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 our readers and the question in the last episode was
My Husband’s Alcohol Withdrawal And Sedation Is Keeping Him Unconscious In ICU. Why Is He Not Waking
Up?
You can check out last week’s 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 Steve who has his wife ventilated with trache and the ICU team wants to transfer her in the LTAC facility then eventually to be sent home.
The ICU wants my to remove my wife’s trache and they want to transfer her to the LTAC. Will it be safe for her?
“You can also check out previous 1:1 consulting and advocacy sessions with me and here.”
Steve: Hello.
Patrik: Hi, Steve. It’s Patrik here. So, I’ve had a read through your last message. The
first thing that stood out to me, Steve, is the pC02 of 66 (blood gas). It’s way too high. And I believe, because she’s breathing on pressure assistance, I believe that’s probably why the pC02 has gone up. And the PEEP of 5 might be too
low. But, that’s something you can discuss with the doctor. I wouldn’t be thinking they would be happy with a C02 of 66.
Steve: Well, they aren’t except that’s low for her.
Patrik: Right, I-
Steve: Due to the fact that she just has never really used the BiPAP.
Patrik: Yeah, I got that.
Steve: Okay. But it does … I keep pressuring them to get it lower by actually ventilating her, instead of just using CPAP.
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Patrik: What’s the outcome that you want?
Steve: I want her to be able to come home and talk and eat normally, and use the ventilator at night.
Patrik: And do you think … I do remember in one of your first emails, you said she hasn’t been using the BIPAP overnight obviously for quite some time. And why do you
think that might change going forward?
Steve: Because this is with the tracheostomy, she has no problem with it.
Patrik: Yeah, it’s easier to tolerate.
Steve: Yeah. And the hospital has somehow formed the opinion, at least today, that they want to get her completely off the trach. And I keep telling her no, her pulmonologist wants her to keep it and use it at night.
Patrik: But if they want to keep-
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Steve: He does think that protocol will get her pC02 down to normal.
Patrik: Mm-hmm (affirmative). But if they want to get her off the trach completely, why do they
send … why do they want to send her to long term acute care?
Steve: Well, they want to send her to where? The hospital?
Patrik: Yes. You said they want to send her on to LTACH (Long-term acute care facility/hospital)
Steve: Yeah, because it appears they do not want to go through the
process of training me to deal with the trach, and they want to get her … you know how payments and all that go. They are ready to move her to another facility. And the one that I have asked that they send her to is actually really good.
Patrik: Right. Look Steve, I … my experience is showing me that we get a lot of inquiries from families who have a loved one in LTACH. What I hear from is, generally speaking, not great. And
maybe you are choosing the right facility. I can just say that most of the time it’s not … the feedback that we get is not fantastic about those LTACHs. From my perspective … and don’t get me wrong, I’m biased, right? A patient on a ventilator should
either be in ICU or at home with ICU nurses. Yes, I’m biased, but an LTACH to me … the skill mix going from ICU to LTACH means the skill mix, the drop in skill mix, is pretty big. Right? And I know you mentioned in your email, you listed the skill mix in LTACH. You’re talking about medical director, nurse practitioner, nursing staff. I tell you what the biggest difference is, though. Especially the nursing staff would not be ICU nurses. And for looking after on a ventilator with a trach, you
need to have the ICU exposure, and the ICU experience. And most LTACHs don’t have it.
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Steve: Okay, this LTACH is a sub-unit of an ICU.
Patrik: Okay. Okay, well that sounds a lot better already.
Steve: Yeah, it’s the only one in Michigan. It is that way, and it’s been that way for 30 or 40 years-
Patrik:
Right.
Steve: … which makes it kind of a pioneer.
Patrik: Okay. And on a level from 0 to 10, how comfortable do you feel at the moment to get her there?
Steve: Well, I think it’s my only option. That’s what they’re gonna, you know … as you point out in some of your videos, some of these
decisions they make and there’s not much you can do about them. They’re not gonna teach me what I need to know to bring her straight home. There’s nothing like what you do available here.
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Patrik: Yeah, I know. I know.
Steve: So, this is … I’ve got her aimed at the best possible facility in Michigan. My RT friend has been there, and says it’s good.
Patrik: Right.
