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 one of my clients and the question in the last episode was
How to get best care and treatment when your loved one has seizures and is ventilated with
tracheostomy!
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 continue answering the next questions regarding James’ and Christine’s Dad in ICU who’s had a
haemorrhagic stroke.
James’ and Christine’s Dad had a brain decompression where they evacuated a large bleed from his brain after the haemorrhagic stroke. And their Dad also underwent a craniectomy (removal of skull) to decrease
the brain pressures after the bleed.
James’ and his sister Christine were getting their Dad in one of the best hospitals in the USA, the Cleveland clinic in Ohio.
In the meantime, their Dad was getting a tracheostomy because he couldn’t be weaned off the ventilator and the breathing tube. He also had a PEG tube for feeding inserted.
He also had ongoing seizures due to the
stroke and his anti-seizure medications needed to be optimized so he could “wake up” and progress to Neurology Rehabilitation.
In today’s episode of “YOUR QUESTIONS ANSWERED”, I answer a series of questions from James again and today I advise James if his Dad is ready to go to a step-down unit and leave Intensive Care.
At this stage, thankfully his Dad seems well enough to finally leave ICU
after 5 weeks in it and we’ll work out today if it’s advantageous for his Dad to leave the ICU or whether James and his sister should try and buy more time for their Dad in ICU.
Today’s consulting and advocacy session is another excerpt from
various 1:1 phone/email consulting and advocacy session with me and the topic this week as part of this series of 1:1 consulting and advocacy session with me and the topic this week is
Is it time for my Dad to go to a step-down unit after he’s come off the ventilator or is it too early to leave ICU?
Patrik: Hey James, how are you?
James: Good, are you working tonight?
Patrik: Yeah, it’s alright. I’m just on a break, it’s all good. So I’ve seen in your email that they want to send your dad to the step-down unit tomorrow, do they?
James: Well, that’s what they’re saying, but they’re saying they don’t know if they have a bed
available. We talked to the ICU doctor today and he made it sound like the earliest he’d be moved is Monday.
Patrik: Look, if he’s been off the ventilator for now 48 hours, I do think it’s a
good move. I do believe that. Yeah, to get him to a step-down, and the reason I’m saying that is you don’t want … The ICU environment is so good for a certain period of time, but it’s not a very conducive environment. Given that he’s in the hospital and given that he is close to the ICU, I would be much more worried if they moved him to LTAC (long-term acute care) tomorrow, but that’s not happening. I think step-down is fine if he’s off the ventilator, that’s the main
thing.
James: Well … I’m glad that you said that, because I was kind of thinking the same thing. I’m just concerned that … I mean, first it was, you know, it could take him up to a year being off the ventilator before he really needs to go to the LTAC. So he really needs to go to the LTAC and now they manage to get him off the ventilator in four days.
Patrik: Yeah, and that’s very positive. That’s very positive. All he needs to do next is get off the tracheostomy then. They can take care of that in step-down. He won’t need ICU just to get off the tracheostomy once the ventilator has been weaned
off.
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James: Well, my question is, are they doing it too rapidly?
Patrik: No, not really. If he had been in ICU for a week, then I would question that. But because he’s been in ICU now for five weeks, keep in mind that he’s off ventilation, off vasopressors/inotropes. He’s off life support … the minute he stops being ventilated, he’s off life support. Right? And that’s really positive.
James: Right, but my question to you is, did they wean him off the ventilator too fast?
Patrik: No, if he tolerated that, no. If he can tolerate it, no. Definitely not. If anything, it’s very positive that he did tolerate it!
James: Okay.
Patrik: The main thing to look for is, can he tolerate it?
James: Well, they
were doing this reinflation every four hours with him and now they’re saying they’re not doing that anymore I guess. They were putting him on the ventilator every four hours and now they’re just going to … they use like this thing every four hours to blow up his lungs and clear his throat.
Patrik: They are probably using what’s called a “cough-assist” machine! And they might still be able to do that in the ward or in the
step-down, right? So that could still be a possibility. Do you know who’s doing that? Is it the physical therapy or is it the respiratory therapy? Do you know who’s doing that, the inflation?
James: The respiratory therapist.
