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 Mom is Critically Ill in the ICU and Reintubated. Is It True That the ICU Team Cannot Do Tracheostomy on Her Because She is on Blood Thinners?

 

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 Julie as part of my 1:1 consulting and advocacy service! Julie’s mother is critically ill in the ICU with sepsis, bed-bounded for three weeks and Julie is asking if her mom is at high risk for pressure sores.

 

My Mom is Critically Ill in the ICU and Bed-bound for three (3) Weeks. Is it a Must for the ICU Team to Place her on an Air Mattress to Prevent Pressure Sores and Minimize Turning?

 

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

 

Julie: I don’t think so.

 

Patrik: Okay. I’ll tell you what it means. On the one hand the doctor is telling you that the chest x-ray looks normal. That’s what I understand, right?

 

Julie: They took the x-ray before they extubated. Go ahead and watch, Marianne. I’ll be in there in a minute. They said that right before the extubation they did the blood gas, blood withdrawal, and they did an x-ray. And he said according to the x-ray, the x-ray looked fine.

 

Patrik: Yeah, okay. Okay. So, that to a degree makes sense but it also doesn’t make sense. The reason it doesn’t make sense is, if she’s on 65% of oxygen, something’s clearly not working in the lungs, right? So, the air, the room air that you and I breathe in now is 21%. Right, 21% oxygen in room air. Okay?

 

Julie: Okay.

 

Patrik: So if she’s on 65%, there’s clearly something going on in the lungs. Now, a chest x-ray can look normal and you’re still having trouble breathing. Sometimes there’s a delay in issues showing up.

 

Julie: Okay.

 

Patrik: Sometimes there’s a delay. Now, if they’ve sucked out some sputum last night, that’s good. I’m pleased to hear that. By the same token, I hope they have sent off a sputum sample for testing, right?

 

Julie: I would –

 

Patrik: Right, because, that’s one way to find if there’s something going on in the chest. Is there a pneumonia, is there another infection, you know?

 

Julie: Yeah.

 

Patrik: That’s one way, right?

 

Julie: Should I write this down and take this in tomorrow and say, “Hey, did you guys test that? Did you take another x-ray? Are you guys working on an infection?” Should I be asking this stuff?

 

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Patrik: Absolutely. I will send you an email with all of that, what you should be looking for. I will send you an email when we come off this call. I’ll make some notes while we talk. So, here is the other thing, though. There could be another infection going on, but I kind of doubt it. I think if she’s on 65% of oxygen, that’s too high. Way too high. I presume there could be another pneumonia that just hasn’t shown up in the x-ray yet. Have they done another chest x-ray?

 

Julie: She also is on another antibiotic that starts with a D, and she’s been on that for a little while now since the whole sepsis and they’ve been trying to fine tune the sepsis infection. So, she is indeed on an antibiotic, but it might not be treating the new infection strain.

 

Patrik: Right. Did you say antibiotics with a D? D for Dora?

 

Julie: Yes.

 

Patrik: Doxycycline, is that the one? Doxycycline?

 

Julie: Yeah, that sounds familiar. I could call right now the nurses and just ask a quick update on oxygen, blood pressure medication and then call you right back. Would that help?

 

Patrik: It would, it would. And as I said, I’m very happy to talk to them too. But, whatever information you can get to begin with would be helpful. The other thing I-

 

Julie: Okay, so let’s … Oh, go ahead.

 

Patrik: The other thing that I would be very curious to know is the results… Because, if she has another infection her white cell count would be high.

 

Julie: Okay.

 

Patrik: Right? So another indicator, in terms of diagnostics, whether somebody has an infection or not, is the white cell count. So, the white cell count, if that goes up that’s a sign that the body’s fighting and infection, right?

 

Julie: Yeah.

 

Patrik: That should be another sign. You talked about the temperature. You talked about the vasopressor starting again, that’s another sign of an infection. But that’s also why I’ve asked, is she back on the Propofol, for example. Given that she’s back on the norepinephrine and probably the Vasopressin, that could be two reason for that. The first reason is there is an infection, because an infection/sepsis brings blood pressure down. That’s number one. Number two, medications like Precedex or Propofol in particular, the main side effect is low blood pressure.

 

Julie: Okay.

 

Patrik: Right?

 

Julie: And so she did go on the Propofol last night. They gave her some passive stuff to re-intubate, and then they did keep her sedated for the rest of the night.

 

Patrik: With the Propofol?

 

Julie: I believe so. I’ll ask to be 100% sure, but I’m going to mainly focus on what all she’s on right now.

