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 was
My Critically Ill Husband is on Dialysis and in the ICU due to Septic Shock. Why is the ICU Team in Such a Hurry?
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 questions from one of my clients Eva as part of my 1:1 consulting and advocacy service! Eva’s husband had a
cardiac bypass surgery, had a stroke in the ICU, and she is asking why her husband’s not being seen by a Cardiologist everyday?
My Critically Ill Husband is On Dialysis and in ICU due to Septic Shock. Which organ is more important, the Heart or the Kidneys?
“You can also check out previous 1:1 consulting and advocacy sessions with me and Eva here.”
PART 1
PART 2
Eva: Hi, thank you.
Patrik: That’s okay.
Eva: So, it wasn’t mine. It was a friend of mine.
Patrik: Oh, I see. Okay.
Eva: Interestingly, today, the whole treatment plan seemed to be out the window.
Patrik: Okay. Well, what do you mean by that?
Eva: Well, the Norepinephrine has been left at the same high level since I got here early in the morning. And the MAP’s running about 66, round thereabout. They just disconnected the CRT, I thought to change it, but haven’t hooked it back up again and all the positioning and breathing went on yesterday is now not happening.
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Patrik: Okay. How high is the Norepinephrine?
Eva: 4.7.
Patrik: 4.7. Okay. And they discontinued CRT just simply because it’s due for a change?
Eva: Well…that was what they said, but generally they just change it and get it back up again.
Patrik: Yeah. Yeah. Absolutely. And how long has it been down for?
Eva: Since about eight.
Patrik: Okay. Well, do you think it would get back again? I mean sometimes it can take a couple of hours, depending. It takes time to make up a new haemofilter in new dialysis machines can take a couple of hours. But definitely keep an eye on that-
Eva: Oh, no it’s all set. All the stuff is here, ready to go.
Patrik: Right, right.
Eva: Yeah.
Patrik: Okay, okay.
Eva: I don’t know. That’s just a change. I’m always concerned about changes from the regular.
Patrik: No, absolutely. Absolutely. And so you should. Look, again, if it’s ready to go I’m sure it’ll happen. Why was it changed? Just due for a change? Or was it clotting?
Eva: There was one big clot in it. It hadn’t been changed out since Monday, which is pretty amazing. Which was left on like that-
Patrik: Oh, okay. Yeah. Yeah. Okay.
Eva: So that was just, it was due.
Patrik: Yeah. No, no.
Eva: That’s probably the last. Yeah.
Patrik: Yeah, okay. Usually it can run for more than 72 hours in one go, so, yeah, that makes sense.
Eva: Yeah. Yeah.
Patrik: That makes sense. Okay. So coming back to the breathing quickly, that’s positive that they’re basically confirming that his breathing is okay now.
Eva: So much better. Well, yeah, he said, your breathing is fine. Don’t worry about a BIPAP, that’s not going to really be a benefit. His lungs are clear, breathing slowly, 13, 14 breaths per minute. Pretty deep, deep breaths. Actually it’s the best breathing he’s done since he’s come in the
hospital.
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Patrik: That’s good. That’s good. Have you heard of arterial blood gases?
Eva: Yes. They do those all the time.
Patrik: Right. Right. It probably should be only a list of questions to ask to get result for the arterial blood gases.
Eva: So what do I want to hear?
Patrik: Yeah, yeah, yeah. Mainly looking for PO2, which is the oxygen in the blood, and C02, carbon dioxide in the blood. Those are the main numbers.
Eva: Yeah. I don’t know that they’re actually a problem anymore. There was some concern last week just in that he’s consistently pretty well profuse, but the blood gases were a little bit lower so they did have him on oxygen for a couple of days last week, and then they took it off because it wasn’t an issue.
Patrik: Sure. Sure. Okay. Okay.
Eva: But I can ask.
Patrik: Yeah, I think you should. And I think you should ask, should put that on your list, just to keep them on their toes, just that they know, I know what I’m looking for. You know? Just subtly sort of keeping asking those questions.
Eva: One of the things that has come up a few times is hypercalcemia, and that that number has been a little bit higher and they don’t really know why.
Patrik: Okay. Yeah that is unusual. Especially when patients are on the dialysis. If anything, all the numbers usually go down, usually. Like potassium, magnesium, calcium, they’re all usually going down when patients are on dialysis. Most of the time.
Eva: Potassium has fluctuated, although I think this week it’s been fine. They had to run a couple of bags without potassium in it to pull it out, but since I guess a week ago that hasn’t been an issue anymore.
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Patrik: Okay. There’s a very high chance your husband is getting potassium while he’s on the dialysis. Very high chance.
Eva: Right.
Patrik: Again, keep an eye. Because usually what happens is when patients are on dialysis, potassium goes down pretty quickly for what I just mentioned, basically, that all the electrolytes are usually going down on dialysis.