Patrik: That’s okay. Ask them if they can continue to do that. Ask them. I think there’s a good chance they
will.
James: Yeah, they said every four hours.
Patrik: Yeah, as long as they keep doing all of that, I really do believe going into step-down will be good. ICU, as I said…
James: So I understand, they’re not putting him back on the ventilator every four hours, they’re doing
it manually with … those breathing things.
Patrik: Right. Again, I’m pretty certain they are using what’s called a “cough-assist”.
I think there’s a very good chance they might continue doing it. There’s also a very good chance that there is physical therapies and the future therapy will continue to assess him over the next few days. That will make sure he’s moving in
the right direction.
James: Alright, well that’s good to know. They made it sound … they changed their tune everyday and they made it sound yesterday like we need to reinflate him every four hours and I think maybe he was doing better. So now they’re like going on a ventilator is going backwards, so now we’re going to use a manual thing to reinflate him instead of the machine.
Patrik: Right. And as I said, I think it’s time that he leaves the ICU if he can. The minute he’s of ventilation, he’s off life support. When patients are off life support, that’s the time when they can leave ICU.
James: How long do you think we have in the step-down?
Patrik: Say again?
James: How long do you think we will have in the step-down?
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Patrik: Probably another … It depends, probably another week I’d say. But I think the next challenge for you will be not so much how long will he be in step-down. The next challenge will be what will be happening after step-down. A rehab bed might not be available straight away.
James: Right, and they do have a rehab facility here with the rehab beds
so.
Patrik: So you need to find out what the next steps are from step down. That’s your next sort of question you need to ask to them.
James: Okay, alright. Well, that’s good advice Patrik. If my father’s not being put on the ventilator and he’s breathing on his own tonight, should I be worried? Should I go check on him?
Patrik: If they put him back on the ventilator tonight, then you’ve definitely got to raise the question whether they can do the same in step-down. In some step-downs they might be able to
do that.
James: No, my question is, if he’s breathing on his own tonight, through the night, should I go check on him in the middle of the night just to make sure he’s okay?
Patrik: No, they will do that. I think what you might what to do is in the morning ask them whether he stayed off the ventilator over night or not. I think that’s a question to
ask.
James: Well I just got kind of like a weird conversation because I was there and they said tonight they have around … 10 o’clock tonight, and the nurse in charge pulled me aside and said we know you and your family have been video recording and voice recording us and that’s not permitted in the hospital here. I really have no idea what the hell she was talking about and then we got the news that he’s moving to the
step-down tomorrow. So I don’t know, these people are just very difficult around here.
Patrik: Right, right. Look they are difficult because you’re asking all of the right questions so take that as a compliment. But at the same time, you’ve avoided the LTAC, he’s now going to step-down and for now, he’s moving forward. He’s made a lot of progress in the last week. Don’t worry too much what they do or what they don’t do. I
would just …
James: Do you know, from a hospital setting, are you not allowed to voice record or video record?
Patrik: Look, it depends. They might have some policies, but on the other hand I would just … You know what my response probably would be, do you have anything to hide? That would be my question to them.
James: Hiding in regard to what?
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Patrik: Well, what’s so secretive about what they have to say? That would probably be a question I would ask if I was you. What’s so secretive about it? Nothing really, is it?
James: Right, exactly.
Patrik: Right so, I would just
ignore them.
James: Yeah, I have. That’s good advice. It just kind of like caught me off guard. I think it was just something to try to bother me because I’ve been fighting with them all week. I mean, it’s been a long week here.
Patrik: It’s been a long five weeks for you.
James: Absolutely. Well, he was in the ICU in New York for a week, so he’s in this ICU for four weeks. I don’t think four weeks in an ICU here after a craniotomy is that long. He just started coming around this week and now it’s like well, he’s got to get out.
Patrik: And he does, he needs to get out. It’s not … It’s the right place at the right time for critically inpatient.
Your dad is ill, but he’s not critical anymore.
James: Right, I agree. Alright, that’s good advice. I appreciate it. I’ll let you go, I’m going to get some sleep.
Patrik: Okay. You can get me over the weekend anytime.
James: Thank you very
much.
Patrik: You’re very welcome. Have a good night. Bye-bye.
James: Thank you, bye-bye.
