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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
Do We Have the Legal Right To Access the Medical Records Of My Ventilated Dad in 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 Isaac, as part of my 1:1 consulting and advocacy service! Isaac’s dad has a tracheostomy and the ICU team is pushing him to
undergo gastrostomy tube insertion. Isaac is asking how can they stop the ICU team from pushing his dad to undergo gastrostomy tube insertion.
How Can We Stop the ICU Team From Pushing My Dad in ICU for a Gastrostomy Tube Insertion?
“You can also check out previous 1:1 consulting and advocacy sessions with me and Isaac here.”
Part 1
Part 2
Part 3
Part 4
Isaac: Hello?
Patrik: Hey, Isaac! It’s Patrik here from the Intensive Care Hotline. How are you?
Isaac: Yeah. Good, good. I’m just here and yesterday he coded on the second floor. They had transferred him out of ICU and then, to the second floor. It’s the second time he coded on the second floor. So, ICU’s a lot better because he gets more. Like, they watch him a lot more than on the second floor. I was in there for about an hour and a half, nobody comes in.
Patrik: Right. Why did they do that?
Isaac: They did a bronchoscopy?
Patrik: Bronchoscopy, yeah.
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Isaac: I guess it’s called a bronchoscopy –
Patrik: Yeah, bronchoscopy, yep.
Isaac: Yeah, in the morning to check it. I guess his tracheostomy wasn’t positioned correctly, so it was blocking the airway.
Patrik: When did he have the tracheostomy, when?
Isaac: On the 17th.
Patrik: On the 17th. Today is the 29th, so about 12 days ago. Okay. Why did they do the bronchoscopy?
Isaac: Because they were trying to figure out about-
Patrik: Sure.
Isaac: The bronchopneumonia process, whether or not to see if he had phlegm, or anything like that.
Patrik: Yeah. Okay.
Isaac: Yeah. I did notice yesterday, though on his tracheostomy part, there was like a big blob of mucous that came out on his chest. I was like, “Wow,” because usually that doesn’t happen before he had the tracheostomy. And they called me that he was on code blue, and I’m like, “Whoa.”
Patrik: Code blue?
Isaac: Yes.
Patrik: Hang on. Yesterday?
Isaac: Yeah, he was out of life for like five to seven minutes.
Patrik: Out of bed?
Isaac: I’m sorry?
Patrik: I’m not following. So, they called the code blue, but why?
Isaac: That’s what I said. And they said, they think because the tracheostomy wasn’t positioned right, so it blocked his airway.
Patrik: Oh, okay. Did you say he was outside of the bed at the time? Was he in a chair? Is that what you said?
Isaac: No, he just, I guess he died. Like his heart stopped for almost five minutes-
Patrik: Oh, my goodness.
Isaac: Yeah.
Patrik: Oh, my goodness. Right, that’s not good.
Isaac: Yeah. And now he needs a blood transfusion because his hemoglobin is at a seven.
Patrik: Have they-
Isaac: And they think it’s an extensive cancer which means that it’s really, really bad.
Patrik: Say that last part again, they think it’s …
Isaac: The cancer.
Patrik: Yeah, okay, it’s growing. Is that what they’re thinking?
Isaac: Yeah.
Patrik: Right, okay. Right. Have they put him back into an induced coma because of the cardiac
arrest?
Isaac: No. I called his name, he responds. I’m just trying to see if he has brain damage because he was out for so long, but-
Patrik: So, they-
Isaac: Then, the question comes back to a percutaneous endoscopic gastrostomy (PEG) tube, like, yesterday, they said he pulled out the feeding tube out of his nose. But I don’t know.
Patrik: Right. Right. Okay, just quickly-
Isaac: She had the nasogastric tube for about four weeks-
Patrik: Yes. Hang on. Hang on. Hang on. Before we go to the percutaneous endoscopic gastrostomy (PEG) tube, just reestablishing, have they done a CT of his brain? Have they done a-
Isaac: Yeah. Everything was good.
Patrik: Okay. Okay. Good, good, good. Okay, so then, now they want to keep talking about the percutaneous endoscopic gastrostomy (PEG) tube because he pulled out his nasogastric tube yesterday.
Isaac: Yeah, but it’s been a topic for like, I guess because it’s been over a month with the feeding tube in the nose.
Patrik: Well, have they put the nasogastric be back in yesterday, or is he without a feeding tube at the moment?
Isaac: He’s, yeah, without the feeding tube at the moment.
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Patrik: Okay.
Isaac: And remember we talked about LTAC?
Patrik: Yeah.
Isaac: His insurance won’t even take him with LTAC even with a percutaneous endoscopic gastrostomy (PEG) tube. They’ll only take him to subacute with the percutaneous endoscopic gastrostomy (PEG) tube. So, one of the doctors keeps getting mad that I don’t sign for the percutaneous endoscopic gastrostomy (PEG) tube. The other doctor doesn’t mind about that.
Patrik: Yeah. Okay.