Eva: Okay. Just because they get pulled out as well?
Patrik: That’s right, that’s right. So they’re removing 120 ml an hour from what I’ve seen, so that’s about two-and-a-half litres a day. And that, you would hope, that keeps his chest clear. Because if you’re not removing enough fluids in kidney failure, one of the first organs
impacted are the lungs, because fluid would come into the lungs. So that’s another reason why your husband’s lungs are probably okay.
Eva: Right now, because of that. Yeah.
Patrik: That’s right.
Eva: That’s what they’re considering euvolemia that that’s what’s going in is what they’re taking out.
Patrik: Right, right, exactly. Is your husband very swollen?
Eva: None of that, they cut it down to that because they actually thought he was a little bit dry.
Patrik: Okay. Okay.
Eva: Not swollen at all.
Patrik: Right. Right. Have you heard of albumin?
Eva: Yes.
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Patrik: And do you know your husband’s albumin?
Eva: Oh, what the level is?
Patrik: Mm-hmm (affirmative).
Eva: No, but I could ask. I know they gave him albumin.
Patrik: How long ago?
Eva: Last week again.
Patrik: Okay. The reason I’m asking is it’s worth finding out what the albumin level is, because if it’s low, and especially with the Norepinephrine still running, he could potentially do with a little bit of albumin. Also earlier this week he had a low haemoglobin. He had some blood
products. And that would replace albumin, but albumin sort of lower than 20-ish it would be good if he had some replacement just simply to get rid of the norepinephrine.
Eva: That extra. Okay.
Patrik: And has he had a ward round yet?
Eva: I’m sorry? Ward round?
Patrik: Yes. The rounds, have they done the rounds today yet?
Eva: Oh, no. No. We’ll be up next, I guess. Yeah, it was his neighbour in the bed next to him that they’re doing.
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Patrik: Okay, so keep watching for those mixed messages and if you get positive messages but the underlying framework is really, well, your husband’s not going to get better, it’s really all positioning. That’s what it is.
Eva: Okay.
Patrik: It’s so important to read between the lines. And actions speak louder than words. Right? What do I mean by that? You know, they planted the seed on Monday, again, giving you the negative outlook, but at the moment they’re doing everything that they can. The actions speak so much louder than the words.
Eva: Right. Okay. Okay.
Patrik: That’s what you need to look for. You know? You need to look for action. But, also, if they are coming back to talk about end of life and whatnot, you need to reel them in and say, I do
not want to talk about this, I told you what I want, and leave it there. And just be repetitive. Don’t be discouraged if they don’t engage with you to begin with. You will need to be very repetitive and also short, to the point. Don’t go overboard in talking to them. Ask your questions and make very clear what you want and what you expect.
Eva: Okay. Patrik, can I just put my husband Frank? His voice is very, very soft, so he’s not going to be able to talk to you, but I think it might be helpful for you just to say some of these things to him.
Patrik: Yeah, absolutely. Okay.
Eva: Okay. Hey, sweetie. This is a fellow named Patrik, and he is someone who helps families who have someone in the ICU. So I gave him a call last night after that conversation we had with the doctors and just said, can you give us some ideas on how to go from here? And we’re feeling a little overwhelmed. So he was giving me some ideas about how to make sure that we’re clear with the doctors on what we want. And he’s also very positive. He’s
one that says, you know, most people have quality of life after ICU. Did you hear all that?
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Patrik: Yes. Hi, Frank.
Eva: Hi.
Patrik: Can you hear me?
Frank: Hi.
Patrik: Hi, Frank.
Eva: Yeah, he’s here.
Patrik: Right, right. Frank, my name is Patrik, I’ve been talking to your wife in the last two hours. Just to give you a little bit of background of what I do and what I’ve done over the years. I’m an Intensive Care nurse by background, I’ve worked in Intensive Care for nearly 20 years and as your wife said, I help families who have a loved one in Intensive Care. Now Frank, I have nursed, over the years, many patients in similar situations
than yours, right, and it’s very important that you understand that most patients, the overwhelming majority of patients survive intensive care. And I’m talking about 90% of patients in intensive care survive. Now, it is very important to put things in perspective, right? The negativity that’s currently coming from the intensive care team, from what I understand they’re telling you that you won’t have any quality of life going forward and whatnot, and that your only options are hospice and blah blah blah.
Look, Frank, as I said to you, I’ve seen many patients in similar situations than yours, and, again, most patients do survive. What ICUs don’t know is simply what your quality of life will look like down the line, because they
don’t have a crystal ball, right? And I would ignore that for now, because your goal at the moment is to get through this, and then take the next step. Simply your goal at the moment is to leave intensive care alive, and then go on to rehab. Right? Do not get bogged down by any of their negativity, right? Because you are here. I’m talking to you, you’re talking to your wife.
