Hi, it’s Patrik Hutzel from INTENSIVECAREHOTLINE.COM where we instantly improve the lives for Families of critically ill Patients in Intensive Care, so that you can make informed decisions, have PEACE OF MIND, real power, real control and so that you can influence decision making fast, even if you’re not a doctor or a nurse in
Intensive Care!
This is another episode of “YOUR QUESTIONS ANSWERED” and in last week’s episode I answered another question from our readers and the question was
What is the Survival Chance of My Sister after a Cardiac Arrest in the ICU?
You can check out last week’s question by clicking on the link here.
In this week’s episode of “YOUR QUESTIONS ANSWERED” I want to answer questions from one of my clients Mikaela, as part of my 1:1 consulting and advocacy service! Mikaela’s sister is with a tracheostomy and is
ventilated in the ICU. Mikaela is asking why the cardiologist thinks differently from the ICU team about her sister’s recovery and is not even pushing for end-of-life.
The ICU Doctor Is Negative about My Sister’s Condition, But Why Does the Cardiologist Think Differently About My Sister’s Recovery in ICU & Is Not Even Pushing for
End-of-Life?
“You can also check out previous 1:1 consulting and advocacy sessions with me and Mikaela here.”
Part 1
Dr. Marie: Yeah, yeah, when she came in.
Mikaela: Okay.
Dr. Marie: Normally we do after the event.
Mikaela: Yeah.
Dr. Marie: There’s no valve issues which is good news, and her right ventricle is okay. Left ventricle is borderline normal.
Mikaela: Yeah.
Dr. Marie: In summary, from the heart scan, ultrasound scan, there was nothing really special. That all, again, make us think it could probably be arrhythmia because if the structure of the heart is normal, valve, muscle everything else and coronary artery supplying the heart, they were normal on the scan, on the angiogram.
Mikaela: So does that result in the contraction being normal as well then?
Dr. Marie: Exactly.
Mikaela: Okay.
Dr. Marie: Contraction is normal. So, again, back to square one. It’s most likely arrhythmia because you can’t see these small fibers that stop electricity of the heart.
Joseph: Yes.
Dr. Marie: To control whether there has been abnormality, and that’s why she went into cardiac arrest. As I said, normally these things are better seen on a cardiac MRI and after that, a defibrillator to prevent things happening in the future.
Mikaela: So they do an MRI of the heart?
Dr. Marie: They can’t do an MRI now until she’s awake.
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Mikaela: Okay.
Dr. Marie: So the protocol is if the patient is awake and she’s up to cardiology, because now she’s depending on oxygen 100%. She’s got tracheostomy as you know.
Mikaela: Yeah.
Dr. Marie: She can’t be by her own.
Mikaela: I think they’re slowly weaning her off that, but I don’t know how much they’ve told you about that.
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Dr. Marie: Correct, yeah. But she’s not able to go for a cardiac MRI now.
Mikaela: No, that’s fine. That’s expected, yeah, of course.
Dr. Marie: Yeah.
Mikaela: Then eventually if they can wait to take her off the ventilator then they can take the tracheostomy out.
Dr. Marie: Yeah, yeah. So from the ECGs that I’ve seen, from the heart tracing I’ve seen, there’s no arrhythmia as such. It has been sinus rhythm which is a normal sinus rhythm. Her heart rate has been up and down, and that’s probably the arrhythmia that you’ve
been told about.
Mikaela: Yeah.
Dr. Marie: I can see that she has been having some sort of infection. So she’s had pneumonia and she’s had infection in the last few days while she was in ICU. We expect the heart rate to become a bit higher with infection. That’s a normal response of the body.
Mikaela: Did you say..
Dr. Marie: I think she’s had antibiotic or something.
Mikaela: Yeah, I wasn’t aware of pneumonia. I think it was just cellulitis.
Dr. Marie: Let me check. I’ll give you all the details from the ICU now.
Joseph: Okay.
Dr. Marie: Correct. So there’s cellulitis and it was suspected that she might have had chest infection.
Mikaela: Okay.
Dr. Marie: Something you can get with the tubes.
Mikaela: Okay, so it was suspected.
