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
My Dad has Stage 4 Lung Cancer in ICU. How Long Will My Dad Stay on a Ventilator?
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 is with a tracheostomy and on a ventilator in the ICU. Isaac is asking how his dad can get off the ventilator and avoid the tracheostomy ICU.
How Can Our Dad Get Off the Ventilator and Avoid the Tracheostomy in ICU?
Patrik: No.
Isaac: Yeah.
Patrik: You don’t give consent. You don’t give consent to a percutaneous endoscopic gastrostomy (PEG) tube. So, the next step really is we need to find out what ventilator settings he’s on. We need to find out what medications is he on. Those would be the most important information to get to find out is it
realistic for your dad that he can come off the ventilator without a tracheostomy or does he needs a tracheostomy.
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Isaac: Yeah.
Patrik: Those are the two most important questions for now. The other thing is… Is he being mobilized? Can he sit on the edge of the bed? Are they doing that?
Isaac: No.
Patrik: Do you think he can..
Isaac: He hasn’t even stood up.
Patrik: Right. Do you think he can, with help?
Isaac: Maybe with help.
Patrik: Okay. Well, because no one’s come… I’ve not seen people coming off the ventilator without being mobilized. Just doesn’t happen. That’s where the
complacency part comes in. It’s easier for them to do a tracheostomy, send him off to LTAC, and LTAC can deal with him, rather than focusing, “Okay, what do we need to do to get your dad off the ventilator and avoid the trach?”
Isaac: Yeah.
Patrik: What do you want to do next? Do you want us to call them now, or do you want to go back there, send some pictures? What do you want to do next? You tell me.
Isaac: We can call them now. Do you want me to call on 3-way?
Patrik: I think so. So, just before you call them, it’s best to introduce me as a family friend that’s trying to help you understand the situation. You can say that I’m a critical care nurse by background. Just keep it friendly. You don’t need to say that I’m a professional consultant and advocate. It might
make them feel threatened. We don’t want them to be threatened, because otherwise we may not get any information.
Isaac: Exactly. So, I just say that you’re a family member, correct?
Patrik: Yeah.
Isaac: Okay.
Patrik: Who are you going to call? A doctor? Nurse? Who are you going to call?
Isaac: The nurse.
Patrik: Yeah, do that.
Isaac: Okay. I’m going to call on three-way right now.
Patrik: Thank you.
Isaac: One minute.
Patrik: Thank you.
Isaac: Okay.
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Nurse Attendant: Sir? Hello?
Isaac: Yeah, hi. I’m trying to reach my dad’s nurse, he is in bed 7, ICU.
Nurse Attendant: ICU, bed 7? Hold one second.
Isaac: Thank you.
Nurse Attendant: Bye-bye.
Isaac: Patrik?
Patrik: Yeah, I’m here, I’m here.
Isaac: Okay.
Patrik: And you’ve met the nurse that’s there today? You’ve met him or her today?
Isaac: Yeah.
Patrik: Good. Good. And, have you spoken to the ICU doctors today as well?
Isaac: Yes. He’s the one recommending the PEG (PERCUTANEOUS ENDOSCOPIC GASTROSTOMY).
Patrik: Yeah, yeah.
Isaac: And I told her it’s too soon, let’s just wait, I’m hoping to wean him off the ventilator, but he says..
Patrik: Yeah. Okay. Let’s get some more facts. And, Isaac, you can visit. There are no limitations around COVID or any of
that.
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Isaac: No, just between 1:00 and 4:00 there’s no visiting.
Patrik: Okay. So, it’s limited hours.
Isaac: Yeah.
Patrik: Right. And, do you know, are they doing a daily chest x-ray?
Isaac: They were, but they haven’t done it since before. The latest the better.
Patrik: Right. And, do you know, does he have a lot of intravenous infusions going in?
Isaac: He did do the procedure of having the tube to drain his fluid, so it’s like a permanent tube out of his lungs.
Patrik: Right.
Isaac: On his side.
Nurse: Hello. How can I help you?
Isaac: Hi. I am the son of your patient in bed 7.
Nurse: Hi, how can I help you?
Isaac: Yeah, for Bed 7?
Nurse: Yeah.
Isaac: Yeah. I have my aunt on the phone, Patrik, and she had a couple of questions. So, we wanted to ask you a couple of questions. We’ve been talking with the family, and the doctor said for us to give you guys a call if we had any questions.
Nurse: Oh, okay. So, you want to talk to the doctor.
Isaac: No, we wanted to talk to you first to see… She wanted to see what settings… Patrik.
Patrik: Yeah. Just trying to find out…
Nurse: Okay, go ahead.
Patrik: Just trying to find out what ventilator settings he’s on. I am a critical care nurse.
Nurse: Oh, right now?
Patrik: Yes, right now.
Nurse: He is on PRVC (Pressure Regulated Volume Control), 25% FIO2 (fraction of inspired oxygen), tidal volume of 400.
Patrik: Yep. And, that he’s getting a set rate from the machine?
Nurse: Pardon me?
Patrik: He’s getting a set breathing rate per minute from the machine and he can breathe on top of that?
Nurse: Yes.
Patrik: Right. And how much is he getting from the machine, how many rates?
Nurse: Right now, let me double check. Hold on.
Patrik: Thank you.
