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

IS IT BEST TO HAVE A BREATHING TUBE /ENDOTRACHEAL TUBE AFTER STROKE AND SEIZURES?

You can check out last weeks question by clicking on the link here.

In this week’s episode of “YOUR QUESTIONS ANSWERED“, I want to answer the next questions from one my clients Andrea who has her 34 year old sister in Intensive Care with non-Hodgkins Lymphoma and a stroke.

Today’s questions and excerpt from the 1:1 consulting and advocacy session is

My sisters’ blood count is low, does she need blood products to get off the ventilator?

You can also check-out previous consulting and advocacy sessions with Andrea here

PART 1

PART 2

PART 3

PART 4

Hi Patrik,

Thank you for your time today and sending through the summary notes below. It was good speaking to you.

I have requested a family meeting with the ICU doctor, the Neurologist and Haematology doctors. This will now probably occur on Tuesday or Wednesday.

I asked the nurse tonight about my sister’s cell count:

White blood cells – 2

Neutrophils – she didn’t know this

Haemoglobin – 64

Her anti-seizure medication is Keppra and it is given two times a day.

She also had the following liquids intravenously:

Actrapid 50 unit

Nutrison

Sodium chloride

That is all I discovered today but will see if I can find more information tomorrow.

Kind regards

Andrea

Hi Andrea,

The ICU nurse should definitely know about your sister’s neutrophils, if she doesn’t know about it, it should take her one minute to look it up on the computer.

With the white cell count so low, it’s a sign that the immune system is down, therefore the risk of the neutrophils being low is a real one. If white cells and neutrophils are down they may have to start thinking about getting your sister in an isolated and negative pressure room.

If she’s not in isolation and not in a negative pressure room, chances are she’s not neutropenic, but I wouldn’t rule it out either until you know for sure.

I have seen some Patients after Chemotherapy and non-Hodgkins lymphoma seen being neutropenic, therefore you probably want to find out rather sooner than later.

Haemoglobin (HB) 64 indicates she will need a blood transfusion or two, especially if she is on inotropes such as Noradrenaline or Adrenaline for low blood pressure. The lower HB the higher the chances that blood pressure is low and therefore the need for life support such as Inotropes/vasopressors. I would urge you to find out if she’s on inotropes to have a better understanding of how much major forms of life support she currently needs.

I would also urge you to find out if they are planning to give your sister blood transfusions or not. This will also indicate to you if they are ‘silently’ enforcing an NFR (Not for resuscitation) order or not.

Now, are you sure she’s had 50 units of Actrapid? Do you know if she’s on an Actrapid infusion? I would imagine she might have 5 units/hour as an infusion with Nasogastric feeds given. 50 units doesn’t sound accurate, it’s way too high, unless there have been unusually high sugars like >20 and even then it would be incredibly high!

As discussed, very happy to dial into a family meeting whenever you can schedule it.

Recommended: 

• FOLLOW THIS ULTIMATE 6 STEP GUIDE FOR FAMILY MEETINGS WITH THE INTENSIVE CARE TEAM, THAT GETS YOU TO HAVE PEACE OF MIND, CONTROL, POWER AND INFLUENCE FAST, IF YOUR LOVED ONE IS CRITICALLY ILL IN INTENSIVE CARE!

I would also be very happy to call the ICU and speak to the bedside nurse or a doctor before the meeting. I would be very happy to call them daily and get updates if you wish to.

You also will need to put it in writing that you want access to the medical records like we discussed over the phone.

Here is also a link to the NSW Dept. of health website clearly stating that you have the right to access health records

http://www.health.nsw.gov.au/gipaa/Pages/default.aspx

I would address your request to the Director of Nursing or Hospital Manager/CEO or to the Patient liaison officer.

You could also make a formal complaint to the people I mentioned above. It worked recently with another client in Brisbane where we wrote a letter/email to the Director of Nursing/CEO and we requested a meeting within 24 hours and they were responsive to that.

I know they are trying to make your life hell and I know you won’t give up. Just keep requesting ideally always with deadlines and start using stronger language such as

• You are trying to kill my sister
  
  

• We are considering seeking legal advice
  
  

• Not giving blood products is negligent, where is your duty of care?

And keep reminding them that you were told your sister is for full treatment, therefore have they been lying to you?

Also, keep asking for their Hospital/ICU policy about “treatment limitations”/ NFR (Not for resuscitation). Again, there is a very good chance they have already breached their own hospital/ICU policy and potentially even the law.

Recommended:

• THE 5 THINGS YOU NEED TO KNOW IF THE MEDICAL TEAM IN INTENSIVE CARE WANTS TO“LIMIT TREATMENT”, WANTS TO “WITHDRAW TREATMENT”, “WITHDRAW LIFE SUPPORT” OR WANTS TO ISSUE A “DNR” (DO NOT RESUSCITATE) OR “NFR” (NOT FOR RESUSCITATION) ORDER FOR YOUR CRITICALLY ILL LOVED ONE!

please find the “end of life care/withdrawal of treatment policy” in NSW attached.

It’s available publicly at the NSW dept. of health website here

http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2005_057.pdf

It’s a shame that they are saying there is no policy, which in essence means they are lying to you and they don’t want to play by the rules. It’s shocking and highly inappropriate…

I would still be asking them for the policy to keep the pressure on.