Dr. Marie: The antibiotics, yeah, she’s had antibiotics for that.
Mikaela: Okay, so it wasn’t that she had had it, it was just suspected that she had it.
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Dr. Marie: Correct.
Mikaela: So they put preventative maintenance in place.
Dr. Marie: Yeah, you would never know because any patient who’s tubed, she’s got a trachea and her tubes into her lungs.
Mikaela: Yes.
Dr. Marie: She’s a high risk for infection, something very common they deal with in ICU. She’s had antibiotics already. So, her heart rate is a bit fast. It’s about 100 beats a minute, but its sinus. So that means it’s quite regular.
Joseph: Is she still having low blood pressure?
Dr. Marie: The blood pressure is normal, low normal.
Joseph: Is she on medication for that? Sorry.
Dr. Marie: So she’s on medication for the fast heartbeat.
Joseph: Yes.
Dr. Marie: She’s taking something called Bisoprolol.
Joseph: Yeah, that’s it, okay.
Dr. Marie: Which is a beta blocker to slow down the heart.
Joseph: Okay.
Dr. Marie: She is on a tablet for blood pressure. I think the ICU team depending on her blood pressure, they are withholding it. She’s also on tablet Ramipril. It’s good for the heart function and also for blood pressure.
Joseph: Okay.
Dr. Marie: I can tell medications that she’s taking now. I’m just in front of the computer. So, she’s taking aspirin. She is taking an antibiotic for suspected infection as I just told you. She’s taking Bisoprolol which is a tablet to slow down her heart. She is also taking a Heparin injection, a small Heparin injection. All the patients in hospital they get to prevent clots and stuff like this.
Mikaela: Yeah.
Dr. Marie: She’s taking Lansoprazole for her stomach because she’s taking aspirin to prevent any bleed or anything and she’s taking a tablet Ramipril. It’s good for the blood pressure and also good for the heart function. She has been on a tablet to lower down her blood pressure. It’s called Amlodipine but I think that has been stopped by the ICU team recently.
Mikaela: I think that..
Dr. Marie: She- sorry. Go ahead.
Mikaela: I think that was also about the kidneys as well at one point last week. I don’t know how much, obviously, you’re involved with the kidney side, but there was something about the kidneys last week as well that they wanted to double check on which I think is cleared out. I don’t know whether you can confirm that or not, if there’s anything in the notes.
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Dr. Marie: I can find out for you. Her kidney function looks okay. I think she might have been dehydrated last week, and I can see that her kidney is a bit deteriorated last week.
Mikaela: Yeah, they gave something potassium as well.
Dr. Marie: Yeah, exactly. So she’s almost back to normal now. Nothing is a concern.
Mikaela: Okay.
Dr. Marie: So..
Mikaela: Sorry.
Dr. Marie: So, I think in summary, I don’t want to give you lots of information. In summary, she had obviously suffered an arrest, a cardiac arrest. She had a prolonged resuscitation of 10 shocks and 30 minutes, that’s documented more or less. That’s almost always a rough
estimate. She’s been to the lab from the cardiologist perspective for the cath lab. Her angiogram didn’t show much, it showed normal coronary artery. That led to a diagnosis that it could be an arrhythmia or abnormal heart rate/beat that caused it. So she’s had an echocardiogram, which is an ultrasound scan of the heart and everything looks okay. I said
sometimes you don’t get to the bottom of this. You need more information like a cardiac MRI and then a defibrillator once they are awake.
Dr. Marie: Because she’s in ICU for such a long time, she’s not been awake as we would like to, then she’s still been managed in ICU. Cardiology, we haven’t been able to add much over the last few days because we are all dependent on ICU and neurology team. I’m not a neurologist, but from my experience I have to be honest with you. Overall, it doesn’t look good. It’s up to ICU and the neurologist and yourself and your father to decide
the best thing for her. But overall, I mean the prognosis is she is not looking good.
Mikaela: Yeah, we’ve been told about that, but it’s just like I said it’s just an argument that we’ve continuously had regarding time and giving her the time to recover herself.