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You know, you are here, and that’s the main thing for now. Take one day at the time, right? Which I believe you have done now for many weeks anyway. But, you know, take one day at the time, look for the small improvements, and really ignore that negativity that’s coming from the ICU, right? They are very poor at looking outside of ICU. They’re very good at saving lives in the short term, but they’re not very good at looking at long term outcomes. Am I making sense
here, Frank?
Frank: Partly.
Eva: Partly, he says.
Patrik: Right. Partly? Right. Right.
Eva: Yeah. Go ahead.
Patrik: Right. Right. Is Frank comfortable? There’s no pain that needs to be managed, is there?
Eva: No, no, none.
Patrik: Right. And the other question that I have Eva, you mentioned yesterday I did see from your email. Does he still have a tracheostomy?
Eva: No, he doesn’t.
Patrik: Okay. That’s good. That’s positive. That’s another sign, that if he managed to get rid of that tracheostomy, he must have a lot of reserve.
Eva: Absolutely. And in less time than they predicted.
Patrik: Right. Right.
Eva: He does things on his own schedule.
Patrik: That’s good. That’s good. This doctor that you were referring to on Monday, he’s still on duty this week, is he?
Eva: Yes. Well, probably. Sorry, I’ll just. Yeah, so I’m having a meeting with our ethics department and then probably bring them in, just to say I’m going to work with them. I just need to have a bit of a conversation, hopefully with some other people present.
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Patrik: Yup. Do you trust that ethics people? Do you trust them?
Eva: Yeah. Yes, I do. Very much so. Yeah.
Patrik: Okay, okay. The reason I’m saying that is at the end of the day, they’re employees of the hospital, right? So are the doctors.
Eva: Yes, but they’ve already helped us.
Patrik: Okay. Great. Great.
Eva: Arguments? Reasonable arguments. Yeah.
Patrik: Okay. They’re not ICU people, are they? By background?
Eva: No, no.
Patrik: Okay. That’s okay. That’s okay.
Eva: One is a nurse, the other’s a social worker.
Patrik: Oh, great. Great. And here is the potential conflict with ethics. ICU might say that by continuing treatment, your husband may unduly suffer. I’m sure they would have mentioned some of that already, right?
Eva: Well, they talked about comfort level.
Patrik: Right, right, exactly, exactly. Whereas, for you it’s about saving the life. And what you might have to be a little bit more vocal about going forward is simply things like, at the end of the day they want to manage their bed,
right? They’re probably busy, they have a huge demand on their bed. So, you know, at the end of the day they want to manage their beds. And you gotta call them out on that. You will need to call them out on that.
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Eva: Yeah. Yeah. Well, I think my question today is not going forward with, I guess I don’t understand the 66 MAP and the 55, and how much is that going to weaken the heart substantially? Do we keep it at 55 because it’s healing? Is that their plan?
Patrik: Yes, absolutely.
Eva: If that’s not their plan, where is the risk in actually increasing it to sixty-five? What is the risk?
Patrik: Yes.
Eva: Why can’t we try at 50? It’s running 66 right now.
Patrik: Good, good, good.
Eva: And has been.
Patrik: It’s not so much weakening the heart. If anything, it’s weakening the kidneys, because the kidneys aren’t getting adequate perfusion.
Eva: Perfusion. Right.
Patrik: Right?
Eva: No, the higher. The 55 would protect the heart is what I was told.
Patrik: Yes, correct. Correct –
Eva: So the 66 would help the kidneys, which potentially weaken the heart.
Patrik: Very much so. Very much so.
Eva: I don’t know, or stress the heart? I don’t know. Is it that big a difference?
Patrik: Well, yeah, look. The reality is that if your husband’s heart can’t manage a blood higher, MAP of 66 or 65, then he is in real trouble.
Eva: Yeah, and so how do we know that without actually trying it?
Patrik: That’s right.
Eva: That’s what they are telling me, that he can’t manage it and that is the issue.
Patrik: Right. And again, that’s where a cardiologist needs to come in.
Eva: So, I asked that question as well, and was told that there is no cardiologist, that the internists just handle it.
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Patrik: What? No. You see, that is very disappointing. Because, clearly, of course ICU at the moment has the overall decision making authority. However, this is clearly a cardiac problem. Right?
Eva: Yes. Okay. That’s a good question as well. We’ve moved out of short term emergency. Now we need to have someone come on board here, until such time as he can be discharged to cardiology.
Patrik: Very much so.
Eva: Which actually wasn’t the problem before? It should have been like the things that were taken care of last time. His heart was fine.
Patrik: Right.
The 1:1 consulting session will continue in next week’s episode.