Other questions that are important tomorrow are

• Will they consider starting her on inotropes such as Noradrenaline or Adrenaline if her blood pressure drops and goes below 90 mmHg?
  
  

• Inotropes/vasopressors such as Noradrenaline and Adrenaline are considered life support and are being used if Patients in ICU are hemodynamically unstable. Inotropes/vasopressors can only be given in ICU and ED because it needs very close monitoring
  
  

• Given that they are currently denying blood products to your sister it wouldn’t surprise if they want to deny inotropes/vasopressors too in case your sister deteriorates
  
  

• The lower the Haemoglobin drops, the higher chances are that your sister will need inotropes/vasopressors such as Noradrenaline or Adrenaline
  
  

• Giving your sister blood products may not eliminate the need for Inotropes/vasopressors but it will increase the chances for not needing them
  
  

• Also, are they considering isolating your sister if her Neutrophils drop lower? Normal Neutrophil levels are 1.5-8.0 and isolation starts if Neutrophils are <1.0
  
  

• Your sister would be very vulnerable to bugs transmitted from other Patients if her immune system is low. Therefore isolation would provide another level of protection given how vulnerable she is

Those are the most important things for now.

Happy to chat in the morning and also happy to chat to a lawyer once you found one.

Also, give yourself a pad on your back for being so strong. Your sister would be very proud of you and I’m sure so is the rest of your family!

I can already see that the ICU there is horrible and they have no compassion whatsoever. Be prepared to have more obstacles thrown your way before it gets better, it usually does get better once they know you’re not giving up.

Please give me a call anytime if you need anything or if you need any questions answered urgently.

Wishing you and your family all the best!

Kind Regards

Patrik

Recommended:

• Book you free consultation call here

Hi Patrik,

Thank you so much for all your help yesterday.

I was researching last night the impacts of low blood counts.

Is it fair to say that low blood counts (low oxygen levels) can cause low blood pressure which may cause an isometric stroke and or a heart attack?

My sister’s ICU doctor said yesterday she had a healthy heart so a reason for her to potentially have a heart attack is extremely low, given her blood counts?

I am very concerned with his decision not to give her blood transfusions and I don’t know who to speak to in the hospital to get this reversed. I feel we haven’t changed his mind nor have any resolution around this.

I would greatly appreciate your guidance and thoughts.

Many thanks

Andrea

Hi Andrea,

a low Haemoglobin (red blood cells) isn’t helping on all levels.

1. it usually causes a lower blood pressure, which is why I keep asking if she’s on inotropes/vasopressors such as Adrenaline or Noradrenaline. Inotropes/vasopressors are intravenous drugs exclusively used in ICU and ED to manage a critically low and often life threatening low blood pressure
   
   

2. Haemoglobin (HB) is also binding oxygen in the blood, hence a low HB is making it more difficult for your sister to come off the ventilator eventually, if she can reach that point
   
   

3. Not giving blood products (Red blood cells, Platelets as well as FFP = Fresh frozen Plasma) leaves your sister vulnerable on all levels. Her body is currently not in a position to produce healthy White cells, Neutrophils, Haemoglobin and/or Platelets because the bone marrow is unable to produce it

As far as your concerns go in relation to a heart attack and/or stroke all I can say is that for anybody in an Intensive Care environment facing a critical illness the risk of them sustaining a heart attack and/or stroke is usually increased.

Low blood count would be one of the risk factors but not the only one. Critical illness and a stay in Intensive Care have been identified as one of the biggest stress factors in life (as you can imagine) and big stress factors can cause strokes, heart attacks etc…

I have seen many Patients in ICU being admitted with I.e. Pneumonia, trauma etc… and then sustaining a stroke or a heart attack down the line.

In your sister’s situation, I would imagine she would have been on a long list of medications with multiple side effects to begin with, including Chemotherapy and Radiotherapy. As you know side effects are huge and therefore the risk for complications such as a stroke are real.

Recommended:

• 1:1 email counselling and consulting with Patrik
  
  

• 1:1 phone and email counselling and consulting with Patrik

At this point with all the information that I have, I’m not too worried about her heart. Which is again why I’ve asked if she’s on inotropes such as Noradrenaline or Adrenaline. When Patients are on inotropes it’s often a sign that the heart isn’t coping or it can be a sign that hypovolaemia (low fluids in the body) is present. Hypovolaemia would be more likely in your sister’s case because of low HB etc…

Also, a stroke can be caused by a thrombus (blood clot) or a brain bleed. As far as I remember you mentioned that your sister had haemorrhagic stroke (bleed on the brain) which would make sense with low Platelets because the blood is thin already.

With minimal or no Platelets and the risk of bleeding it does minimise the risk of a heart attack, because a heart attack- similar to a stroke- is being caused by a thrombus (blood clot). Hence no Platelets and the blood being thin minimises the risk of a Thrombus and a heart attack.

Also, even though your sister is very ill, the risk for a young person like your sister to sustain a heart attack is significantly less compared to an older person with a severe critical illness.

In terms of how we would go about reinforcing that your sister needs blood products, we can bring this up in the family meeting. I will also have a look at the policy from NSW health and see how we can use this policy to plead our case.

I hope this helps for now, let me know if you have any questions or if you want to get on the phone.

Kind Regards

Patrik