Isaac: But they said they might need to change the tracheostomy because for a longer tracheostomy going down, there is a tendency that it might happen again. So, I told them, “I don’t want to sign for a percutaneous endoscopic gastrostomy (PEG) tube, the feeding tube, if you guys don’t fix the tracheostomy problem.”
Patrik: Yeah, yeah, of course. Of course.
Isaac: And she’s like, “Oh, no, we could still do it.” But-
Patrik: What size tracheostomy does he have? I’ll come to the percutaneous endoscopic gastrostomy (PEG) tube. What size tracheostomy does he have? Do you know?
Isaac: No, I don’t.
Patrik: Okay.
Isaac: I will ask.
Patrik: Please. Please.
Isaac: Do you know what size of tracheostomy he have?
Dan: An eight.
Patrik: Eight, okay. And did he have a smaller one yesterday when the tube blocked?
Isaac: No.
Patrik: No. So, they haven’t, part of the blockage is not or, they don’t think that the size was the issue because of the blockage.
Isaac: Yeah, she said it needs to be longer.
Patrik: Yeah. Okay. Okay. Other question, does he have an inner cannula? Ask them.
Isaac: An inner what?
Patrik: So, some tracheostomies, not all, have what’s called an inner cannula. What that-
Isaac: Did he have an inner cannula?
Dan: I don’t know. I’m going to ask the respiratory therapist.
Isaac: Yeah, okay. Inner cannula. Okay. He’s going to ask the respiratory therapist to make sure. He’s not totally sure.
Patrik: Well, the nurse should know.
Isaac: Yeah.
Patrik: Just that very clear, because the nurse should know. But just that we’re very clear.
Isaac: I asked him. Yeah. They don’t know.
Patrik: Oh, that’s terrible.
Isaac: That’s why on the second floor, I’ve seen it too. I waited about an hour and a half to see how long it took somebody to come into see him because his blood pressure goes up and down, and I figured he was going to code blue on that floor.
Patrik: Right.
Isaac: And I don’t know why they transferred out of ICU to begin with, but they kept wanting to shift him on. Then, they kept saying that, “We can’t take him nowhere because he doesn’t have the percutaneous endoscopic gastrostomy (PEG) tube.” I said, “Yeah, I know.” I said, “Let’s try to fix what’s going on here,” because he has pneumonia back again. They took a culture. Now his blood count’s at a seven, so he’s going to get a blood transfusion. But, they just went back to the percutaneous endoscopic gastrostomy (PEG) tube. I was like, “Well, right now, he’s on IV. Let’s not even, I don’t even want to talk about that.”
Patrik: Right. Okay.
Isaac: I told them, “Eventually, I’ll get the percutaneous endoscopic gastrostomy (PEG) tube. The percutaneous endoscopic gastrostomy (PEG) tube is not the problem right now,” you know?
Patrik: Yeah. No, no, it’s not. Hang on. Hang on. But keep-
Isaac: My dad will have a percutaneous endoscopic gastrostomy (PEG) tube. But, I’m not even worried about that right now. I told them, “I don’t even want to do that. Until you guys get this fixed, I don’t want to do this. I don’t mind you guys getting upset, because I don’t want to do it right now.” I told it also to the man who’s getting the consent for the percutaneous endoscopic gastrostomy (PEG) tube because he’s getting
around.
Patrik: Yeah. Let’s just not worry about the percutaneous endoscopic gastrostomy (PEG) at the moment. Let’s just stick with the tracheostomy at the moment. If he had a cardiac arrest yesterday, because the tracheostomy tube blocked off, let’s just stick with that for a moment, because they need to make sure this is not happening again.
Isaac: Yeah.
Patrik: So, the nurses don’t know if he has an inner cannula. That’s a concern, in and of itself. The nurse should know straight away whether he has an inner cannula or not. That’s a concern.
Isaac: A lot of them down here, don’t know a lot because it’ll come to the next shift and then I’ll ask them. They’re, “Ah, I don’t know.” I’m like, “Oh God.” Yeah.
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Patrik: Right. That’s a concern. The reason I want to talk about the inner cannula, just for another minute, because I think it’s very important for you to understand. So, when someone has an inner cannula that needs to be changed, I’d say, at least three times a day.
Isaac: Oh yeah. I don’t think they change it.
Patrik: Right. If they’re not changing it, the risk that it’s blocking off is huge, right?
Isaac: Yeah.
Patrik: I’m not saying that is what led to the cardiac arrest, but that’s one theory. That they didn’t change the inner tube, assuming he has one. And then, the tube blocked off. One of the reasons you need to change the tube regularly is you need to see how much sputum is in there. That’s one of the reasons. It’s not the only reason, but that’s one of the reasons. And I would argue that it’s a concern, straight away, if they don’t
even know whether he has an inner cannula or not. That’s a massive concern, straight away.
Isaac: Yeah.
Patrik: Right? So, that’s what you-
Isaac: Yeah.
Patrik: You may need to understand about the tracheostomy.
