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Today’s article is about, “Quick Tip for Families in Intensive Care: My Husband's Back in ICU with Tracheostomy, NG (Nasogastric) Tube & Osteomyelitis, Can He Go to Rehab?”

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Quick Tip for Families in Intensive Care: My Husband's Back in ICU with Tracheostomy, NG (Nasogastric) Tube & Osteomyelitis, Can He Go to Rehab?
 

Hi, it’s Patrik Hutzel from intensivecarehotline.com with another quick tip for families in intensive care.

So we have a membership for families of critically ill patients in intensive care that you can be a member of, if you’re going to intensivecarehotline.com. And if you’re clicking on the membership link or you go to intensivecaresupport.org directly. And there we answer all of your questions, intensive care related.

Let’s read out the question from one of our members who has her husband in intensive care with a tracheostomy and a nasogastric tube. Let’s read out her latest email where she says my husband doesn’t have any recent fever and his vital signs and oxygen levels have been good. I tried to get him into a rehabilitation center again and the case manager sent in negative notes and he was denied admission. Is there any way you can assist me with this issue of getting him into this particular rehab facility?

I will be viewing a few other rehabilitation facilities like subacute. I was told he was denied to two rehab facilities because he was not actively participating in physical therapy and occupational therapy. Sometimes these services are coming to him after a wound change and he’s tired and sleepy from the pain. I know mobility is very important.

The wound care nurse is recommending an X-ray for my husband because he states the wound is near to the bone and he might have osteomyelitis. The internist states, he doesn’t think he has osteomyelitis. He just has pneumonia. I told the nurse today to put in a request for him to see the pulmonary doctor to check on his tracheostomy and general surgery to rule out the osteomyelitis. The speech therapist worked with him on Thursday by giving him the FEES (Fiberoptic Endoscopic Evaluation of Swallowing) test and putting the camera in his nose to check his swallowing ability. She states he has to strengthen his swallowing muscles now with additional exercise.

What are some questions and input I should be asking the speech therapist if I decide to take my husband home, I would definitely want to get respiratory care to come to the house? I will have to ask the doctor to verify that his insurance does cover home respiratory care, by him calling the provider line of Medicare. The doctor here is trying to push the PEG (Percutaneous Endoscopic Gastrostomy) tube.  I know your thoughts on it. But if he’s going to a rehab facility, I think he’s fine with the nasogastric tube. The PEG tube is a surgery. He already has a tracheostomy and wounds. I don’t want him to do anything else to his body if it’s not necessary. One nurse told me that patients also pull out the PEG tube at times. So it seems as if it’s not that secure. It’s surgery, bringing more money for the hospital. If my husband is home and it comes out, it will take him to the gastroenterologist. He has an appointment for a hyperbaric wound evaluation in a few days.

Thank you for your valuable advice and your valuable service.

So here is our response.

Thank you so much for your email. And we’re really glad to know that your husband is maintaining normal vital signs, no fever, normal heart rate, normal blood pressure, normal oxygen saturation, and no signs of pain. A good sign of progress. We are always praying and hoping for the best for you and your husband. May all things go well with his best care and treatment.

Please talk and ask the doctors the reason for denying your husband admission to the rehabilitation facility that you would want. Know the cause of the doctor’s denial and think of measures and solutions that will improve and correct the cause of the denial. Another thing that comes to mind here is, you are saying he’s not participating in physical therapy and he’s not participating in occupational therapy.  Well, my question is, are they really encouraging him? Are they sitting him out of bed to get him stronger? You’re asking what makes his swallow stronger? Well, for example, sitting up will make his swallowing stronger. Imagine you’re lying in bed as opposed to sitting up. What that does to your swallowing abilities? It’s common sense that sitting up, is the right course of action for someone that needs to relearn swallowing again.

Get yourself familiar with the schedule of your husband’s physical therapy, speech therapy and occupational therapy sessions and try and be there. And also suggest a schedule of the wound care dressing if possible after the therapy sessions. So that the medications given to your husband for pain during every wound care dressing procedure will not affect the physical therapy, occupational therapy and swallow study exercises of your husband.

Your husband needs all of these therapies which are beneficial for his healing and a speedy recovery. His active participation in the therapy sessions will help your husband to be recommended by the doctor for his admission to the rehabilitation facility. Effort and resources will only be wasted if your husband will then be transferred to other facilities without his desire and participation and without your input. Your husband needs to be active and awake during the sessions to co-operate and actively participate in his therapy, which will then facilitate his progress. Your husband’s wound condition needs an accurate assessment by the doctors and by the wound care nurses. The doctors and wound care nurses will determine the extent and severity of the affected wound, and his valuable advice and recommendations will tell whether a debridement, restorations, reconstructive surgery are required. The surgeon, plastic surgeon and infectious doctor need to be consulted.

Follow up visits of pulmonary, surgical, infectious and gastrointestinal doctors, physical therapist, occupational therapists, speech language, respiratory therapists, et cetera are needed to assess and evaluate your husband’s response to the treatments or for new recommendations according to your husband’s current presentation. So, what question should you be asking the speech therapist?

Well, first off, what’s your husband’s prognosis based on his initial evaluation? What is a realistic goal for your husband’s therapy and next steps? What tools and treatments will your husband need for his safe healing and recovery? He needs a treatment plan.  Does he need aggressive treatments because he does not show benefits to the exercise? How often does the husband need the exercises when he’s discharged home, hopefully, eventually, without a tracheostomy? Is he allowed to take oral intake in small amounts like ice chips, water, or completely nothing per mouth? What safety precautions need to be observed? Especially when your husband will go home for discharge, without a tracheostomy.

