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 Mother Had a Cardiac Arrest and Her GCS is 3. Will She Be Weaned from the Ventilator?
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 Stephanie as part of my 1:1 consulting and advocacy
service! Stephanie’s mother is a post cardiac arrest patient in the ICU and she is asking why her mom’s white blood cell count is increasing.
My Mother Had a Cardiac Arrest and Her WBC is Increasing. Is It A Sign That She is Getting More Worse?
PART 1
PART 2
PART 3
PART 4
PART 5
PART 6
PART 7
PART 8
PART 9
PART 10
PART 11
PART 12
PART 13
PART 14
PART 15
PART 16
PART 17
PART 18
PART 19
Stephanie: Hello, Patrik?
Patrik: Hello, Stephanie, how are you?
Stephanie: I am good. I have my family here.
Patrik: Wonderful!
Recommended:
Stephanie: I can tell you who I have, hold on. You can sit wherever you want to sit, I just want to make sure you can hear. Oh, I’m sorry for telling everyone where to sit. So I have Miranda, George
Patrik: Hi, Miranda, Hi George.
Miranda: That’s Patrik?
Patrik: Pardon?
Miranda: He is on the phone?
Patrik: Yes, I can hear you.
Stephanie: Okay, that’s Rebecca.
Patrik: Rebecca, yes. I spoke to most of you last night, in the early morning hours, your time.
Stephanie: Exactly, I have Tonette.
Tonette: Hi.
Patrik: Hi!
Tonette: How are you?
Patrik: Very good, very good.
Stephanie: -on Wednesday. Where should we start, Patrik? I know…
Patrik: Are there any updates about Carmen since we last spoke?
Stephanie: Are there any updates? Two things you wanted to know was about the antibiotics and the lungs. Miranda’s going to call, I thought maybe, yeah. You’d like to know that, right?
Patrik: Yeah, it would be good if we knew what they were doing with the infection. Do we know?
Stephanie: Because the white blood cell count went from 22,000, to 44,000.
Patrik: That’s right, that’s right. Do we have an update on that, or…
Stephanie: Miranda is calling now.
Patrik: Okay, right, right, and I’m just trying to think, there was something else we wanted to find out, are they stopping the Phenobarbital and are they, is she breathing, you know, what her ventilation setting is like? You know, we can find out, I’m sure we can.
But the hospital hasn’t been calling you and saying, Carmen has deteriorated or anything of that, there wasn’t any of that?
Stephanie: No, not at all, and so somebody says were moving up.
Patrik: Right, that’s good. When you’re saying somebody said, do you know who that…?
Stephanie: Hold on, Miranda’s on the phone now.
Patrik: Right, right.
Recommended:
Stephanie: We are just having the conversations now. I thought we would’ve gotten that information in advance.
Miranda: They didn’t do no lab work? She has an infection, so she was supposed to have her lab work. She has an infection, so she was supposed to have that. Right, that’s what I’m asking, Ma’am. I want to know, yes ma’am.
Eva: A couple new things on the white blood cell count, but besides that, everything else was pretty stable.
Miranda: Right, now in reference to the white blood count being high.
Eva: It 30, but it was 40 the other day, so it is coming down.
Miranda: That’s good, so…
Eva: Yeah, so that was taken at 2 o’clock this morning.
Miranda: Okay, and Ms. Eva, is there any possible you can tell me if they got her on an antibiotic and working through the infection?
Eva: I don’t have any antibiotics to give her. I would do doctor session in a minute now, I just know from my medicine cabinet, I don’t have anything to give her tonight. All I have is her regular medicine, the Phenobarbital, and stuff like that, the stuff that you can offer aids.
Miranda: You still on Phenobarbital, and Dilantin.
Eva: Phenobarbital, Epilim shot, cholesterol medicine, just normal stuff. I don’t have anything, any antibiotic or anything to give her.
Miranda: Okay.
Recommended:
Eva: You have to understand, you can ask those to the doctors, because we don’t have that kind of stuff. I think it will be better.
Miranda: No problem, let me ask you another question. How’s her blood pressure?
Eva: It’s a little all over the place, but, it’s been like that. It goes from the 130s to 90s, or 140s but it’s been doing that for days, I believe, so exactly normal. I looked at the trends and, kind of up and down, up and down, but depends on if she’s pretty anxious, like moving around and stuff, usually it’s little higher. If she’s just hanging out it’s a little bit lower. But no problems there.
Miranda: Okay, and then do they…
Eva: We didn’t give anything for blood pressure today.
