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 last week was
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 10)
You can check out last week’s episode by clicking on the link here.
In this week’s episode of “YOUR QUESTIONS ANSWERED“, I want to actually showcase how I can answer many questions in a short period of time when helping clients directly over the phone
or via Skype.
I showcase a conversation between one of my clients, a doctor and myself.
This is really a case study where I can leverage your time and get down to your most pressing questions very quickly.
My Dad has been in ICU with a stroke and respiratory failure! Now he’s on the ward, I’m worried he needs to go back into ICU, will the doctors take him back to ICU if he deteriorates?
I was working with a client Peter recently and his Dad had just come out of ICU a few days prior but Peter was worried that his Dad was at risk of going back to
ICU but that they weren’t doing all the right things.
By me speaking to one of the Doctors I could find out very quickly what was going on, what the hospital was hiding and I was able to find out critical information that was difficult for the family to find out, because they simply don’t know what questions to ask.
Here is the conversation between Peter my client, the doctor and myself.
Patrik: Patrik speaking.
Peter: Yes Patrik. Hi, it’s Peter Smith.
Patrik:
Yes.
Peter: Patrik I’ve got, that doctor just showed up in the room.
Patrik: Yes. Get him on. Get him on.
Peter: Hang on now. I’m going to put you on and get you off this
speaker, yourself a speakerphone. Hang on. I hope she’s still there, she was just sitting on the room. I’ll let her know that I really want to talk to her.
Patrik: Doesn’t matter whether she wants to talk to me or not. I’ll talk to her.
Peter: No I’ll just introduce. She’s still
here. She’s working on the computer right now.
Patrik: Is she working with your dad?
Peter: I don’t know she’s working on my– I don’t want to– I’ll catch her before she leaves here. She’s– Only thing, I don’t want to interrupt her, they’ll throw me out of the room.
Patrik: No. That’s not what they-
Peter: You don’t like being bothered, the doctors when they’re in there. They’re like on a computer on here, you know?
Patrik: Right. You got to change that.
Really got to change that thinking Peter, got to change that thinking of what they think about you or, that’s not going to serve you.
Peter: Let me just let her know that I’m waiting to talk to her.
Patrik: Yes. Which hospital is your dad in? What’s the name of the
hospital?
Peter: Can I just talk to you a minute? Very important.
Peter: I have him on the phone, my friend. He wanted to talk to you about my Dad. He just wants to talk to you about how my Dad is doing, I’ll tell him…
Lisette: Yes okay, that’s fine.
Peter: Just a, absolutely. Patrik?
Patrik: Yes.
Peter:
Yes she– I don’t know if you heard the doctor just– She’s going to talk to us but she’s going to go ahead and talk to us for about five minutes. Five, 10 minutes.
Patrik: Okay. Why don’t you give me a call?
Peter: Hang on.
Lisette: One second okay?
Peter: He’s an ICU nurse. She was just worried about the oxygen saturation, why we lose it and what happened in the last 24 hours! He works in ICU. Okay, Patrik I’m here with the doctor.
Patrik: Okay. Hi my name is Patrik how are you?
Lisette: Good. How are you?
Patrik: Very good thank you.
Lisette: My name is
Lisette.
Patrik: Lisette is it? Nice to meet you, nice to talk to you. You’ve got a busy work day?
Lisette: Yes.
Patrik: I’m sorry, no that’s– yes yes I can hear you, I can
hear you. Look, I’m just trying to get a little bit more information about Peter’s dad. I understand he has been in ICU for a couple of days now he’s on the ward. What’s his current situation? I was talking to the nurse briefly. She couldn’t tell me what his Glasgow Coma Scale was. What’s your understanding, what’s your impression of his situation at the moment?