Dr. Marie: Normally, the cardiology team wouldn’t actually interfere with this because this is beyond our knowledge. I mean ICU, intensive care and neurologist, they are the best to provide. Someone who’s been intubated and with low GCS, and wait for a long, long time, that’s not a good sign. I think
you probably have to have another discussion with the neurologist and the intensive care for her best interest. To see what the best we probably can offer her.
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Mikaela: Yeah.
Dr. Marie: I mean once she’s off ICU, I mean if she recovers from this and she’s now obviously she’s oxygen dependent, she’s not breathing by her own. If she recovers from this the next step would be getting a bit more and trying to prevent this from happening, like I said, by putting a defibrillator. I think this is the least of your worries now.
Mikaela: Yeah.
Dr. Marie: I think we need to have a plan. What’s the next step? I think you need to speak to the neurologist because they would be able to have a look at the CT scan. I can only see the report. There are more explanations. They can have a look at the scans themselves. They can have a look at the EEG‘s themselves, and they can tell you an honest expert opinion about what you should expect from this action.
Joseph: I was going to ask you as well. One of the consultants was saying the decision regarding the DNR.
Dr. Marie: Yeah.
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Joseph: If her heart stops and they may not start it off and revive her. We’re against that because we would still like her to be revived. We still feel that her heart is still okay in that sense.
Dr. Marie: Yeah.
Joseph: I mean what’s your thoughts on that? What do you think?
Dr. Marie: It’s a very difficult decision. I understand. As you’ve probably been told before it’s normally a medical decision. So you don’t have to be pressured about this at all. I think, as I said, I agree with you. Her heart is completely normal from the structure, from the echo and from her coronary artery. She might have conduction abnormalities. As I said, normally to prevent this in the future is an ICD (implantable cardioverter
defibrillator) or to put in a defibrillator. Don’t forget that her brain is not normal because she suffered this hypoxic event and prolonged hypoxia. Normally, we know that the brain cells, they don’t regenerate. Once the brain cells are dead, once you get a hypoxic injury it’s there. Normally something difficult to regenerate or expect any
improvement.
Dr. Marie: So I think if her heart stops, you might bring her back by shocking her again, but I think is that the best thing for her? If she’s going to be suffering again the same. We know that she has a hypoxic brain
injury. I think this is something that can be very difficult for family, but I think you have to have a discussion again with the neurologist to have a real prognosis. Have a chat with ICU about it. These difficult scenarios, it’s very difficult for the family and even for the intensive care doctors. This scenario is not something easily taken. She’s young. She’s got a good heart, but the problem now is not her heart. The problem now is her brain.
Dr. Marie: Think about it. Think about her best interest. Have a chat with the neurologist. What’s the prognosis from the brain point of view? If the neurologist say, even if you prolong the intubation for days of weeks, there’s no benefit, or her brain is not going to improve, then it’s a really difficult scenario. So, I’m to the best person to ask this. I agree with you that her heart is okay, but just think about her brain and her best
interest in this scenario. If she gets another heart arrest, that’s not normally a good sign, knowing that she’s had this hypoxic event in her brain.
Joseph: I mean to what extent? They’ve not actually done the MRI scan on the brain as such either.
Dr. Marie: They’ve not, sorry?
Joseph: They haven’t actually done the MRI scan on the brain.
Dr. Marie: They have no MRI on the brain. Yeah, I agree with you. I don’t know if it’s going to help anything.
Joseph: I just feel all the input that we have with her, I mean it’s really difficult to explain but we do see the signs there.
Dr. Marie: Yeah.
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Joseph: I bet that it may not seem that much to you in your professional judgment but we feel, as a family, there are some signs there was more time given to her, they could improve on over time. It’s just we don’t know the structure of the brain is such a complex brain isn’t it?
Dr. Marie: Yes.
Joseph: We just don’t know what’s going on inside all the time.
Dr. Marie: Exactly, we can know what’s going on inside because we can do an MRI if needed, but I guess the reason she hasn’t had an MRI yet is she’s already had a CT scan of the brain which you normally do the MRI as a second step if there’s a doubt, if there’s more information you need. A CT scan shows there is injury and there’s an insult to the brain.
Joseph: Has there been another CT scan since then? I mean how many?