Miranda: Okay, and the other question I have is,
Eva: You’re really breaking up real bad.
Miranda: Okay, can you hear me now?
Okay, is there any way we can do it, or we can call… well, no. I said you want me to move, I don’t know. Did you want me to move it around? I can just call right back, then. Yes ma’am.
Can they put a cooling blanket on her? Okay, she’s at 38? Okay, and if you don’t mind me asking, who is the doctor that’s there tonight? Is the doctor there tonight? Yes, ma’am. Oh, okay. Same doctor, Dr. Nancy. Oh okay. Is there any way possible she can provide us a call tonight?
Is there any way possible she can provide a call tonight? Nah, it’s okay or maybe I can just call back and speak to her. Okay. I know two nights ago, I had the other RNs ask them about the infection in her body, and still haven’t heard a response back.
Okay, well, let me ask you another question. Is she still with blood in her urine?
Eva: Her urine looks dark yellow to me right now.
Miranda: Dark yellow, okay. Any other questions?
Okay, just give me one moment. I wrote down what, I wanted to ask one more question. Hello, Mr. Patrik?
Recommended:
Patrik: Yes.
Miranda: Did you have any other questions you wanted to ask her?
Patrik: What are her ventilation settings? Is she breathing above the ventilator? Is she taking breaths by herself?
Miranda: Okay, I knew what it, ma’am, thank you for your patience. I knew what I wanted to ask you. What I wanted to ask you was, how is she doing on the ventilator? Is she over breathing it? Is she breathing above the ventilator like she always have? Sometimes, she breathes well with that.
Okay, so she’ll breathe at rate, but she breathes over it. Is she breathing?
Okay.
Patrik: And, Miranda…
Miranda: Yes, ma’am
Patrik: Miranda, can you hear me?
Miranda: Yes.
Patrik: Can you ask, do you remember last night, Miranda we spoke about the Glasgow coma scale. Can you ask whether the Glasgow coma scale is still-?
Miranda: I want to know one more thing about her Glasgow
Patrik: Coma Scale, GCS.
Miranda: She’s still a three.
Eva: The only thing I get a response from her, is she has corneals, and she is not responding to anything I’m doing neural at this point.
Patrik: And, if that’s the case, can you ask her, there are three things. This is a matter of sedation or does she think this is an issue because of a brain injury? You know, is she not responding because of sedation, or because of the brain injury?
Miranda: Phenobarbital? Not like that.
Recommended:
Eva: Walking around talking and the phenobarbital which makes her calm, seizures that she was having. This was minimal response to pain, she’s having, I give her very painful stimulation, and she will not respond at all. This is not normal. It’s not from the medicine.
Stephanie: So, what about when you do it behind her knee. Does her foot jump at this point? Are you testing, when you give the stimulation from behind the knee, okay? Okay. This should be better. Okay.
So you stimulate behind her-
Stephanie: What’s your extension, we’ll call you. Are you at 7****?
We got weird line, hold on.
Stephanie: No, you don’t want my phone. 7***-****.
Miranda: Ma’am do you want- Yeah, I want him to talk to her. He has pointed questions that he can ask her. And see if she’s gotten her thing. So, you can just say I want you to talk to my husband or he’ll tell him who he is. I just want to make sure we get the information, because the more information the better. But she’s saying, there’s no stimulation at all. When we pinched her back behind her leg, her foot did jump. So, I’m wondering if
that’s still happening or not happening, because she’s like at all.
No stimulation at all. That’s kind of new, if that’s the case. If she’s the one doing it right, but the neurologist does it as well.
I know and Patrik. He said she has response last night. This lady sound like she doesn’t know to be honest with you. No.
Patrik, we’re waiting for the nurse to call us back, sorry!
Patrik: Yep, that’s okay. That’s okay.
Stephanie: He’s going to address that. No answer. We should call her from this phone. And let him talk with her.
Recommended:
Miranda: Hold on Mr. Patrik.
Patrik: Yeah, yeah.
Miranda: Hello, Mr. Patrik?
Patrik: Yes.
Miranda: Hello? Yeah, but I was calling Ms. Eva, I was trying to find out if I can just call you on my other phone with my friend on the phone. So that we can get more understand…
No, ma’am. I just called 7***, we normally call that one. 9***? Okay. Thank you.
Eva: You there?
Miranda: Ms. Eva, I’m here. I got cut off on the phone, and I just wanted to get clarification in reference to…
Eva: Yeah, no I honestly, that was like the most broken up conversation I think I’ve had. I understood some stuff that you guys said, but it was really hard for me to understand you, because you were like, eh, eh, eh. But, yeah, go ahead.