Lisette: Well, in terms of his neuro status, he’s essentially unresponsive at times. He’ll intermittently withdraw the painful stimuli or grunt or
something like that, but that’s about it and then in terms of his respiratory status, it seems like overall, he’s been stable here on the floor. He does intermittently cease that. He’s on face mask at 40% oxygen. He intermittently desaturates but he seems to be in a relatively stable, his chest x-ray is improving. We think he’s got a lot of volume on. He’s got about two plus pitting oedema in his lower extremities, this wrong crest route as long. It looks like he has to be a pleural effusion on the left side so we’re just trying to continue diuresis. We’re just escalating the Lasix and hoping that that improves it. He did send us-
Peter: Call it brain
medicine. If you could back up on the c–
Lisette: Yes. That’s right so he did have some right-sided, what seemed like myoclonic jerks. I hadn’t seen it myself but when he was in ICU until we’ve placed on continuous neuros EEG. He has some epileptiform discharges and they thought that he certainly has the stroke areas in the past and he has a reason. He’s high risk for seizure and so Neuro wanted to start Keppra and it was just a feeling that he definitely seemed more lethargic after starting Keppra so we tried it for a couple of days and, after talking to Peter and hearing his concerns, we’re going to discontinue it today and just see if he perks up a little bit in terms of– It’s my understanding that Peter was saying that at times he would open his
eyes at home and at least seem to maybe track a little bit. We’ve not been able to see that here in the hospital over the past couple submissions.
Peter: In the ICU even three days ago, he was waking up night about three hours ago. Then the bleeding happened and then they hit him with the Keppra and then he never woke up since.
Lisette: We’re going to stop the Keppra and so that’s his Neuro. Respiratory mentioned some of that but also he did complete a course of BIPAP for a few days. We are continuing him on Cipro because he did have a Pseudomonas UTI. But it is sensitive to
Cipro so actually going to continue that for a full 14 day course I think. We think all of his infection could certainly be contributing to his lethargic …
Peter: What about the attempted MRI? That’s the other concerns that is the attempted MRI and then when he tried to do the MRI, his sash dropped on the 80s. They couldn’t do the MRI to access his brain.
Lisette: Yes so– I’m sorry Pat. Go ahead, I don’t want to interrupt you.
Patrik: No, I just wanted your thoughts on with the MRI. I guess my question would also be with the bleeding. Would you have any concerns that there was an intracranial bleed? Especially if it’s–
Peter: We’re not originally negative. The brain scan was negative.
Lisette: You mean the bleeding in the past or that bleeding from the Foley catheter?
Patrik: My understanding is he had a bleeding on this admission around his round his suprapubic catheter so the migration would be– Would you have any concerns that there may be a brain bleed as well?
Lisette: We don’t think so. We didn’t have
non-con head CT so we don’t think that that’s contributing and in the Foley insertion, it seems like that that was possibly a traumatic catheter and so that was a big part of the bleeding.
Patrik: Right. You
wouldn’t be concerned about his coagulation, that wouldn’t be off that his INR or his APTT would be out of balance and he would have sustained a brain bleed given that you– I understand that usually the CT on admission but no MRI has been followed up with, so that wouldn’t be any concern at this point in time?
Lisette: Yes so we felt like the CT would be the best thing to show the bleed
and then in terms of the MRI, our thought was, we were always plus minus on the MRI because it wouldn’t really change our management, just possibly give answers and so we wanted to pursue an MRI unfortunately, he does reach out when he lies flat, we did do a trial before he went out for MRI yesterday, he did great with that but then when he got down there, maybe he had a mucus plug, who knows, he did Desaturate though when we laid him flat, so our thought was to give him a few days, wait until
he is a little bit more stable and get onto his nasal cannula and maybe try again, once he is a little better diuresed, but it seems like there’s been step wise decline over around 2015 and unfortunately his mental status if so didn’t seem to really be improving.
We want to see how it goes stopping the Keppra continuing to treat Pseudomonas UTI and then in terms of his like APO
and frequent embolic events we are going slow with his Warfarin, he has had a lot of ignition which I’m sure you aware of where you have a really labile INR, and so we are working literally with phamarcies, like they join our rounds and like it’s directly involved with times trying to titrate anti-coagulation in the safest way. We are going very slow with that, we’re bridging him with Lovenox right now.
Peter: Its getting late, that is why he doesn’t like it. We were just worried about the blood pressure and maybe go on back to the MICU because of the fact that he had, his mask fell off today and his Sats went down to 80 and Pat would have worried. Is that true Pat? You were worried about why, he’s not in MICU.
Patrik: Yes, that’s right. I understand everything that’s happening, I guess if his saturation comes down to 80% which I understand it has happened at some point, would he need to go back into ICU as part of your medical emergency criteria? I understand there will be other things too like hyper tension, I guess, we are just trying to find out what happens in case, he deteriorates. Would he be better of back in ICU? He’s got sleep apnea, I understand
you’ve tried the CPAP mask that didn’t work, I guess with his de-saturation would he be better off going back on the CPAP over night? You have talked about improving his respiratory status. I’m just trying to find out, what management is.