Dr. Marie: I can figure out for you now. After the CT scan, the neurologist studies the brain, the EEG of the brain which they look at the waves and everything else. I can see the report in front of me that the EEG finding are abnormal and from that report it’s a diffused brain injury. There is a diffused brain injury from that. They say most likely its hypoxic insult to the brain.
Joseph: Are the CT scans done every day or is it?
Dr. Marie: Say that again, sorry?
Joseph: Are these CT scans done every day or are they?
Dr. Marie: No, you can do a CT scan every day. A CT scan is normally done once.
Joseph: Once.
Dr. Marie: To find out, to get a diagnosis. I can see that she’s had actually two CT scans, so one was done just two weeks ago.
Joseph: Yes.
Dr. Marie: I think probably when she came in.
Joseph: Yeah.
Dr. Marie: And then another one after 2 days.
Joseph: Right.
Dr. Marie: And that-
Joseph: Since then no further scans?
Dr. Marie: Yeah, it’s not normal practice to get more CT scans if you have a CT scan that shows progression of hypoxic injury. I think that’s why they did the scan in two days’ time. If you remember, I told you normally in some scenarios patient come in with cardiac arrest. Then they go to the lab. They go to ICU, intensive care, but after a couple of days they normally recover.
Joseph: Yeah.
Dr. Marie: If they don’t recover in a couple of days, that’s when they do another CT scan and find out why they’re not recovering. The CT scan she’s had, the second one, that shows there’s a progression of..
Joseph: This is what you’re saying, but then at the beginning she wasn’t opening her eyes or anything.
Dr. Marie: Yeah.
Joseph: But now she’s opening more and more of her eyes.
Dr. Marie: I mean-
Joseph: I know that might not mean much to you. But..
Dr. Marie: Not at all. It does mean a lot that she can open her eyes, but patients with hypoxic brain injury, it’s not everyone the same. It depends where insult is and it depends how bad it is.
Joseph: Yeah.
Dr. Marie: I think that’s why they did the EEG of the brain and it shows that it’s quite diffused.
Joseph: Okay. Yeah, I mean the brain to some extent can repair itself as well.
Dr. Marie: It can. No, I agree with you. It can. It takes a long time and can repair itself but if someone has a diffused brain injury, normally it’s difficult for the patient to regenerate completely.
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Joseph: I understand she’ll never be 100% the way she was.
Dr. Marie: Yeah.
Joseph: But even if she’s like 30% to like she was..
Dr. Marie: Yeah.
Joseph: … we’ll accept that as a family.
Dr. Marie: No, I understand, obviously. You want her to be with you. There’s no doubt about it. From my experience, if she can be by her own, without any help from the machine and the patient might require what we call neuro rehabilitation.
Joseph: Okay.
Dr. Marie: That’s in case if she’s not machine-dependent. If she’s breathing by her own at some point. That’s why they’re trying to wean her off oxygen and stuff like this to see her behavior.
Joseph: Yeah.
Dr. Marie: It has been very slow progress, but from my understanding is she’s not yet breathing by her own. She’s still requiring oxygen. It’s been difficult to wean her off oxygen, and that’s the next step that we think about. Even if part of her brain is damaged, some people might not, as you said, might not be able to remember things, might not be able to do things by their own, but some of them require admission to neuro rehabilitation.
They might be off hospital. But that’s in case they can breathe by their own. She had a prolonged admission now in intensive care. I can’t see the benefit of prolonging it from my opinion. Like I said I am not the best person to speak with. You’ve done the right thing. The neurologist, they have more experience than myself or any cardiologist. Because they see this every day. I think these questions..
Joseph: Yeah, I understand that. You keep on saying it’s a long time in ICU. Yes, to a certain degree, okay, I understand it. It’s a brain injury. Can you put that in the same context as when you have a bone that’s been broken for instance and has been placed in the ICU for a broken back.
Dr. Marie: Yeah.
Joseph: You’ve been in ICU for a year for a broken back to be mended.
Dr. Marie: No, I’m not saying it’s long for ICU.
Joseph: Yeah.
