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 in the ICU with Sepsis. Why Does The ICU Team Want To Do Tracheostomy and Gastrostomy on Her at the Same Time? Help!
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 for more than three (3) weeks and the doctor is planning to transfer her mom to the LTAC facility after they do tracheostomy on her. Julie is asking if the nurses and the doctors in LTAC facility are qualified to take care of her mom.
My Mom is Critically Ill in the ICU and the Doctor Wants Her to Go to LTAC? Are the Nurses and Doctors there Qualified to Take Care of My Mom?
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PART 2
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PART 6
PART 7
PART 8
PART 9
PART 10
PART 11
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PART 13
PART 14
PART 15
PART 16
PART 17
PART 18
Julie: How long does it take for those to get out of her system?
Dr. Smith: Oh, no, we just hold it for… I’m not saying it’s a complication, but you know, it’s another layer of risk, in that, you know, she can get the procedure. In any case, I’m not saying that that’s going to stop us from doing what we need to do, but it’s kind of a case in point that, you know, things get more complicated the longer anyone’s in the hospital longer. But it sounds to me, I’m getting the feeling that you
guys want to continue to get the tracheostomy and the feeding tube, and so we’re going to work on doing that, unless of course you guys want to have her transferred, then we’ll work on that with the case manager.
Julie: Do you, are we going to start, do you think we can do that gas line, that we’d be able to put that in just for safety measures, and going forward being on the ventilator?
Dr. Smith: The what? What is it?
Marvin: The arterial line.
Dr. Smith: Oh, the arterial line. Arterial line, we generally use them if the blood pressure is low, despite having multiple vasopressors to support your blood pressure. I don’t think that it’s needed.
Patrik: That has been the case. She has been on multiple vasopressors. She has been on sedatives, she’s been on norepinephrine in the past. The other issue that Julie mentioned yesterday is she’s got the blood clot in her arm, and she thinks that could be a reason from the noninvasive blood pressure cuff. So again, maybe having an arterial line would have prevented the blood clot in the arm. Those are reasonable questions, I believe, to ask.
Julie: Because I came in on Saturday, and her hand was swollen, and we brought it to the attention to the nurse, and then my aunt came in on Sunday, and the blood pressure cuff was on so tight around her wrist that it left an entire red mark, and it would get even tighter when it would activate to take the blood pressure. Then my uncle came in, and saw that as well. It was addressed, but all times I felt like that could have
led to why she got the blood clot.
Dr. Smith: Yeah. These are unfortunate, unintended consequences of being in a hospital as long as she has.
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Patrik: Dr. Smith that could have been prevented by putting an arterial line in, and not needing to take a noninvasive blood pressure. That could have potentially been prevented. Because now you’re running the risk of potentially doing a tracheostomy, and needing to stop the whatever she’s on
vasopressors or heparin, or whatever, and putting her sedated, and potentially developing another blood clot. Those are issues that could have been prevented by following what standard practice intensive care.
Dr. Smith: I don’t agree.
Patrik: Yeah, you may not agree, but the family needs to be aware what standard practice in intensive care, because I don’t think you’re following what’s best practice in intensive care.
Dr. Smith: Yeah. An arterial line, is like I said, a monitoring device. It’s not a therapy. I don’t think it changed the outcome.
Patrik: Yeah, maybe, I chose my words wrong, but it’s a device where you can gauge therapy. Again, for somebody who’s ventilated for three weeks, and on and off high doses of vasopressors, you can’t tell me that an arterial line wouldn’t be appropriate. Show me the literature over the ICU where you wouldn’t put an arterial line in when somebody’s on multiple vasopressor and ventilator. Show me that ICU. This is the first ICU that I see where
this is happening. I believe it’s malpractice, and I have no other words.
Dr. Smith: That’s your opinion, sir.
Julie: I also.
Dr. Smith: I already know she’s very sick.
Julie: I also, when she very first came in there, she went into a self-induced coma from being put on sedation on the BIPAP, and there, because there wasn’t a line at that time as well, we don’t know how long she was breathing going into the, with the CO2 and everything, and it ultimately led to what got her into intubated and emergent, why she was emergently intubated. I feel like if that gas line would have been. .
Dr. Smith: She was initially intubated because… I mean, we can argue about an arterial blood gas for all night, but it really, and we can, you know, it’s, what can I say? We see a lot of patients here, we take care of a lot of sick people, and
an arterial line is only indicated during certain circumstances. An arterial line has not been indicated.
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Patrik: Show me the literature. Show me the literature. That may be your practice, but show me the literature to back that up. That literature doesn’t exist.
Dr. Smith: Yeah, I’m not sure what you’ve been… It doesn’t make any sense to me. But you can think what you want.
Patrik: Well, you can say what you want either, but I, after 20 years of ICU nursing, I think I know what I’m talking about. You show me the literature, what you’re telling me, and I’ll look at that. But unless you show me any literature around your practice, it’s not best practice what you’re doing there.
Dr. Smith: You haven’t been here, sir.