 

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Patrik: Yeah, absolutely, absolutely. Here’s another quick tip. You mentioned they turned her and then she crashes when they turn her to prevent pressure sores. Is she on an air mattress?

 

Julie: No.

 

Patrik: Okay. So I’ll tell you something. When patients are at high risk of pressure sores, they need to go on an air mattress. Now, given that your mother is literally crashing when they touch her, I’m exaggerating here, but she literally crashes as soon as they touch her, she needs to go on an air mattress so they can minimise the turning.

 

Julie: Okay.

 

Patrik: Right? An air mattress is designed to prevent pressure sores.

 

Julie: Oh, okay. Is that something that I… The things that you tell me, is that something I can absolutely demand, or am I at the mercy of what they will allow?

 

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Patrik: I tell you the answer to that. If you think you can, you can. If you think you can’t, you can’t. So, does that help?

 

Julie: Okay.

 

Patrik: Does that help?

 

Julie: Yes.

 

Patrik: Look, you need to be comfortable in asking for things, and I know you are. I know you’re comfortable in asking for things.

 

Julie: Yes, I am.

 

Patrik: And you need to ask for that, and you know, for the reasons that I mentioned. I’ll flick you an email, and I’ll summarise it as well, but they know by now that you’re talking to someone who understands the area, right? There’s a very good reason why you would ask for an air mattress. I mean, she literally crashes as soon as they turn her.

 

Julie: Yes.

 

Patrik: It’s almost like life-threatening. By asking for an air mattress, it’s not unreasonable. It’s not unreasonable. I’m surprised. Your mom has been in ICU now for three weeks and she’s been bed-bound for three weeks. She should have an air mattress by now anyway.

 

Julie: Okay.

 

Patrik: Right? As soon as you see in ICU another patient, it’s two weeks plus, they need an air mattress. It should be standard procedure.

 

Julie: Okay. Another thing… Okay, that makes sense to me too, and I will. Another thing is they keep coming in and jamming holes in her wrist to get the blood gases and they said that they don’t… They think that the blood gas monitor is only … It’s super invasive to do it and so they don’t do it. They said, “We will keep checking as we feel needed.” Is that something else I can request as a constant or how invasive is that to do that to my mom where it is hooked up to the machine?

 

Patrik: Okay, so let me just clarify this. You are saying that when they do an arterial blood gas, they stab her?

 

Julie: In her wrist, yes.

 

Patrik: Oh my goodness.

 

Julie: They do them crazy deep. 

 

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Patrik: Yeah, yeah, yeah, yeah.

 

Julie: Deep arteries.

 

Patrik: Yeah, yeah, yeah, yeah.

 

Julie: Yeah.

 

Patrik: Oh my goodness. That’s terrible, that is… I believe that is dangerous practise and I’ll tell you why. You would have seen a week ago or maybe two weeks ago, she would have had an arterial line. Do you remember that? Do you know what that looks like?

 

Julie: She never got it. They’ve only been doing it through her wrist.

 

Patrik: From day one?

 

Julie: From day one.

 

Patrik: That’s malpractice.

 

Julie: I’ll tell you, that my mom went in there super strong. She was like, “I don’t feel sick.” She was having behavioural issues where she was like, “Get this mask off my face.” And then it got overwhelming for them, so instead of just tying her arms down and putting gloves on, they decided that they were going to sedate her with no arterial gas line. I can’t say that right, but they never put the gas line, which that Sunday night when this all started, when she got intubated for the first time was because her CO2 levels went through the roof and her blood was toxic from it. And they didn’t find that out until 24 to 48 hours later.

 

Patrik: Oh my goodness.

 

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Julie: Yes. When they finally deemed it necessary to poke her wrist. That’s how I found out.

 

Patrik: Oh my goodness. That’s terrible. So, Julie, I have never worked in an ICU where you would ventilate a patient without an arterial line. I just haven’t. Okay?

 

Julie: Okay.

 

Patrik: So, the advantage of an arterial line is, you need to do stab the once and then you’ve got an arterial line and then you can take blood gases whenever you want, and it’s not painful for a patient.

 

Julie: Yeah. And not dangerous practise.

 

Patrik: Absolutely.

 

Julie: Not dangerous practises.

 

Patrik: Have you seen them taking a blood test? Have you seen it yourself?

 

Julie: Yes, it’s really bad.

 

Patrik: It’s very bad. It’s very bad. It’s like, the way I look at this is, if I would work in a unit like that I would probably run. I would say, “What are they doing? I’ve never seen that.” I would probably run a million miles.