Steve: And he even
knows the doctor who started it.
Patrik: Right. Have you been there yourself? Have you-
Steve: No, no.
Patrik: Right. How far away is it from where you are?
Steve: 40 minutes.
Patrik: Is that acceptable to you?
Steve: Oh, yeah. They were trying to get me to this one 20 minutes away, which is not a very good place.
Patrik: Okay.
Steve: It’s accredited, but it’s really an urgent care facility with testing things and this
other thing attached to it. They take care … The neat thing about the one that the University of Michigan operates is that unit has 30 beds that are dedicated only to people who need a ventilator 6 hours a day or more.
Patrik: Right, right.
Steve: So they don’t try to be all things to all people. Could I ask you a couple questions?
Patrik: You certainly can.
Steve: Okay. One is, I’ve read about a Blom valve-
Patrik: Blom valve? Speaking valve?
Steve: Yeah. What do you think of those?
Patrik: Speaking valve, definitely yes. The only way you can use a speaking valve though is, number one, your wife needs to be off the ventilator at least for periods of time. And number two, the cuff needs to be down. Do you know what I mean
by that?
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Steve: Yeah, the Bloom or Blom, whatever it is, I got their propaganda on it. And they seem to imply they’ve got some kind of flap at the top that lets the
cuff stay inflated for inhaling. The air, instead of coming back out through the ventilator, goes up through the normal-
Patrik: Oh, yes. Yes.
Steve: That’s-
Patrik: Yes, I know what you’re saying. Yes, I know that this is a relatively new invention. I don’t think it’s been on the market a
long time, but it’s definitely worth a try. Definitely worth a try, always. I mean-
Steve: ‘Cause I’ve witnessed a … There’s a YouTube they have where the woman is just talking … you know, lip talking. And then they do something to this valve and she sounds perfectly normal. And of course, it’s the best thing since sliced bread, and sell ’em, but-
Patrik:
Yeah, yeah. Sure, sure.
Steve: But it was a pretty impressive demo.
Patrik: Right. What about … Is your wife having time off the ventilator at all?
Steve: Yes. Basically, she’s been now well over 24 hours with nothing but CPAP.
Patrik: Okay, but … Yeah, okay-
Steve: And they put a T … they call it a T-piece on her.
Patrik: T-piece. Yeah, yeah. T-piece. Mm-hmm (affirmative).
Steve: And that is supposed to also make her breathe more on her own.
Patrik: It should do, it should do.
Steve: And she continues to do fine on it.
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Patrik: Okay.
Steve: My concern is that she’s building up C02. And I think I’m over my cold, and I’ve got
these super-duper anti-viral meds I bought, and I’m gonna go there tomorrow, finally, and make sure. They take her ABG every morning.
Patrik: Okay, great. Great.
That’s-
Steve: So we’ll know tomorrow morning if leaving her off has been … I know it has to have gone up. I can’t believe it hasn’t. But-
Patrik: And when … Is there sort of a threshold that you know? I mean, a pC02 of 66 … If she’s not drowsy with a C02 of 66, because she’s probably used to a higher level of C02.
Steve: Right, and she’s got 42 in the bicarb that’s keeping her pH right at 7.4.
Patrik: Yeah, yeah. So, she’s not drowsy or confused you think with the C02 of 66?
Steve: No, but I think she’ll do even better if we get this down, because-
Patrik: Oh,
oh, absolutely.
Steve: … This is like the first time that I can see since we’ve had all these problems, that she can get very close to normal blood chemistry.
Patrik: You see … and for example, over night, are they putting her back on the ventilator with the CPAP? Is that what they do?
Steve: No, no. That’s what I talked to them about today.
Patrik: Yeah, because isn’t that what you want?
Steve: Yes, and they … I have to get there and talk to some people. Somebody thinks the goal is for her to just breathe room air with a cannula all the time. And that’s not the goal. Her doctor used to run that
place, and still has a lot of respect there. And they finally agreed that the case manager would call him. He invites him to call. And I think he’ll tell … I mean, you know, I’m just a guy, but he’s a very … Actually, I think he’s one of the 100 best doctors in the US or something. He’s well-respected, and they’ll listen to him.
