryngology, Boston University Medical Center, Boston, Massachusetts, USA.
          • Viehweg TL, Roberson JB and Hudson JW (2006). Epistaxis: diagnosis and treatment. J Oral Maxillofac Surg 64: 511-8. Oral and maxillofacial surgeons are called on to evaluate and treat various emergencies, including acute epistaxis. Epistaxis is relatively benign in nature, but it can produce a serious, life-threatening situation. It has been estimated that up to 60% of the population has had at least 1 episode of epistaxis throughout their lifetime. Of this group, 6% seek medical care to treat epistaxis, with 1.6 in 10,000 requiring hospitalization. With fewer and fewer otorhinolaryngologists participating on hospital call schedules, it is critical for the oral and maxillofacial surgeon to be familiar with the anatomy, diagnosis, and treatment of acute epistaxis and associated medical concerns. Considerations concerning mechanism of injury, coagulopathies, and potential treatment options need to be assessed quickly and accurately to ensure the most appropriate treatment and positive outcome for the patient. The need to treat epistaxis in an emergent setting will often require the involvement of an oral and maxillofacial surgeon. By reviewing the anatomy, potential complications arising from associated medical conditions, and treatment options, patients can be accurately assessed and treated appropriately. Department of Oral and Maxillofacial Surgery, The University of Tennessee Medical Center, Knoxville, TN 98431, USA.
          • Wang L, Zhou Y, Yan Y, Zhu L, Pan T and Xie L (2006). [A clinical analysis of intractable spontaneous epistaxis with 289 cases reviewed]. Lin Chuang Er Bi Yan Hou Ke Za Zhi 20: 64-6. OBJECTIVE: To explore the clinical characteristics and the prevention strategy of intractable spontaneous epistaxis. METHOD: Two hundred and eighty-nine patients with intractable spontaneous epistaxis were retrospectively analyzed. RESULT: Intractable spontaneous epistaxis was characterized by the onset season, age, sex, and the associated disease. Nasal septums were the most common sites of bleeding. Recurrent epistaxis was mainly associated with the failure of locating the bleeding sites. CONCLUSION: Control of elevated blood pressure is essential for the prevention of intractable spontaneous epistaxis. Once epistaxis occurs, the importance of the first treatment for the haemostasis should be emphasized. For the uncontrollable epistaxis, multiple interventions are necessary. Department of Otolaryngology, Third Hospital of Peking University, Beijing 100083, China.
          • Almeida GS, Diogenes CA and Pinheiro SD (2005). Nasal endoscopy and localization of the bleeding source in epistaxis: last decade's revolution. Rev Bras Otorrinolaringol (Engl Ed) 71: 146-8. Epistaxis remains one of the most common otolaryngology emergencies. Despite considerable interest in the subject, there is still no consensus on the most appropriate primary therapeutic modality. AIM: The purpose of this study was to evaluate the bleeding source of acute or recurrent epistaxis in adults. STUDY DESIGN: Clinical prospective. MATERIAL AND METHOD: Thirty adults patients with acute or recurrent epistaxis were evaluated through the use of frontal light and endoscope for identification of the bleeding source in the nasal cavity. RESULTS: Use of the nasal endoscope allowed diagnosis of the bleeding site in all patients. CONCLUSION: A careful examination of the posterior nasal cavity allows identification of the bleeding source in most patients and should be a routine procedure. Federal University of Ceara, Hospital Otoclinica, Fortaleza, Ceara.
          • Lund VJ, Preziosi P, Hercberg S, Hamoir M, Dubreuil C, Pessey JJ, Stoll D, Zanaret M and Gehanno P (2006). Yearly incidence of rhinitis, nasal bleeding, and other nasal symptoms in mature women. Rhinology 44: 26-31. OBJECTIVES/HYPOTHESIS: To evaluate, by a prospective questionnaire study, the incidence of spontaneous nasal pathology in mature women over a 12-month period, in particular nasal bleeding and the relationships of these symptoms with various factors. METHODS: Participants were drawn from a sample of 12,735 adult French volunteers participating in a study of antioxidant nutrients ("SU.VI.MAX"); 3500 women aged 50-64 years were randomly selected from good responders in the SU.Vl.MAX population. The responses of 2197 women were analysed. RESULTS: Nearly 70% of subjects reported at least one episode of rhinitis, with a mean (SD) of 1.88 (2.17) episodes per subject. Rhinitis was related to passive exposure to tobacco smoke (adjusted odds ratio [OR] 1.31, 95% CI 1.05-1.63), menopause (OR 1.47, 95% CI 1.16-1.88), and occupational exposure to vapours or dusts (OR 1.55, 95% CI 1.01-2.37). Nasal bleeding was reported as traces of blood by 16.5% of subjects, and as epistaxis (significant nasal bleeding) by 7.6%. Both symptoms were related to passive exposure to tobacco smoke (OR 1.63, 95% CI 1.22-2.19; OR 1.56, 95% CI 1.05-2.32, respectively) but not to use of systemic or topical medication. CONCLUSION: A substantial number of mature women experience nasal symptoms during the course of a year. Rhinitis and nasal bleeding were correlated with passive exposure to tobacco smoke. Institute of Laryngology and Otology, Royal National Throat, Nose and Ear Hospital, London, United Kingdom.