Lisette: Yes, we have him on the monitor 24/7 and we have a very low threshold to transfer to MICU, but we feel like his pressures have been stable,
other than those intermittent desats, he’s been doing okay and we had respiratory come by and we’re going to do with a trial of CPAP tonight and see how he does, so I’ve been over quiet…
Patrik: As I said, my concern just by what you are describing, with the neurological condition, I understand you haven’t been able to do the MRI because he is de-oxygenated, de-saturated, I guess my
concern would be especially with the Warfarin and the volatile iron arm, had there been an intracranial bleed that has gone undetected so far that would be my concern just by everything that you’re describing but maybe a follow up with an MRI might be possible at some point but I understand he’s got he’s got to be able to tolerate that of course. Are his pupils reacting to light at least?
Lisette: His pupil on the right is sonically pinpoint, none the less its minimally doesn’t seem like that, been unstable, sound like walk home for surgery so it’s hard to go by the pupils but we’re reassured by their existence.
Patrik: It sounds to me like the MRI is going to happen when David is more stable, they want to see him get more– it sounds like the CPAP is happening tonight which is good so and it sounds to me like
you’ve got a low threshold for getting him back into ICU if that’s what’s needed so thank you.
Peter: You are worried about him… We’re just worried about that the fact he’s so sensitive that his oxygen drops so quickly why and what’s continental. Is it is something wrong as we do why… what’s causing those drops, that’s why Patrik was worried about whether he should be in the ICU and till
they figure out that and I’m when they discharged him from ICU he was like 96 on like four liters of O2. He was doing really good when he got here.
Lisette: When he came here and was on the face mask, like between 35 and 40%. One of the main reasons that we think that this either continues or to requirement is the fluid so he’s on 2 feeds and he required some free water flushes for
hypernatremia so it’s cool about and he has some issues with like renal secretions and stuff like that so that’s why we’re escalating the Lasix to try to get rid of fluid off of his…
Patrik: Right, that sounds great. I think I understand now what is happening and at anytime have you tried to predict at any time frames you think could the MRI, you think that might happen over the
weekend?
Lisette: It certainly could. We want to do it when it is safe.
Patrik: Yes, by giving him the CPAP overnight that might improve his respiratory condition and maybe he will get a little bit more awake as well by having all the pressure and what not but yes I understand. That
makes now a lot more sense with everything that you are describing giving the IV antibiotics, giving the full course of Frusemide, the Lasix and planning for the MRI you’ve taken off the Keppra, all makes a lot of sense that that you’re doing everything you can to hopefully get him to improve if that’s possible.
Lisette: Yes that is definitely our hope.
Patrik: For sure, thank you so much.
Peter: He just wanted me understand, that we can get him to the ICU if there’s any kind of, if this continues, just in case that he doesn’t move and rests over here we want to catch it before it happens.
Lisette: Yes. We’ll keep you posted, but our hope is that we can keep him out of the ICU but he has such a complicated history and he’s very tenuous and it could certainly happen when he has to go back and were, definitely would not be opposed to that at all but he is really okay for now.
Peter: Is the
fact they need so much oxygen doesn’t worry you? They had to do 50% to get him up to 95. We would like his oxygen Sats to be 94, 95%.
Lisette: Okay.
Patrik: Thank you so much Erica for all your time and for your help. I really appreciate it. Thank you
Lisette: Yes. No problem. Let me know if you have any other questions.
Patrik: Yes, we’ll be in touch. I’ll be in touch. Thank you so much.
Lisette: All right, thank you.
Peter: Thanks a lot. Thank you. Bye bye.
Patrik: Look, I do believe they are doing everything they can. She confirmed that he is to go back into ICU if he deteriorates. I tell you why he’s not in ICU at the moment. He doesn’t– Even though he would be better off in ICU, there’s no question around that,
he doesn’t fit the criteria for ICU yet.
Peter: They talk like they got him on a low threshold for that, I guess she said that that means that he’ll go over as soon as they think that he’s not stable.
Patrik: Yes. That’s right. That’s exactly right and that was good to hear that from
her. The other thing that I felt she wasn’t defensive. She wasn’t defensive to my questions.
Peter: Yes.
Patrik: Right?
Peter: At least she got your foot in the door
anyway.