Patrik: No, I haven’t, but I’ve worked in ICU for 20 years. I don’t need to work in your ICU to understand what’s best practice. If you are extubating a patient, and the patient is failing, and you’re only doing a blood gas every, I don’t know, two days, and you’re stabbing a patient. Number one, that’s cruel. That’s very painful, and I don’t need to tell you that. In order to make sure that extubation doesn’t fail, well, maybe do blood gases more regularly and see what the numbers are showing. If your extubation is failing, well, maybe something went wrong. Maybe you should have gone to tracheostomy straight away. I don’t know. But I’m asking the question, and the question is not unreasonable.
Dr. Smith: Yeah, the question is unreasonable. I’m not going to discuss it any more.
Julie: Oh, my gosh.
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Dr. Smith: So, yeah, so that’s what I wanted to bring to the table here. It sounds like there’s a lot of bickering here, and I didn’t have this meeting just to argue. I want to provide the best care I can give to her, and it seems like all we want to do is point fingers here, so I think we should just end this meeting. Maybe, and I think, well, I guess what we have to decide on, do we want to perform the tracheostomy and
feeding tube, or do you want to just transfer her? I’ve given you my opinion that there’s a high likelihood that she’s going to remain ventilator dependent, and I think you guys have to realize that.
So you know, she’s a very sick person. More complications develop as the longer she stays here. But you know, it’s, give her a chance. She’s going to need a tracheostomy. So we can do that, but we just want to make sure that everything is clear and put on the table here. You know, if it were my mom, I’m not sure I would be doing the procedure. Because, you know, as the days turns to weeks, and the weeks eventually turn to months, she’s going to go through a lot
of suffering.
Julie: Okay.
Dr. Smith: It’s not very clear whether we’re going to have a good outcome. In fact, it’s likely that she’s not.
Julie: Okay.
Dr. Smith: All right.
Julie: So I guess, we’ll have to sit on our, talk about this more, and then figure out what we’re going to do. Is she going to see, hopefully a specialist will be doing the tracheostomy as well.
Dr. Smith: That’s correct. We’ve already discussed it with an ear, nose, and throat specialist. Dr. James Wallace is going to be doing the tracheostomy at least that’s the plan. To do it as soon as, like I said, she did get a little bit worse lately in the last couple days after we extubated her, but that seems to be turning around.
Julie: She’s getting better, you said, a little bit?
Dr. Smith: Correct, yeah. Once we, when we took out the tube, I mean, we think that she may have aspirated a little bit, and so her blood pressure went down some, and she developed those fevers, and that’s starting to improve over the last couple…
Julie: Okay. Okay. Then if she was to go on this tracheotomy and be on a ventilator, how long does she, because I definitely don’t want her to end up in one of those facilities that’s not qualified to take care of tracheotomy, or patients on a ventilator.
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Dr. Smith: You know, at that point, once she gets a tracheostomy, then she would be better served in a facility that takes care of chronic ventilate.
Julie: What kind of facility is that?
Dr. Smith: They’re called long-term acute care facilities, or LTACS. They have a staff there that’s geared for taking care of chronic ventilator dependent patients, with the hope that they can wean her off.
Julie: So does she stay, because I don’t want her to end up in one of those facilities. Does she stay with you guys doing therapy and doing rehab to give her a long enough chance where she’s…
Dr. Smith: Generally after someone get. .
Julie: Huh?
Dr. Smith: Generally after someone gets tracheostomy and a feeding tube through abdomen, and has been critically ill for this long, they go to a facility like that. Not immediately.
Julie: Right away?
Dr. Smith: No, not immediately, but the plan is to shift towards that. If the plan is successful.
Julie: What are the other options?
Dr. Smith: The other options? I’m not understanding.
Julie: The other options, other than if I didn’t want her to go there. Is there other options?
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Dr. Smith: Well, the, when the plan becomes for this to become a chronic process of ventilator weaning, that’s going to take not days or a week or two, then you know, generally go into a place where they can stay for a long time, hospital, acute care facility like our hospital is not the right place for her. So generally people go to a long-term acute care facility, and you know, there’s several of those facilities around.
They have doctors, they have nurses, but then things become more geared towards the chronic illnesses.
Julie: Okay, because I just, I read, the first doctor that I met there at the hospital, she had kind of told me about mom possibly needing to be at one of those facilities, and that they aren’t very good facilities, and she said, sometimes they are two hours away from the family, and she said, they’re not good. She said you need to consider that, and I did a lot of research on them, and read a lot of things saying that it’s
like sending your loved one to pass away a slow, painful death.
Dr. Smith: Yeah. That’s not always the case. You know, LTACs are somewhere between a hospital and an acute care facility like a hospital, and a little bit like a nursing home, kind of a cross between those two. Where you have, you do have doctors that round daily, and you do have goals of getting people better, but, you know, it’s more chronic conditions. Generally, like I said, that’s what happens after, that’s where she
will go.
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Julie: Okay, and so are the people there qualified to take care… Because at your hospital, you’re working with her, and you’re a specialist, and then she’s got respiratory specialists all working with her to man that vent and get her off, and I don’t think that the people at those facilities are very qualified. I’m just wondering is there other route, because we really do not want to end up there.