Patrik: What’s your dad’s weight, roughly?
Isaac: He’s around 95 pounds.
Patrik: Yep. Okay.
Isaac: He’s about 5’4″.
Patrik: Yep. Okay. Good.
Nurse: 20.
Patrik: 20. Okay. And is he breathing on top of that himself?
Nurse: No.
Patrik: No. Okay. Is he still sedated?
Nurse: No. No sedation.
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Patrik: Right, no sedation. So, he’s awake, alert, obeying commands?
Nurse: Yes.
Patrik: Right. So, that means his respiratory drive is really low. Do you have an arterial blood gas at all?
Nurse: I don’t have the latest one. Let me double check when was the last time they did the arterial blood.
Patrik: Thank you. Thank you. Really appreciate it. Thank you.
Nurse: Yeah.
Patrik: All right. The ventilator settings he’s on is very much… What’s the word? It’s high support, high levels of support.
Isaac: Yeah.
Patrik: And now we’ll get an idea… Once we have an arterial blood gas, we have an idea of how good his lungs are, and then we can determine next steps from there. But yeah, those two things are very important, ventilator settings and the blood gas. And then we can see what…
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Nurse: Hello?
Patrik: Yeah, yeah.
Nurse: Hi. The last arterial… the blood gas that was done was on the 30th. They didn’t have anyone take one lately.
Patrik: I see. I see. So, you’re saying the last blood was on the 30th of September?
Nurse: Yes.
Patrik: Right. Okay. Fair enough. Does he have any chest drains in still?
Nurse: Can you repeat that?
Patrik: Does he have any chest drains or pleural drains in his chest?
Nurse: Yes. He still has… yes.
Patrik: Right.
Nurse: On the right.
Patrik: And they’re still draining?
Nurse: Yes, they’re still draining.
Patrik: Right. And how long has he been off sedation for?
Nurse: Let me just go back. This is the first time I have him.
Patrik: Sure.
Nurse: Let me just double check.
Patrik: Thank you.
Nurse: Since end of the month.
Patrik: Oh my goodness. Okay. Right. I see.
Nurse: Yeah.
Patrik: I see.
Nurse: Yeah.
Patrik: Okay.
Nurse: He’s off sedation since month end.
Patrik: Right. I see. Other than that, kidneys are working, he’s digesting feeds, he’s not on any..
Nurse: Just the heart. Just the heart.
Patrik: He’s not on any vasopressors?
Nurse: Right now, we have norepinephrine only. Very minimal, but his blood pressure goes low very frequently if you turn it off also.
Patrik: Right. Okay.
Nurse: But just norepinephrine, yeah, very little.
Patrik: Okay. But he’s not fighting an infection. He’s not septic.
Nurse: Let me double check when’s the last time they gave the lactic acid and..
Patrik: Lactic, and maybe a white cell count?
Nurse: White cell? It’s 9.9 today.
Patrik: So, that’s normal.
Nurse: When he’s on antibiotics, because previously he had infection previously.
Patrik: Right. I see. But he’s digesting feeds, he’s opening bowels, kidneys are working?
Nurse: Pardon me?
Patrik: I said he’s..
Nurse: Yes.
Patrik: … absorbing his nasogastric tube feeds, bowels are working?
Nurse: Yes. Yes.
Patrik: Kidneys are working? He’s making urine?
Nurse: Yes, yes. He’s making good… urine are good.
Patrik: Okay. And his hemoglobin is stable?
Nurse: Hemoglobin is stable right now. It’s 11.6 today.
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Patrik: Right. So, the biggest obstacle here is the ventilator, really. He’s not breathing up.
Nurse: Yeah.
Patrik: Yeah. And are they doing daily chest x-rays?
Nurse: They just did a chest x-ray right now, but the results are not out yet.
Patrik: Sure.
Nurse: Because they just did like five minutes ago, before I came here to talk to you.
Patrik: Yeah. Sure. Now, look, really, really appreciate all your help. I’m sure you’re busy. Really, really appreciate all your help and insights, so that we can hopefully make a decision.
Nurse: Okay. Yeah. Sure. Thank you so much.
Patrik: Thank you so much. Really appreciate it. Thank you.
Nurse: You’re welcome.
Patrik: Bye.
Isaac: Thank you.
Patrik: Bye.
Nurse: Bye-bye. Bye.
Patrik: You there, Isaac?
Isaac: Yes.
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Patrik: So, that’s enough information to get a good overview.
Isaac: Yeah.
Patrik: He’s..
Isaac: And then I’ll still send you the pictures of the ventilator and the bed.
Patrik: Definitely. Look, it’s enough information for now, and he seemed very nice, and he didn’t avoid any questions. I think, yeah, he definitely need medical
records… Just looking at the ventilator and whatever else we talked about, he’s on maximum support, and given that he’s not on any sedation, given that he’s been off sedation since the end of last month, that’s a concern. So, I can see..
Isaac: Yeah.
Patrik: I can see why they would want a tracheostomy. However, why is he not breathing if he’s awake? That doesn’t make any sense.
Isaac: Yeah.
Patrik: Doesn’t make any sense. He didn’t have a stroke at some point?
Isaac: No.
Patrik: No seizures previously?
Isaac: No.
The 1:1 consulting session will continue in next week’s episode.