          • Aneeshkumar MK, Osman E, Shahab R and Roland NJ (2005). Look before you pack: key point in epistaxis management. Emerg Med J 22: 912-3. We report a patient with epistaxis who used cotton wool to pack his nose before reaching the hospital, and underwent further packing in the accident and emergency department, which probably pushed the cottonwool further back. This led to the formation of foreign body granuloma inside the nasal cavity. It is difficult to examine the nose without proper equipment and experience, and the examination is more difficult in the presence of active bleeding to find a foreign body such as cotton wool. Hence, it is important to ask the patient about any temporary pack they have used in the nose and to look for and remove it before inserting a proper pack. It is also important for trainees to have a better understanding of the different levels of management of epistaxis. Hence, we propose the term "epistaxis management ladder" for easy understanding of the treatment of epistaxis. Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Aintree, Lower Lane, Liverpool, UK.
          • Pellard S, Boyce J and Ingrams DR (2005). Consent and the use of Foley catheters in epistaxis. J Laryngol Otol 119: 822-4. The Medicines and Healthcare Products Regulatory Agency stated in 2003 that doctors should endeavour to avoid using products in treatments not covered by their product licence. Foley catheters are commonly used in the management of epistaxis although their product licence does not cover this. We undertook a questionnaire survey of members of the British Association of Otorhinolaryngologists--Head & Neck Surgeons to study the extent of the use of these catheters and the knowledge that members had of their legal status. Most members appear to use Foley catheters in the management of epistaxis; however, many are not aware that the product is not licensed for this purpose. Because of this lack of knowledge, only half obtain verbal consent for treatment with this device and only a very small number obtain written consent from patients. In the era of increasing litigation, documentation of informed consent could be considered mandatory to protect us from possible legal action, and this needs to be known by all practising otolaryngologists. Department of Otolaryngology--Head & Neck Surgery, Royal Gwent Hospital, Newport, UK.
          • Almeida GS, Diogenes CA and Pinheiro SD (2005). Nasal endoscopy and localization of the bleeding source in epistaxis: last decade's revolution. Rev Bras Otorrinolaringol (Engl Ed) 71: 146-8. Epistaxis remains one of the most common otolaryngology emergencies. Despite considerable interest in the subject, there is still no consensus on the most appropriate primary therapeutic modality. AIM: The purpose of this study was to evaluate the bleeding source of acute or recurrent epistaxis in adults. STUDY DESIGN: Clinical prospective. MATERIAL AND METHOD: Thirty adults patients with acute or recurrent epistaxis were evaluated through the use of frontal light and endoscope for identification of the bleeding source in the nasal cavity. RESULTS: Use of the nasal endoscope allowed diagnosis of the bleeding site in all patients. CONCLUSION: A careful examination of the posterior nasal cavity allows identification of the bleeding source in most patients and should be a routine procedure. Federal University of Ceara, Hospital Otoclinica, Fortaleza, Ceara.
          • Feusi B, Holzmann D and Steurer J (2005). Posterior epistaxis: systematic review on the effectiveness of surgical therapies. Rhinology 43: 300-4. OBJECTIVE: The optimal surgical treatment for patients with posterior epistaxis and failed conservative therapy is unknown. Therefore we planned a systematic review studying all available publications assessing the effect on bleeding recurrence and postoperative complications of ligation of the internal maxillary artery or the sphenopalatine artery. METHODS: We searched the electronic databases Medline, Medline In Process, and Cochrane Library. Data extraction was performed following standard methods. RESULTS: Twenty-eight studies could be included in the systematic review. All studies were retrospective and no single study comparing different methods could be identified. Fifteen studies reported on the effect of the ligation of the internal maxillary artery (LIMA) and 13 on the effect of the ligation of the sphenopalatine artery (LSA). The severity of postoperative complications and duration of hospital stay seem to be lower in the LSA group. A conclusive statement about the frequency of rebleeding in the two groups is not possible. CONCLUSION: According to the available data on postoperative complications and duration of hospital stay ligation of the sphenopalatine artery compared favourably to the ligation of the internal maxillary artery. The most effective treatment for patients with posterior epistaxis including costs should be evaluated in a controlled clinical trial. Horten Centre, University of Zurich, Switzerland.
          • Loughran S, Hilmi O and McGarry GW (2005). Endoscopic sphenopalatine artery ligation--when, why and how to do it. An on-line video tutorial. Clin Otolaryngol 30: 539-43. KEYPOINTS: Endoscopic ligation of the sphenopalatine artery (ESPAL) has recently become the treatment of choice for refractory epistaxis. This paper reviews the background, indications and potential complications of ESPAL. The main focus of this article is an online video tutorial on the anatomy and surgical technique of ESPAL. Web links lead to video clips of operative steps and therefore this paper should be read in front of a computer with access to the Internet. To study the techniques the links detailed below should be followed. (For computers running RealPlayer software the .wmv extension in each of these links should be replaced with the .rm extension.) * Incision, * Flap elevation, * Pedicle location, * Clip application, Department of Otolaryngology Head and Neck Surgery, Glasgow Royal Infirmary, Glasgow, Scotland, UK.