 

Julie: Do you think that I should then demand these things or do you think that I should be looking into moving her since this is normal process for them?

 

Patrik: Look, excuse me, I do remember when we first spoke last week, I do remember you mentioned thinking about moving her. You were mentioning it then.

 

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Julie: Because she’s in a smaller hospital. 10 minutes up the road is a big hospital. You said there would be a 24 to 48 hour delay, and I just don’t know that we have a 24 to 48 delay with everything that keeps popping up. But at the same point, would a new eye with someone who hasn’t given up already be a better, like a fresh breath of air?

 

Patrik: Absolutely.

 

Julie: I’ll keep in touch with this doctor.

 

Patrik: Tell me a little bit… The hospital she’s in now, how many beds are in this ICU roughly?

 

Julie: I would say like 10, maybe 15.

 

Patrik: So, it’s fairly small. Is it a teaching hospital? Is it affiliated with any universities, do you know?

 

Julie: I don’t know that.

 

Patrik: Okay. What’s the name of the hospital? I just quickly want to Google it. What’s the name of the hospital?

 

Julie: It’s West Valley Hospital

 

Patrik: West?

 

Julie: Yeah, it’s West Valley. W-E-S-T  V-A-L-L-E-Y

 

Patrik: Yep.

 

Julie: West Valley Hospital.

 

Patrik: Okay. And, it’s in… Where about are you? You’re in South Carolina, but where about?

 

Julie: Yes, it’s in Williamsburg, South Carolina.

 

Patrik: Okay, okay.

 

Julie: I got a message back, because my fiancée is actually with my mom right now, and she has been on an air mattress.

 

Patrik: Great.

 

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Julie: A VasoPress compression on her calves. The x-ray was good. No signs of blood clot in the lungs and a minimal sign of pneumonia.

 

Patrik: Yeah, okay.

 

Julie: And he’s in the middle of texting more right now.

 

Patrik: That’s okay.

 

Julie: Her O2 level is still at 65, and she’s still on eight PEEPS.

 

Patrik: Yep. Yep.

 

Julie: Last x-ray taken was this morning.

 

Patrik: Okay, okay. You see, if there’s no blood gas they don’t really know whether 65% of oxygen is sufficient or not. It doesn’t mean anything to me. Right, it doesn’t mean anything to me. The other thing you get from a blood gas, you want to know oxygen levels but just as equally important is the carbon dioxide level. That’s just as equally important.

 

Julie: They keep telling me that the ventilator does not allow CO2 build up or something like that.

 

Patrik: Look, I would question that. Just give me one sec. I’ll just quickly putting up the pictures of the ventilator that you sent me last week. Just give me one sec please.

 

Julie: Okay.

 

Patrik: Just give me one tic, I’ll just quickly bring this up. Oh, no, no, not at all. I mean that’s a ventilator that I worked with for many years, of course it… I mean, yeah you can control CO2 to a degree with a ventilator, but only to a certain degree.

 

Julie: So, by them not checking her gases she might not really be at 65%.

 

Patrik: No, I understand the 65% of oxygen is the oxygen delivery. That’s my understanding. Or, are you saying that’s the result in the blood gas?

 

Julie: That 65% is what the ventilator is set at, so she would get 40% when they extubated. Yes.

 

Patrik: Yeah. So, the only way to see whether that’s effective or not is by doing a blood gas. Yes, you can see on the monitor, oxygen levels like 90%, 95%. That’s good that it’s there, and it’s certainly a good guide post, but the real answer you will get from a blood gas.

 

Julie: Okay.

 

Patrik: As long as she doesn’t have an arterial line, they’re walking in the dark as far as I’m concerned.

 

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Julie: Yeah, I think so too. So she has a temperature of 101.3, she’s at… Her breathing is at 98, her blood pressure is 99/61. What’s the 93 in green, what is that?

 

Patrik: The 93 in green? Oh, that would be the heart rate, I would think.

 

Julie: Oh yep. So her heart rate’s at 93. Yeah, blood pressure and the … What is that blood pressure they keep in parentheses? That’s at 76.

 

Patrik: Yeah, what is it? What is it?

 

Julie: 76.

 

Patrik: Okay, that’s good. It needs to be about 65.

 

Julie: And then she she’s taking the P-A-T-N-Y-L-E-P-H-R-I-N-E. What’s that?

 

Patrik: That’s in the blood gas, the pH. You should have a number around seven.

The 1:1 consulting session will continue in next week’s episode.