Miranda: Patrik.
Patrik: Hi, how are you? My name is Patrik. I’m a family friend. How’s your shift?
Eva: You’re a family friend?
Patrik: Yes.
Eva: Okay, and the daughter’s okay with me sharing information?
Miranda: Yes, yes I am.
Eva: Okay, sure.
Patrik: I was just trying to find out what her Glasgow Coma Scale is, is it still a three?
Eva: It’s three.
Patrik: Right, right. Do you think that’s a result of the brain injury, or is it a result of the sedation pill? What do you think?
Recommended:
Eva: That would be it. There is no sedation on. Today, she hasn’t been on, she hasn’t been on anything for seven days.
Patrik: Isn’t she on Phenobarbital still?
Eva: Correct, but that is not a med that will not allow you to respond to pain. She is not responding to anything that I’m doing.
Patrik: Right, okay.
Eva: This is not due to Phenobarbital at all.
Patrik: Right okay. And any more seizures?
Eva: Not that I’ve been, I’ve been here since 7:30, she hasn’t done anything since 7:30, I wouldn’t know.
Patrik: Right.
Eva: But she hasn’t done anything since I’ve been here.
Patrik: Right, and she has been on regular Keppra, regular Dilantin to manage the…
Eva: She has been on the seizures, yes.
Patrik: Right, fair enough. And in terms of ventilation, is she breathing spontaneously, or is she still in a controlled ventilation mode?
Eva: She’s on a controlled ventilation, but she sometimes breathes with the vent and sometimes breathes over, the same thing she’s kind of been doing. But sometimes she’ll breathe over, and sometimes she’ll breathe with the vent.
Patrik: Yeah, no that’s fair enough.
Recommended:
Eva: I think the rate is 16, so she’ll breathe 16 most of the time. And then after you suctioned her or something, she’ll breathe a little bit over the vent, and then she’ll come right back down.
Patrik: Right, that’s fair enough. And I understand she’s got a white cell count that’s a little bit on the high side, has an infection…
Eva: Yeah, they pan-cultured her when they got the results the other day, and nothing’s come back positive yet.
Patrik: Right, and she’s not covered with antibiotics at the moment?
Eva: No, not at the moment, because I guess they’re maybe not sure what actually to cover her with.
Patrik: Yes.
Eva: Because like I said, nothing’s actually come back positive.
Patrik: Yes, no that’s all fair enough. And she doesn’t have a central line at the moment? No central line, no A-line?
Eva: No central line at the moment, just a peripheral line.
Patrik: Yeah. And everything else, kidneys, liver, gut seems fine, there’s no issues there?
Eva: I’m sorry?
Patrik: Anything else like kidney function, liver function?
Eva: No, all of her labs besides that were pretty normal. They’ve all been pretty steady. So nothing, only thing that’s been abnormal with her labs are her white count.
Patrik: Right, right, that’s fair enough. And does she have a temperature?
Recommended:
Eva: Oh, she’s 38 esophageal temp.
Patrik: Right, okay, okay.
Eva: Which I would think would be like 99 or 100.
Patrik: Close to a hundred. That’s fine.
Eva: I don’t think that’s changed though, since there hasn’t been a change since like 12 or 24 hours, been kind of steady.
Patrik: Yeah, from your perspective, what do you think is next, a trach? What’s your point of view?
Eva: She’s been intubated for over 14 days. It’s well over the time that one person should ever be intubated. So, she absolutely, if we’re not going to be thinking in other terms of things, she needs to be trach and PEG to prevent infection. All these things that we do are to prevent
infection. She should not, nobody should have an intubation tube in for this long.
Patrik: No, I appreciate that.
Eva: And I do think her tongue might be, like she’s getting swollen, her tongue is swollen, her lips are swollen, and this is all related to having an intubation tube in your throat.
Recommended:
Patrik: Yes, no I appreciate that. And there’s nothing standing in her way to have a trach? She’s not bleeding, her INR and her APTT are normal?
Eva: She does have some of the Cangrelor on, a blood thinner, she does have that running, but, she is not, there’s no more blood in the urine, there’s no sign of bleeding. Nothing like that, so, I don’t see why there wouldn’t be a reason to able to be trach and PEG. You know what I mean, like we would still do it, even if she was on Heparin or what have you. They would probably stop the Cangrelor before they do the procedure.
The 1:1 consulting session will continue in next week’s episode.