Isaac: The inner cannula?
Patrik: Inner cannula.
Isaac: Yeah. And they said something about they would have to take him to surgery to change something else? What would that be? Is that the inner cannula?
Patrik: No, not at all. If they do take him to surgery, they would change the whole tube. But that shouldn’t require surgery. That should not require surgery, Isaac.
Isaac: Okay.
Patrik: I can change a tube because I’m-
Isaac: What did you say?
Patrik: I said I can change a tracheostomy tube because I’m trained for it, right?
Isaac: Yeah.
Patrik: So, anybody, unless there is some indication for him needing surgery, which sounds very unusual when it comes to tracheostomy tube changes. Yeah, I would definitely ask. I can’t make sense out of why he would need surgery. I can’t make sense out of it.
Isaac: Yeah. I think they want to. They’re like, “Oh, we’re changing out if we do the percutaneous endoscopic gastrostomy (PEG) tube at the same time.
Patrik: Oh, I see. Yeah, yeah, I see. I see. Yeah.
Isaac: Like a two in one.
Patrik: Yeah, okay. Okay. Yeah, that makes sense. That makes sense.
Isaac: I don’t know if he’s better off doing it and getting out of here, or what at this point because-
Patrik: Just explain to me again, why did they move him to another floor? What was the reason for that?
Isaac: They had him discharged and then I was like, “Dang, you’re discharging him because now he still has a feeding tube in his nose.” I didn’t say nothing. They said, “Oh, he’s stabilized.” “No, he’s not that stable, to me.” But, whatever, they just wanted to get him out to the second floor, and then they had a discharge, and then they’re like, “Oh, great, can’t get discharged because his son doesn’t want to sign for the percutaneous
endoscopic gastrostomy (PEG) tube.” And then a case manager, they called, and they said, “Yeah, if you don’t give him the percutaneous endoscopic gastrostomy (PEG) tube, LTAC won’t accept him in subacute.
Isaac: And then they said, “Actually, even if you do get a percutaneous endoscopic gastrostomy (PEG) tube, his insurance does not cover the LTAC. He has to go straight to subacute. But we can’t get you there unless you sign for the percutaneous endoscopic gastrostomy (PEG) tube.” I said, “He’s not, he still has pneumonia, I’m not going to sign to take him to subacute. You guys cure the pneumonia and let’s figure out what’s going on here,”
and then-
Patrik: Right.
Isaac: That happened.
Patrik: Okay. So, this ICU, where he’s at now, is that like a stepdown ICU?
Isaac: I’m not sure. It’s just a hospital ICU that they have in there.
Patrik: Okay. So, it’s not a different level of care, is it?
Isaac: No. No, it’s ICU.
Patrik: Okay. Okay. That’s good. That’s good. Okay. Coming to the percutaneous endoscopic gastrostomy (PEG) tube now. Look, do you think if they put in another nasogastric tube, do you think he’ll pull it out again?
Isaac: No. I think they took it out, to be honest-
Patrik: Oh, they took it out.
Isaac: Because they stopped the feeding because he was going to have a bronchoscopy. And then they said he pulled it out.
Patrik: Oh, I see. I see. Okay.
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Isaac: I don’t know, I think one of the nurses took it out thinking to stop the feeding because he’s gonna have a bronchoscopy. But I could be wrong. I didn’t see it. Before the code blue, I was here a couple of hours before and he had that feeding tube in and he wasn’t touching it. I did notice, in the actual hole of his tracheostomy, a lot of secretions were coming out in an actual hole. And I’m like, he kind of was going for his
tracheostomy. I thought he was going to pull the tracheostomy out. I go, “No, no, don’t do that. They’re going to it there again. And then what I have seen he was pointing to, that he had like the size of my palm. It was like green and yellow phlegm coming out of an actual hole in his neck. And I was like, “Oh, wow,” because usually, I see when they suction him, it goes through the tube. I had never seen it coming out of the tube, so I said, “Oh, wow. What happened here?”
Patrik: Right.
Isaac: And I told them. I called them right away and then a couple of hours later that happened, so I just started to think, “Did he drown in his phlegm? Was there like a blockage or something? Why was there coming out of the hole of the tracheostomy?”
Patrik: Right. How long ago was that?
Isaac: That was yesterday, probably about 1:40, 3:00 and then, 6:00 PM is when he coded.
Patrik: Right. Okay. Okay, coming to the percutaneous endoscopic gastrostomy (PEG) tube, well, what ventilator settings is he on? Do you know?
Patrik: Can you send me a picture?
Isaac: Yeah. Assist-control volume control (ACVC). He was at a 30, yesterday, even after and his oxygen was at 90-something.
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Patrik: Right. Okay. And-
Isaac: But where do you think the bleeding came from? Because I’m not sure if it’s the cancer that’s causing it. They’re trying to figure out where his bleeding came from.
Patrik: Yeah. The first thing that probably-
The 1:1 consulting session will continue in next week’s episode.