Patrik: Because if she was meant to have BIPAP at home overnight before the hospital stay, I can’t see how they all of a sudden can work around that.
Steve: Well, you’re right. They can’t. But they can get … This hospital is the hospital we have to go
to.
Patrik: Sure, I understand.
Steve: One of their problems is, they have these locational 12-hour shifts. You get somebody new every time.
Patrik: Yes.
Steve: And I have to give them the history- the this, the that.
And one problem with her pulmonologist is … While he used to be the chief doc in the ICU, he’s now 70 years old and decided he couldn’t live with all that adrenaline, and no longer visits the hospital; although, his partners do. And I talked to them today, and they’re gonna send one of their people over there. He maintains a case manager for every patient who is in the hospital, so they’ve been following her. And I mean I … As you point out in your videos, you have to keep on these
people.
Patrik: Absolutely, you have to. You have to.
Steve: Uh-huh. And tell them what … I mean, the hospital is controlling people when they’re in the hospital.
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Patrik: Very much so.
Steve: But once they’re out of the
hospital, they’re back in the control of their real doctors.
Patrik: Yes, correct.
Steve: But meantime-
Patrik: Yeah, in the meantime-
Steve: I mean, I must say they have made great progress. She had … I think you might
remember … She had 300 seizures.
Patrik: Yeah, you mentioned that.
Steve: And they’ve got her back from all that. They’ve
done a lot of good for her.
Patrik: Yeah, yeah. Oh look, for sure. It looks like it. But I think … You see, if they can keep her for a little bit longer, and wean her off the ventilator, or optimize her ventilation to get her home, that would be better for you, wouldn’t it?
Steve: Yes, if they would train me.
Patrik: Yeah, they wouldn’t do that. And the LTACH-
Steve: That seems to be the
kicker.
Patrik: Right. And the LTACH would train you?
Steve: Yes, that’s what they’ve already told me. She’ll be in the LTACH … or they call them Vent Dependent Units. They’re a little more precise. That’s one of the things for sending her there is to use the home medical equipment, what they’re gonna use instead of a hospital
ventilator-
Patrik: Sure.
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Steve: … to get that adjusted, and also teach me how to use it. Although she’s been using the Trilogy, which is probably what they will use.
Patrik: Yeah, yeah. It’s a known
home ventilator, the Trilogy, we use it in our INTENSIVE CARE AT HOME service for some of our clients.
Steve: Yes, that’s supposed to be pretty good.
Patrik: Yeah, they are
pretty good. And they are almost the go-to ventilator in the community. So, you can’t probably go wrong there. And yeah … Look, I don’t know how I can help you really at this stage, unless you know … I don’t know-
Steve: Well, you’ve helped me with the Blom. You’re saying that’s worth a half trial.
Patrik: Any speaking valve is worth a try. Any speaking
valve.
Steve: And the other question I have is, I have this good friend who’s the RT … if he still lived in Kalamazoo he would be here all the time. But he does not come over but maybe once a week. And then I have this friend in Florida who-
Patrik: Yeah, you mentioned. Yeah.
Steve: And I
don’t know how much I should do myself, and how much I can trust in these other people.
Patrik: Yeah, yeah, yeah. Yep. I’ll give you my answer to that. So, I’ll give you some examples so you’ll know why I’m saying what I’m saying. So, as you’re aware, we are looking after ventilated patients at home with tracheostomies as part of INTENSIVE CARE AT HOME. That’s one of our core businesses as you know.
Steve: Yeah.
Patrik: So, I can tell you that we do a variety there. We do adults, we do children from all ages. The commonality is ventilation and tracheostomy. Sometimes no tracheostomy, only ventilation, and sometimes only tracheostomy, no ventilation. But that’s spectrum, right? I can tell you that all of our clients, even if they have 24-hour care with an intensive care nurse, are struggling. You are describing this very well in your
email, and you’re thinking about how you can manage that. I don’t want to be negative or you know … and I’m not questioning your capabilities. But looking at … You’re going from hospital intensive care, or from LTACH, to a home care environment, potentially by yourself with minimal support. I do believe it’s doomed to fail. And I don’t want to be negative here, but I do believe it’s doomed to fail. Because we provide a 24-hour service, and it’s challenging. Challenging for everyone. We manage.