Dr. Marie: I mean we’re not counting the days. I think you’ve got me wrong. I’m not saying it’s long for ICU. There are patients that can stay in ICU. There’s no limit for a patient to stay in intensive care. If we can do something for them. We don’t have to day 200. It’s not like this. When we say prolonged admission, it means normally the brain would recover or there are signs of recovery from the brain perspective. You would expect the
patient to breathe by her own or at least require less oxygen and stuff like this. That’s what we try to say from prolonged admission.
Mikaela: From my understanding, it’s a sprint weaning is what’s being done at the moment.
Dr. Marie: Exactly, yeah. I understand from intensive care it has been difficult to completely wean her off oxygen, I mean 27 days is a long time to wean someone off oxygen. That’s my understanding. That’s what we mean when we say prolonged admission. We’re not saying there’s a limit for intensive care.
Mikaela: I think the weaning has only been done from about a week ago.
Dr. Marie: Yeah, I know that. I think they’re trying to wean her on and off several times.
Mikaela: Okay.
Dr. Marie: That’s my impression. That’s my understanding. Again, I think I’m here only to call you from the cardiology perspective.
Mikaela: Yeah.
Dr. Marie: Don’t forget that. I’ve been asked by intensive care since we arranged to give you an update. I think you wanted people from the cardiology team. I’m just giving you a perspective from the area I’m expert in. I can tell you about her coronary arteries. I can tell you about her echo. We can speak about her heart, but I think from a neurology perspective, I’m telling you this only from experience. I think the best one to speak with
would be a neurologist.
Mikaela: Yeah.
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Dr. Marie: They are more expert in this. We see heart patients probably twice a day. They see it every day as well, so they can give you a thorough expert opinion about their expectations and I think, don’t take my word for anything I said about brain. That’s only from experience. I think neurologist is the best one to speak with at the minute for that.
Mikaela: I just wanted..
Dr. Marie: If the neurologist feel there’s a benefit for her staying longer, she will stay longer. There’s no issue with that.
Mikaela: Yeah, there’s obviously recovery from something like that. I mean after it involves a prolonged, life-long process of treatment, I guess and rehabilitation, right?
Dr. Marie: Exactly. Like I said from my experience, my own personal experience, someone recovers from this if she’s off oxygen and she can be by her own even if the GCS is a bit low, they might go for rehabilitation. But they have to be awake for this. They have to breathe on their own. If someone has GCS of 3 or 4, that means they can’t breathe by their own. They need a machine. If there’s no recovery from this now, it’s difficult to
expect any further recovery. But again, speak to a neurologist.
Mikaela: No, that’s fine. That’s definitely what we’ll do.
Dr. Marie: You’ve gotten an appointment with the neurologist already.
Mikaela: Yeah, I think tomorrow.
Dr. Marie: That’s the next step forward. Okay, let’s go forward and see what they can add and what they expect from this.
Mikaela: No that’s..
Dr. Marie: It’s a very tough situation for family even for us to be honest about it. Your sister has been looked after by intensive care twice daily by cardiology team, once a day we’ll see her, 24/7 she’s been looked at. So if anything happens, they always call us.
Mikaela: Yeah.
Dr. Marie: From a cardiology perspective, do you have any questions or if your dad has any questions to ask me.
Mikaela: No, I think we’re okay with that.
Joseph: No. Thank you.
Dr. Marie: Okay.
Mikaela: Thank you so much for calling Doctor.
Dr. Marie: No, not at all. I’m around tomorrow as well.
Mikaela: Okay.
Dr. Marie: The consultant for this week is Dr.Gino, if you want to speak with him. She knows about your sister as well.
Mikaela: Yeah.
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Dr. Marie: So, we’re happy to give you an update if you have any questions to speak with us anytime.
Mikaela: That’s appreciated.
Dr. Marie: I think the neurology discussion is a key point.
Mikaela: Yeah, okay. That’s perfect.
Dr. Marie: It’s okay.
Mikaela: Thank you so much for that, Doctor.
Dr. Marie: All right.
Mikaela: Cheers. Have a good day.
Dr. Marie: Thank you.
Joseph: Thank you.
Dr. Marie: Bye. Good bye.
The 1:1 consulting session will continue in next week’s episode.
