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 frequently asked question from our readers and the question last week was
How long does a critically ill Patient stay on a ventilator after open heart surgery?
You can check out the answer to last week’s question by clicking on the link here.
In this week’s episode of “YOUR QUESTIONS ANSWERED“, I want to answer another question from one of our readers and the question this week is
My 57 year old Dad has been in Intensive Care with Cardiomyopathy and Pneumonia for 5 weeks! He’s still in an induced coma and still doesn’t have a tracheostomy, HELP! (PART 5)
This series of questions from Garry are excerpts from numerous 1:1 phone and email counselling and consulting sessions with me over a two month period.
Previous questions from Garry you can access here Part 1, Part 2, Part 3 and Part 4.
Garry and his family went through many challenges while his Dad was in Intensive Care and I felt very privileged helping Garry through this difficult time in his and his Dad’s life!
Garry writes
Hi Patrik,
it’s been another hectic day. I could not get a hold of the consultant today. He was on call in another hospital.
I asked one of the junior doctors to clarify the “withdrawal of treatment” to which I was told, that is not the case. He is still (apparently) being treated medically, even though he’s not on Dialysis for his failing kidneys.
They
are telling me that he’s getting Frusemide/Lasix to keep Improving his Urine Output. They have however assured me that he will get Dialysis if the Frusemide isn’t having the desired effect.
He is down to 50% oxygen, and is now on noradrenaline, is that a type
of Inotrope? After a bit of Google it seems that it’s given in cases of low blood pressure.
His infection markers in his blood are down a bit as well.
He is on the whole, much the
same with a slight improvement over yesterday.
I spoke to a very helpful nurse who is now helping me with the request for his medical records, but that could take days she said.
I have provisionally booked a time with the consultant, next Tuesday @ 12:30pm. Could you be available then to call in? I’ll provide further details at that point.
I also found out that a Cardiologist has consulted on my Dads case, and by that I mean never visited him only reviewed his ECHO / ejection fraction. My next step is to try and contact him to see how he reached his treatment decision and why he has not done anything
else.
Thanks again for everything so far.
Talk tomorrow!
Garry
Hi Garry,
I can be available on Tuesday 12:30pm to speak with the consultant.
You see, now it’s
confirmed what I always suspected that he’s working somewhere else and that this ICU and their Patients may not even be his priority… and again a three bed ICU doesn’t really warrant a full-time consultant anyway.
Very rarely would they treat somebody as sick as your Dad and neither should they!
Smaller ICU’s are usually there to establish first line and base line treatment for critically
ill Patients before they can be referred and moved to bigger, better equipped/resourced and simply more experienced ICU’s where they have all the options available that should have been available to your Dad when he first got diagnosed with Cardiomyopathy!
As far as I understand from what you’ve been telling me they are not withdrawing treatment (yet), however wanting to issue a DNR (Do not resuscitate)/NFR (Nor for resuscitation) order is usually the first step almost leading up to it. One of their next steps may also be to limit the
amount of Dobutamine and the amount of Noradrenaline they are giving, as well as the Oxygen on the ventilator.
That’s why they also mentioned a few days ago that your Dad wouldn’t be a “candidate” for Dialysis.
In essence, inotropes/vasopressors and ventilation/tracheostomy is constant life support, without it your Dad couldn’t stay alive at this point.
Again, the end goal for any Patient in Intensive Care is to get them off life support as soon as possible but in your Dad’s case they’ve missed the boat early on, by not referring him to another
ICU that would have had all the treatment options available to him like ECMO, VAD and/or heart transplant.
It’s a positive sign that he’s down to 50% oxygen on the ventilator and it’s probably due to
a) the IV Antibiotics working
b) high doses of Dobutamine
c) the Noradrenaile
d) Frusemide/ Lasix for increased urine output
and yes the Noradrenaline is an inotrope/vasopressor given for low blood pressure. In essence the way Noradrenaline works, it’s a vasoconstrictor, constricting the blood vessels and therefore concentrating more bloods towards the heart and therefore increasing blood pressure.
Dobutamine is an inotrope given for a weak heart and it improves the contractility (=pump function) of the heart. It also decreases peripheral vascular resistance and/or afterload so that the heart can pump blood against lesser resistance in the blood vessels.
Therefore, high doses of Dobutamine also lower the vascular resistance in the veins and arteries, eventually lowering the blood pressure. Therefore Noradrenaline,
which is a vasoconstrictor and is in essence constricting veins and arteries in the peripheries and therefore is centralising blood flow towards the heart and hence increasing blood pressure. Both drugs, Dobutamine and Noradrenaline are having some synergies when they work together!
I’m sure your Dad would have been on Noradrenaline before at some stage. It’s also a sign that your Dad may still be septic, even though his infection markers may have come down.
It’s also good to hear that the oxygen down on the ventilator to 50%, again maybe a sign that the chest is improving for now with the Inotropes as well as the Frusemide/Lasix (=drug to increase Urine
output).
Now, the next steps really are to make sure that they continue to do everything within their power to keep your Dad alive!
Recommended:
Even though, your Dad’s situation hasn’t improved much, it’s way too early to give up on him and it’s good that you’ve made that very clear to them that you expect that!
If I was you, I would still try and get him to another ICU where they are used in dealing with such sick Patients.
For now, make sure that there are no treatment limitations and that you don’t agree to any treatment limitations.
The next steps are to make sure that if your Dad’s kidneys continue to deteriorate that they are commencing him on Dialysis.
Furthermore, given that
you’ve had such bad experience with meetings with the Consultants, make sure you don’t go into any meetings before we’ve spoken again.
We will discuss in detail how you should go into another meeting with the Intensive Care team so that you are prepared.
Related:
Definitely try and contact the Cardiologist. It’s always good to speak to other people, even though it’s most likely that you won’t get many news from
him.
Again, given that the ICU team has only consulted the Cardiologist once and not spoken to him again since, shows how amateurish and negligent they really are.
In cases of severe Cardiomyopathy, a Cardiologist should be consulted all throughout the ICU stay. Again, you’ll find that in smaller hospitals, Consultants have other jobs in bigger hospitals and looking after Patients in a 3 bed
ICU is a “side gig” for them and Patients suffer because of it.
I also agree with you that you should request the medical records for your Dad so that we can look at what happened in the early days of his ICU admission!
How did you go about getting a second opinion?
Also, besides the consultant you are referring to, are there any other
consultants that you’ve dealt with who seem more competent or approachable?
Many thanks