          • Christensen NP, Smith DS, Barnwell SL and Wax MK (2005). Arterial embolization in the management of posterior epistaxis. Otolaryngol Head Neck Surg 133: 748-53. OBJECTIVES: Treatment of severe epistaxis can encompass many modalities. Control rates with all treatments are good. Morbidity among treatment groups varies. Angiographic embolization is one such method that has a very low complication rate. Over the last 10 years, it has become the preferred treatment at our institution. STUDY DESIGN: Tertiary medical referral centers: OHSU, Portland VAMC. MATERIALS AND METHODS: Retrospective review of 70 patients transferred or admitted with posterior epistaxis and treated with selective angiographic embolization from 1993 to 2002. RESULTS: Patients had bleeding for a median of 4.5 days prior to admission. 79% were unilateral. Etiology of bleeding was: idiopathic (61%), previous surgery (11%), anticoagulants (9%), trauma (7%), and other causes (12%). 30% required blood transfusions prior to admission to OHSU (average 4.4 units). No patient required a transfusion postoperatively following angiographic embolization or during their hospitalization. The internal maxillary artery (IMAX) was embolized in 94% (47% unilateral or bilateral IMAX only, 47% unilateral or bilateral IMAX in combination with other vessels, 6% other vessels besides the IMAX). Mean length of stay was 2.5 days. 86% had minor or no complications after the embolization and were discharged within 24 hours. 13% had a major rebleed that required surgical intervention within 6 weeks of the embolization. One patient had a serious neurological complication. Using the data available on 68 of 70 patients, the cost of hospitalization averaged dollar 18,000 with direct costs of embolization averaging dollar 11,000. CONCLUSIONS: Angiographic embolization is a clinically effective treatment for severe epistaxis. EBM RATING: C. Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, OR 97239, USA.
          • Passali D (2005). [Haemostatic ointment efficacy in the treatment and prevention of epistaxis: a multi-centric study in 100 patients]. Clin Ter 156: 139-43. OBJECTIVE: To evaluate the protective effects of an haemostatic ointment, at rhinosinusal mucosa level, on the development of bleeding in patients affected by epistaxis or with a positive clinical history for epistaxis in previous 7 days. PATIENTS AND METHODS: 100 patients affected by epistaxis or with a positive clinical history for epistaxis in previous 7 days. Patients underwent 15 days of treatment with an haemostatic ointment 2 times/day. RESULTS: The haemostatic ointment significantly reduced the percentage of patients affected by epistaxis and the number and severity of bleeding episodes (p < 0.001). 51% of patients experienced nasal obstruction during treatment, which persisted at the end of therapy only in 11% of them (p < 0.001). Nasal burning, nasal itching and rinorrhea involved less than 40% of patients in the first days of treatment and no more than 10% at the end of therapy (p < 0.001). CONCLUSIONS: The use of the haemostatic ointment in the treatment and in the prevention of not severe epistaxis acquire, in our opinion, a strong rationale. Dipart. di Scienze Ortopedico Riabilitative, Radiologiche ed Otorinolaringoiatriche, Policlinico Le Scotte, Universita di Siena, Italia.
          • Schlegel-Wagner C, Siekmann U and Linder T (2006). Non-invasive treatment of intractable posterior epistaxis with hot-water irrigation. Rhinology 44: 90-3. Posterior nose bleeding is a frequent and challenging emergency. The authors report their experience using hot water irrigation as a non-invasive treatment option for posterior epistaxis. Between January 2003 and January 2005 a group of 103 patients were enrolled in this prospective study evaluating the effectiveness of a "hot water irrigation" technique to control acute posterior nose bleeding. All patients with posterior epistaxis were included, whereas anterior epistaxis was controlled using conventional methods. The patient's nose was initially anaesthetized with topical Tetracain 4% (without vasoconstriction) and a modified epistaxis-balloon-catheter was introduced into the bleeding nasal cavity obstructing the choana. The bleeding nasal cavity was continuously irrigated using 500 ml of 50 degrees C hot water. In a total of 84 patients (82%) the bleeding was successfully and permanently stopped. Forty-seven of these patients (56%) regularly took antiplatelet agents or anticoagulants. The method failed in 19 of 103 patients (18%). In the group with unsuccessful irrigation, 11 patients (58%) were receiving treatment with antiplatelet agents or anticoagulants. Their proportion was not different from the successfully treated group. The success rate of hot water irrigation as non-invasive treatment of posterior epistaxis appears at least as effective as conventional methods. However it avoids painful packing, hospitalizations, or immediate surgery, and allows the patient to breath normally through his open nasal cavities. Department of Otorhinolaryngology, Head and Neck Surgery, Kantonsspital Luzern, Luzern, Switzerland.
          Last edited by Wise Young; 04-02-2006, 05:04 PM.