We keep people at home. But it’s challenging, ’cause people are unwell. They need life support at the end of the day, and it has its challenges. I’m not saying it’s impossible, but it’s challenging.
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Steve: Okay. And my response is I, first of all, understand what you’re saying. But I would add that the doctors expect her to improve if she will only ventilate at night. That’s what he’s wanted for 10 years.
Patrik: Right.
Steve: So, a secondary
question is, let’s suppose everyone, the blood gases, all that gets settled correctly, and during the day she can function relatively normally … Does that change your view that this is … Well, think of the trach as simply a different way of hooking up the Trilogy. We were already using the Trilogy. But that doesn’t change your view?
Patrik: Can you repeat that last part, please? I’m not-
Steve: Well, okay. Think of it this way. The Trilogy is constant.
Patrik: Yeah, yeah. Mm-hmm (affirmative). Oh, and you’re talking about- [crosstalk 00:20:13]
Steve: Yeah. He expects her to get better-
Patrik: Yeah. And yeah,
yeah-
Steve: … over baseline.
Patrik: Yeah, absolutely. And how mobile is your wife at the moment? How mobile is she? Is she out of bed?
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Steve: She can walk.
Patrik: Okay.
Steve: Not far.
Patrik: Even now? Even today?
Steve: Yeah, they had her in a chair.
Patrik: Great.
Steve: She walked to the chair.
Patrik: Great, great. That’s good, that’s great. But I can tell you … She’s walking to the chair, she probably had one or two people with her while she was doing that.
Steve: Oh, yeah.
Patrik: Right. So, even though she will improve, as long as she’s at least partly ventilator-dependent, even if it’s only overnight,
and as long as the C02 is varying, I can tell you from experience there’s a high risk of falls.
Steve: Of what?
Patrik: Of a fall.
Steve: Oh, a fall, yes. She has fallen. She broke her leg, they fixed that. She’s broken ribs. I don’t let her just go walking
anymore.
Patrik: Right. So besides the mechanical ventilation and the trach, the fall risk … If you were trying to manage this by yourself, the risk of either your wife falling when she’s getting out of bed, but also of yourself injuring … getting an injury yourself because you might hurt your back, or … It’s going to be physical work. You’ve gotta consider all of that.
I’ll
give you another quick example. I was talking to a client yesterday. She took her mom home, just like you want to do with your wife. She took her mom home for a month, with a trach and with a ventilator. Within a month, the lady was back in hospital because she couldn’t manage.
Steve: The patient or the caregiver?
Patrik: Both. The patient was back in
hospital with a chest infection (pneumonia), and the lady was burned out. The caregiver was burned out because she didn’t sleep at night.
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Steve: Well, I am used to her waking me up.
Patrik: But-
Steve: That’s been going on for a couple years.
Patrik: So, but … right.
Steve: I’m retired, so I can take naps during the day.
Patrik: Sure, sure.
Steve: And I’m always beside her
for my nap.
Patrik: But you’ve got to keep in mind, in the future if that was to go forward, you not only have your wife by your side, you also have potentially a ventilator and a trach, and that means you would have to do some suction. You would have-
Steve: Oh, yeah.
Patrik: … yeah. You
would have to know what to do in an emergency. Right? Because-
Steve: Right. A bagger of-
Patrik: Correct. Right.
Steve: We also have a-
Patrik: Change the trach, you’ve gotta keep all of that in
mind.
Steve: Okay.
Patrik: But my time is limited.
Steve: Well-
Patrik: I hope that was of some help for you.
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Steve: Yep. It’s realistic.
Patrik: Yes.
Steve: We’ll keep on
going-
Patrik: Right.
Steve: … and see what happens. I do wish you had your INTENSIVE CARE AT HOME service going in Michigan.
Patrik: I know, and it’s not … We might be there one day, but we’re not there yet. You know? It’s not going to help you now. I’m sorry, I’m so sorry. We would love to.
Steve: Yeah. Thank you very much for your time.
Patrik: Okay, you’re very welcome. You’re very welcome, Steve. Wish you and your wife all the
best.
Steve: Okay, thank you.
Patrik: Take care. Bye-bye. Bye.
Kind Regards
Patrik
