Hi, it’s Patrik Hutzel from INTENSIVECAREHOTLINE.COM where
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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
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 6)
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 7)
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, Part 4, Part
5 and Part 6.
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,
I hope you are well! – sorry for
not getting back to you again, I have been in and out of ICU to see my Dad and try and get a handle on what’s happening.
Would you be free tomorrow for another phone session at 12:30pm?
Things are generally good at the moment with my Dad at the moment, he’s making (very slow) progress.
As you know he is off the sedation and is fully
mentally aware of what’s going on.
He is still in the same ICU. I was a little bit happier with his treatment in this ICU after I told them I was thinking about moving him, but I think it’s going backwards again.
He is still not able to speak, as they can’t seem to ween him off the vent. He has lots of secretions.
He has become very
agitated and anxious and has daily panic attacks, which is not like my Dad normally.
They also seem to have stopped doing tests on the heart for now I believe. No more ultrasounds or echocardiograms of the heart.
Given that he’s still on inotropes Dobutamine and Noradrenaline, I’m very worried that they stopped doing things, it almost looks to me like they are giving
up!
Look forward to speaking with you soon.
Rob
Hi Rob,
thanks for getting in touch again.
It sounds to me like your Dad might be plateauing for now, with him not going backwards but also not moving
forward.
I’m glad to hear that they have been a little bit more responsive to you and your Dad’s needs given you have made clear to them that you’d like him in another ICU and again I believe he would still greatly benefit from leaving this environment, as we have discussed at great length in our last phone call.
As far as your Dad’s current situation is going, the following issues emerge
and need to be addressed.
As long as your Dad is having lots of secretions and needs to be suctioned regularly, they will have a very hard time weaning him off the ventilator and the tracheostomy.
On top of that if he’s getting minimal Physical therapy/Physiotherapy- and you have confirmed that he’s hardly getting any of it- it’ll be hard to build up his strength and stamina. He will be
unable to build up his strength and stamina if he’s lying in bed 24/7 with little to no movement.
Again Rob, they just lack the skills, resources and “know-how” in how to deal with your Dad’s current situation because they wouldn’t have seen Patients with Cardiomyopathy very often.
Given that Cardiomyopathy requires such specialized treatment and attention to detail, they have- sorry for saying it once again- missed the boat and they have been negligent by not referring your Dad to another more specialized, better equipped and better resourced ICU.
From what you are describing the following is happening
currently.
With your Dad having lots of secretions is most likely a sign that his weakened heart is not coping. What it means is that either he’s having excess fluids on the lung because the heart is congested and therefore can’t pump blood around the body efficiently.
This often leads to fluid accumulation in the lungs, resulting in excess secretions. It’s also a result of the heart not
contracting properly with the Cardiomyopathy hence why he needs the Dobutamine in particular.
But given that your Dad has now been on Dobutamine for nearly two months, there is only so much more that can be done Rob, especially in
such a 3-bed ICU environment.
Also, given that his general condition has been deteriorating significantly after two months in ICU- as you can imagine and appreciate, any ICU stay is burdensome, let alone a long-term stay in ICU- he currently has little chance getting off the ventilator and the tracheostomy.
Recommended:
This is not only because of his weakened general condition, but also because of the same mechanisms that lead to your Dad having lots of secretions on his chest that he needs to be suctioned for constantly.
Again, your Dad’s heart is being weak and not pumping sufficient blood around the body will make your Dad’s lung weak as well, because the lungs are not getting supplied with sufficient oxygen from the body, hence why he needs the ventilator.
The ventilator and the tracheostomy leave him unable to speak and therefore frustrated.
You’re also saying
“He has become very agitated and anxious and has daily panic attacks, which is not like my Dad normally.”
Again Rob, imagine you’ve been stuck and you’ve been confined to a bed in ICU on a ventilator and you’ve spent
many weeks in an induced coma whilst being critically ill.
Now that your Dad is being more awake and may also get a better understanding of how sick he is, he might get more
panicky.
You often see this, especially in long-term Intensive Care Patients.
It could also be part of ICU delirium and ICU Psychosis.
ICU delirium and ICU Psychosis has mainly been described for Patients that have been in Intensive Care and in an induced coma for prolonged periods.
Again, I need to go back to your Dad’s first few weeks in ICU where they
- Didn’t refer him to another more specialized, better resourced and more experienced ICU where he would have had all the necessary skills, “know-how” and probably also good-will available to treat his condition appropriately and therefore with increased chances to get out of ICU alive and in a more reasonable time-frame.
He would have had all the appropriate treatment options such as ECMO, VAD and/or heart transplant available to him
- Didn’t do a tracheostomy in an appropriate time frame and instead they left him on a ventilator in an induced coma for 5 weeks
Especially
this prolonged time that your Dad had on the ventilator with a breathing tube instead of an early tracheostomy was such a blunder by the doctors in this hospital.
As we discussed Rob, by your Dad having the breathing tube in inappropriately for such a long period, he would have also needed more sedatives and more opiates (=pain killers) such as Midazolam(Versed) and Morphine or Fentanyl.
All of these drugs are highly addictive and also put huge strains on other major vital organs such as the heart, kidneys and the liver, including the lungs as some of the major side effects of
those drugs are respiratory depression.
All of those drugs are also highly addictive, therefore again, the use of such drugs should be minimized as much as possible.
What did they do instead?
Instead of doing an early tracheostomy and wean him off sedation and opiates as quickly as possible, they kept sedating him heavily and unnecessarily
for nearly five weeks before they finally did a tracheostomy.
Related article/video:
HOW LONG SHOULD A PATIENT BE ON A VENTILATOR BEFORE HAVING A TRACHEOSTOMY?
During those five weeks your Dad’s body would have become addicted to the Midazolam (Versed) and the Morphine or Fentanyl.
Therefore, part of your Dad’s agitation, confusion and delirium is most likely caused by withdrawal from those potent and addictive drugs that he
had for many weeks.
This is often a vicious cycle, because of the agitation he now may need other medications to calm him down. Other medications they may be using for the delirium are drugs like Seroquel and/or Haloperidol. Sometimes Clonidine can be used as well, but Clonidine needs to be used sparingly with an already low blood pressure your Dad is dealing with.
You see Rob, their whole
approach to your Dad’s case is now showing off in a way that you couldn’t have predicted when he first got admitted to ICU.
You thought that they would have his “best interest” at heart. Now that I’ve opened your eyes to what’s really going on, you have unfortunately seen where they have let you and your Dad down.
You simply don’t know what you don’t know…
I’m not surprised to hear that they have minimized testing and diagnostics for his heart.
I’m certainly concerned by that but not surprised.
Again Rob, with your Dad having such a weak heart and with him being diagnosed early on, he should have been referred to another ICU very quickly.
It certainly looks they are
giving up on your Dad, but again it’s not surprising given how they’ve handled this whole dilemma.
As time goes on, no other ICU will take your Dad, because he’s so weakened by now that any other advanced treatment another ICU can offer might be of no benefit to your Dad.
I will elaborate more on those issues when we talk again tomorrow at
12:30pm.