          • #6
            This thread just made me chuckle out loud. Wise, you're nothing if not thorough!

            Have you ever seen a human heart? It looks like a fist wrapped in blood! Larry in 'Closer', a play by Partick Marber


            • #7
              Thank you Dr Young. That was a bit more info than I expected!

              I'm going to talk to my doctor about it.

              (Stop laughing at me cspanos! )


              • #8
                i don't use a wadded up kleenex because it seems ineffective to me. and i also don't like to use my finger

                i use qtips instead. i have very minimal bleeding and no blood clots.

                maybe that would help?
                Never take life seriously, nobody gets out alive anyway

                Frank's blog:
                My regular blog:


                • #9
                  Um, it's kinda funny to be talking about this, but....

                  Q-tips don't work as well for me as the wadded up kleenex. Actually, toilet paper is what seems to grab 'em the best.


                  • #10
                    lol, you may have to rename this thread, Tehniques for picking your nose without using your finger.
                    The trick is in what one emphasizes. We either make ourselves miserable or we make ourselves strong. The amount of work is the same. ~ Don Juan Matus
                    We are Virginia Tech… We must laugh again… No one deserves a tragedy… We are strong, and brave, and innocent, and unafraid…We are better than we think and not quit what we want to be…We are the Hokies…We will prevail, we will prevail, we will prevail. We ARE Virginia Tech! ~ Nikki Giovanni


                    • #11

                      Before I started this thread, there was a little voice in my head saying, "Don't do it!" Of course I didn't listen to that little voice.

                      Where the hell is good ole joyt? I can't believe she hasn't been here to make fun of me yet. I suppose her children pick her nose for her. OMG, I can't believe I just said that.


                      • #12
                        I had nose bleeds this year for the first time ever. I do take asprin and put it off on that but my blood pressure has been a little high too. I thought it was my sinus because after the bleed my could notice I felt better under my eye. I would just be sitting around a BAM a nose bleed. Maybe allergies?


                        • #13
                          Q-Tips don't work for me. No grab action like wadded up toilet paper crammed and twisted in my nasal cavity.

                          I get more clotty globs and bleeding in the colder weather because the air is drier. Mucosal tissues seem to be more sensitive then.

                          Are we actually discussing this?

                          Why, yes we are!

                          Shannon, I hope your doctor can tell you what's happening with the clots and nose bleeds. I'd be a little worried if I had blood clots and bleeding all the time, especially after your ankle swelled up.

                          I hope you get answers soon.


                          • #14
                            Originally posted by LaMemChose
                            Q-Tips don't work for me. No grab action like wadded up toilet paper crammed and twisted in my nasal cavity.
                            Yay, I'm so glad I'm not alone!!!

                            I had to go to the ER today, and yes, I do have a blood clot in my ankle, but I didn't bother them with the nose blood clots question. I'll save that for when I see my regular doctor.


                            • #15
                              Your nose is not designed to have rough or hard objects inserted into it. This includes Kleenex and Q-tips. Bleeding is most likely due to trauma to the delicate nasal tissues. Over time this can cause problems with chronic irritation and bleeding. If you need to remove nasal secretions because you cannot blow your nose, a baby nasal bulb syringe is the safest way to do this.

                              The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.