Dr. Smith: There’s pulmonary specialists that visit these patients as well, yeah. There are specialists that do this type of work at a chronic facility. That’s where she would need to go.
Julie: She goes there before she even recovers with you guys, right?
Dr. Smith: Generally, that’s what happens, correct.
Julie: Wow. Okay.
Patrik: Let’s cross that bridge when the tracheostomy’s done, Julie, I would suggest, let’s not look too far ahead.
Julie: Okay. Okay. All right. Okay, so I guess we’ll talk about what needs to, just talk tonight about everything, and just see where to go from there.
Dr. Smith: You let us know. But,
Julie: Okay.
Dr. Smith: Yeah. All right. Take care.
Julie: Okay, thank you. You too.
Patrik: Are you there?
Marvin: Hello.
Patrik: Hello?
Marvin: I’m here.
Patrik: Is Julie still on the call as well? Hello? Or is it just…
Marvin: I don’t know if she hung up, or…
Patrik: It looks, hang on, I can, I’m driving. Just give me one second. When I can stop I can actually see whether she’s still in the call or not, but she sounds like she’s silent. Sounds like it’s only the two of us. I hope I wasn’t too, I didn’t want to be rude, but at the same time I really thought that what happens there is not appropriate. You know?
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Marvin: Yes.
Patrik: I just felt like I had to bring my point across, and I know he didn’t like it, but he also needs to know that we’re watching. He needs to know that.
Marvin: Yeah.
Patrik: Have I upset him a lot, or…
Marvin: He was getting a little defense.
Patrik: Pardon?
Marvin: He was getting a little defensive. You can tell he was getting a little agitated.
Patrik: Right. That’s all right. He can, I’m sure he can take it. Look, I think on the one end it’s good that you don’t have to argue about the tracheostomy any longer. Right, because I think yesterday to me it sounded like they weren’t even sure they would do a tracheostomy. So I’m pleased to
hear that they are doing a tracheostomy without having to fight for it. Then the next steps, you know, you will wait and see, you know, I guess a transfer to another hospital that’s closer to you is probably good. You know, but, yeah, get that tracheostomy done first.
Marvin: Okay.
Patrik: Then get that tracheostomy done first, and then see what’s next. Yeah, it looks like Julie has gone out of the call, yeah. She’s out of the call. I would argue, get that tracheostomy done as quickly as possible. Get, you know, look into potentially getting her to another hospital that’s closer to home for you, and I believe, look, how old is this guy, Dr. Smith? What do you think?
Marvin: I’d say he’s probably late 30s, early 40s.
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Patrik: Oh, okay. So fairly young. Okay. Because I’m just trying to work out, is he sort of close to retirement age, and he’s been running this ICU like that for decades, you know, and hasn’t looked outside of his scope of practice? You know, that’s what I’m wondering about. Because that’s sometimes the case, if somebody’s sort of close to retirement age they run this place for decades, you know, the way they’ve run it. I’m just trying to work
out.
Marvin: Yeah.
Patrik: Right, but if he’s that age, I’m sure he’s seen other places. You know, you would think. You would think. But, anyway.
Marvin: Yeah.
Patrik: Yeah, I would suggest get that tracheostomy done. I’ve had a lengthy chat with Julie yesterday about the LTACs. LTACs are dead end. They’re dead end. You know, and the next challenge will be once he’s got the tracheostomy, the challenge will be to keep her in ICU as long as possible so she doesn’t have to go to LTAC. That will be the next challenge. We’ve certainly done that for other clients. It’s a matter of advocating, but let’s, she
needs to have the tracheostomy first.
Marvin: Okay.
Patrik: Right.
Marvin: Would you recommend doing the tracheostomy here before moving her?
Patrik: I think it’s safer for, I think it’s safer for transport.
Marvin: So have the tracheostomy first?
Patrik: I feel so. I feel that way.
Marvin: So do the tracheostomy here.
Patrik: Yeah.
Marvin: Then transfer.
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Patrik: Yes, that’s how I feel.
Marvin: To get closer.
Patrik: Yeah. Yeah.
Marvin: Okay.
Patrik: I don’t know. I’ve just had a missed call, a private number. That might have been Julie. I don’t know. But she could have just stayed on the call, I think. Maybe it was somebody else. Anyway.
Marvin: No, I think she’s upset and she hung up.
Patrik: Right, right, right, right, right. Okay, okay. All right. Look, I will be busy for the next three quarters of an hour, but if you or Julie need anything need anything after that, let me know.
Marvin: Okay.
Patrik: Okay, and keep an eye on what they’re doing. Keep an eye on what they’re doing, and if you think there’s anything suspicious, let me know.
Marvin: Will do.
Patrik: You know, but, yeah, get that tracheostomy done. I think that’s the next step.
Marvin: Okay.
Patrik: All right. Let me know if you need anything.
Marvin: Will do. Thank you.
Patrik: Okay, thanks, Marvin. Thank you. Bye. Bye.
Marvin: Okay.
The 1:1 consulting session will continue in next week’s episode.