Patrik: That’s exactly right. She wasn’t defensive. I know when people are defensive. I know that. She was transparent and that’s a good sign. That’s a good sign.
Peter: Yes. I learned more from that conversation about what’s wrong with Dad then they told
me.
Patrik: Yes. That’s what I mean because I asked, I know what questions I need to ask.
Peter: Anyway, I don’t know exactly how to get them to, until they make you but…
Patrik: He doesn’t meet the criteria yet. But I think, from what she was telling me, they definitely know that he’s at a high risk of going back and they would get him back if things change. I have no concerns there from what she was telling me.
Peter: Okay, got it. Okay, Patrik. I just thought I’d, at least we get is ball
rolling.
Patrik: Exactly.
Peter: We put the bee in their bonnet. That way they know we’re watching what’s going on.
Patrik: Exactly, and tell me what’s the name of the hospital
that he’s at. I just want to have a bit of a search of what their website is saying.
Peter: Medical Center in XXXXXXXX
Patrik: Okay. Yes. Thank you.
Peter: XXXXXX. It’s one of
the big hospitals in XXXXXX.
Patrik: Right, okay. I’ll have [crosstalk]
Peter: Yes, there’s XXXXXXXX, you probably heard of that.
Patrik: Yes.
Peter: Then there’s the x Hospital. Then there’s the Y Hospital and Women’s Hospital. Those are the three major hospitals. I just don’t like them writing him off.
Patrik: No and I don’t like that but it doesn’t sound to me like she did. Doesn’t sound to me like she did.
Peter: I just worry about brain damage. You want to know what worried me other day? They don’t let me stay with him in the ICU. I have to leave. When I’m with him here on the floor, in a single room in the ICU. I wasn’t with him overnight and I just wonder if somehow, I went in there early one morning and he was lying flat on the bed and the nurses got mad at me. He’s not supposed to lie flat because he has
sleep apnea. He’s a person with sleep apnea and I happen to say to them, “What’s he doing lying flat in the bed because he could suffocate.” And she got mad at me, “Now you all supposed to call. Before you come in this room. Before you come in the ICU, you’re supposed to call and ask for permission. You can’t just walk in.”
Patrik: Well, you can. You can.
Peter: I call every time now, afterwards. But what I’m getting at is that I don’t know what happened to him. After seeing him being left flat. I don’t know what happened to him overnight while he was in MICU. They could have have got him hypoxic or whatever.
Patrik: Yes, absolutely.
Peter: I’d not know.
Patrik: You know what?
Peter: Even though there’s no, go ahead.
Patrik: What we could do and nothing maybe urgent but we could always ask for the medical records. We could always
ask for the documents.
Peter: Yes. This is an ongoing right now. Won’t be able to get the current one, right?
Patrik: No, you can. Done that with other clients. You can. Always. But for now, Peter, I think she wasn’t defensive. I can tell you I’m dealing with people who are defensive
all the time. She wasn’t defensive. She answered all my questions. She wasn’t avoiding any of it. She sounds like, tell me if I’m right there, she sounds like she’s young. Would that be correct?
Peter: Yes. I’d say she’s in her 30’s.
Patrik: Yes, she’s young. She’s probably a little
bit inexperienced but I have a good feeling.
Peter: She’s a resident. At least she’s going to listen, I hope and I think it’s good to at least let them know that we’re watching.
Patrik: Correct, and they know that by now. The nurse knows. The doctor knows and as I said, the main
thing to me was, she wasn’t defensive. As I said to you I’m dealing with people who are defensive all the time and she wasn’t. That’s a good sign.
Peter: Right.
Patrik: Did you have a feeling that she was defensive? I didn’t.
Peter: No. She said more to you than she said to me.
Patrik: Yes because I asked all the right questions. I know where to hone in.
Peter: Anyway, Patrik, I don’t want to bother you too much. I
figure you would take that up a soon-
Patrik: Absolutely.
Peter: In case something happens overnight or early in the morning, she’ll be thinking of the conversation and maybe she’ll get them over there.
Patrik: Exactly. Give me a call anytime, Peter. I’ve just sent you an email with some stuff before you called. Have a look at that.
Peter: All right.
Patrik: We’ll talk whenever you need me.
Peter: Okay. All right now. You take it easy.
Patrik: And you. All the best.
Peter: All right.
Patrik: Bye bye.
Peter: All right. Bye bye.