Next, the placement of a PEG, generally speaking, is a safe procedure. However, we advise against it for as long as possible. But if your husband can have the tracheostomy removed, he most likely won’t need a PEG tube. If he can’t have the tracheostomy removed and he can’t swallow, then he will need a PEG in the long run, but he’s not there yet. The first step that needs to happen here is to have the swallowing assessment carried through and through. And then if God forbid, he fails all of that, but that’s when a PEG tube might come into play. So, the risks are reasonably low such as infection tube, dislodgement, aspiration, pneumonia, et cetera. A PEG tube is inserted surgically into the stomach through the abdominal wall. The tube is kept in position by a retention flange in the stomach and the flat disc. PEG is low-cost, less invasive and has no need for general anesthesia in most cases. With the correct use, PEG tubes can provide 100% of a patient’s nutritional needs.

However, that’s not what you want. These are just the mechanics that I described what you want is for your husband to have the trach removed, have the nasogastric tube removed and have no need for a PEG tube. And that can be achieved by getting him moving, by getting him mobilized by getting him to do more and more physical therapy. Step by step so that he can avoid the PEG. Here’s the problem with the PEG. The PEG has the perception in hospitals in ICUs nursing homes of a permanent PEG. But it should never be permanent. It should be temporary. PEG or nasogastric tubes should be temporary. The goal should always be for patients to eat and drink again. No, it’s very easy for hospital staff or nursing home staff to just use a PEG, connect feeds, and not try for a patient to eat and drink again. Think about it, you don’t want to give them that tool that gives them the perception of permanency that your husband will never eat and drink again. That’s another reason why you should not give consent to a PEG. Your goal should be to focus on the swallowing. So that your husband can have the tracheostomy removed. And you’re right, PEG tubes can be pulled out as well by patients. But it is for someone that can’t come off a tracheostomy, can’t come off a ventilator. The PEG is the safe option, but your husband is not there yet. He is not there yet.

Also, in regards to the doctor saying he might have a pneumonia versus osteomyelitis. Well, I believe they can find out very easily whether he’s got a pneumonia by simply doing a chest X-ray. That’s very simple. It’s probably a little bit more complicated to diagnose osteomyelitis. But generally speaking, how is osteomyelitis diagnosed? Well, it’s diagnosed by blood tests, such a complete full blood count and look for increased white cell count. Also to check for erythrocytes, sedimentation rate because this test measures how quickly red blood cells fall to the bottom of a test tube. When swelling and inflammation are present, the blood’s proteins clump together and become heavier than normal. They fall and settle faster at the bottom of the tube. The faster the blood cells fall, the more severe the inflammation also checking CRP (C-Reactive Protein) that also helps to diagnose inflammation or an infection. Blood cultures, of course, needle aspiration or bone biopsy, x-ray of course, and make images of tissues, bones, and organs, bone scans, pictures or x-rays, again, to see whether infection or bone abnormalities are present. CT (Computed Tomography) scan will help, MRI (Magnetic Resonance Imaging) scan and ultrasound. So that would be the steps to properly diagnose osteomyelitis.

Now, also, as you know we’re all for home care, your husband could go home with Intensive Care at Home. If all fails, he’s probably better off at home with Intensive Care at Home. And you can find out more information at intensivecareathome.com, but your husband is not there. Imagine the best step for your husband is to actually have the tracheostomy removed, have the nasogastric tube removed, and then go home. If all fails, go to Intensive Care at Home, and you can get more information at intensivecareathome.com and you can contact us there if you want to go home or if you have a loved one in a similar situation, needing home care for tracheostomy, ventilation, Home TPN, please contact us at intensivecareathome.com.

So thank you so much for watching.

And once again, if you want to become a member of our membership for families of critically ill patients in intensive care, go to intensivecarehotline.com. Click on the membership link or go to intensivecaresupport.org directly. In the membership, you have access to me and my team 24 hours a day in the membership area and via email and we answer all questions, intensive care related.

I also offer one-on-one consulting and advocacy for families in intensive care over the phone, via Skype, Zoom, WhatsApp, or whichever medium works best for you. I have worked in intensive care for over 20 years in three different countries where I also worked as a nurse unit manager for over five years and I have been consulting and advocating for families in intensive care all over the world for the last 10 years. Please check out our testimonial section to see what our clients say.

Also when I do one-on-one consulting over the phone, Zoom, Skype, WhatsApp, I also talk to doctors and nurses directly and I ask the questions that you haven’t even considered asking, but you must ask so that you make informed decisions, have peace of mind, control, power and influence.  I also represent you in family meetings with intensive care teams. But before we even do that, we strategize whether you should even go into a family meeting with intensive care teams. You need to have a strategy. Most families, 99% of families in intensive care, lack of strategy, they’re going into those situations blindly. They have no idea what to do. They have no idea what questions to ask and then they wonder why things are not going their way and that’s what we can help you with very, very fast.

We also offer medical record reviews in real-time so that you can have a second opinion in real time once again so that you make informed decisions, have peace of mind control, power and influence. We also offer medical record reviews after intensive care. If you have unanswered questions, if you need closure or if you are simply suspecting medical negligence, all of this you get at intensivecarehotline.com. Call us on one of the numbers on the top of our website or send us an email to support@intensivecarehotline.com.

If you like my videos, subscribe to my YouTube channel for regular updates for families in intensive care. Click the like button, click the notification bell, share the videos with your friends and families, and comment below what you want to see next or what questions and insights you have.

Thank you so much for watching.

This is Patrik Hutzel from intensivecarehotline.com, and I will talk to you in a few days.

Take care for now.

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