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
Is It Safe For My Brother To Get Out Of ICU Quickly Once He’s Off The Ventilator?
You can check out last week’s question by clicking on the link here.
In this episode of “YOUR QUESTIONS ANSWERED” I want to answer a question from one of my clients Megan, as part of my 1:1 consulting and advocacy service! Megan’s brother is in ICU with
tracheostomy and Megan is asking if the tracheostomy is not as painful as it looks?
My Brother is in ICU with Tracheostomy. Is it True that the Tracheostomy is Not as Painful As It Looks?
“You can also check out previous 1:1 consulting and advocacy sessions with me and Megan here.”
Part 1
Megan: Hello.
Patrik: Hi Megan. It’s Patrik speaking here.
Megan: Patrik, good morning.
Patrik: Good morning. How are you?
Megan: Not bad.
Patrik: That’s good.
Megan: Coping. Hanging on.
Patrik: Right. So I’ve just spoken to Shiela.
Megan: Yes.
Patrik: So she gave me all the information that I asked for. She was a bit strange in the end, but I’ll go through the information first. So they’re definitely mobilizing him and I think that’s genuine. I think they’re really focusing on that. Then I asked her about whether they take him off the ventilator and then she said, “Oh, he’s still on CPAP.” And I said to her, if he’s going to be weaned off the ventilator and he’s had time off the ventilator in the past, why is he not getting off the ventilator? Now it’s morning time. I would think this would be the time to get him
off the ventilator. So then she referred to the weaning plan and then I said to her, “Well, what is the weaning plan?” And she couldn’t explain it to me. She was referring back to the doctors and the physios about the weaning plan. She should definitely know about the weaning plan. She had no idea.
Megan: No idea.
RECOMMENDED:
Patrik: I was probing twice and I said, “What’s the weaning plan? Is it like…?” Often it’s two hours on the ventilator, two hours off the ventilator, and then hopefully you can increase time off the ventilator, but she had no idea. She had absolutely no idea because I was probing twice, because then I was saying, “If you’re not taking him off the ventilator, what are his blood gases like? What are his tidal volumes like?” Tidal volumes is… So when he’s taking in a breath, they can see on the ventilator how big his volumes are.
Megan: Okay.
Patrik: And they should be roughly 10-mls per kilo. Now I’m a metric person. I have to apologize. Do you know Ryan’s weight, roughly?
Megan: Well now it’s… I don’t know, because he seems so much thinner.
Patrik: Sure.
Megan: I would guess about 10 stone, 11 stone. He’s not big.
Patrik: 10 stone. Just give me one sec. 10 stone in kilos that would be…
Megan: I’d say 10, 10 and a half, maybe.
Patrik: That’s 63 kilos. Okay. So yeah, that’s good. So his tidal volumes should probably be anywhere between 470 mls and 650 mls, but I’ll put that in an email to you. Because when you’re there, you can actually see it on the ventilator.
Megan: Right. Wonderful.
Patrik: All right. I’ll put that in an email. So she had no idea about the weaning plan, which is really concerning to me, because that to me is a given. That you, as the bedside nurse, understands what needs to happen from a weaning perspective. Then I asked her about tidal volume. I asked her about gases. She said, “That’s all fine,” which then, again, if that’s all fine, why can’t you take him off the ventilator?
Recommended:
Megan: Yes, I don’t think he’s ever been off it, Patrik. He’s only ever got as far as CPAP.
Patrik: No, my understanding was he had up to eight hours off the ventilator.
Megan: No, on CPAP.
Patrik: Okay, I misunderstood.
Megan: He had eight hours on CPAP, then the next day it was down, then now, come one o’clock will have been 24 hours on CPAP.
Patrik: Okay, but that’s progress.
Megan: Yes, I think it’s amazing because normally they say at night, “Oh, we must rest him,” and yet yesterday they said, “No, we don’t want to rest him, we want to continue with CPAP over the night,” and he apparently was absolutely fine, and he slept and he had CPAP, was on CPAP all night and he was on CPAP when I rang this morning.
Patrik: Right. Okay. That’s great.
Megan: But not off, never off.
Patrik: Okay. Then I did hear wrong, because I said, “Oh, he’s been off the ventilator before.” Then I did hear wrong.
Megan: Never mind.
Patrik: No, she’ll survive.
Megan: She will. She’ll have to. We can’t worry.
Patrik: No.
Megan: No, he’s not been off as far as I know at all, but the big development is that he was on… Do you remember the Begum said he’s not on eight hours CPAP?
Patrik: Yes, that’s right.
Megan: Yes. He had been, but then he went down… Do you remember when the doctor said he wouldn’t make it, he had started to regress?
Patrik: Yes.
Megan: And then as soon as they got him in the chair and she said that the other nurse said yesterday, he was lifting his arms up, they were getting him to push back on his legs, get back on his legs. And he was lifting up his arms, which is why he’s waving his arms around now because they caught him standing, they pushed the chair up and they caught him and he was lifting up his arms.
Patrik: That’s great.
Megan: So, that sounds good?
Patrik: Look, that sounds very good. If he can manage 24 hours on CPAP, then I’d say, in the next 24 to 48 hours, he should be able to have time off the ventilator, which is why I asked how are they managing secretions or how is he managing secretions? It sounds like it’s not too bad at the moment. They seem to suction him here and there.
Megan: Yes, I’ve seen them do it. They come with that… They suction it from the thing and they get out some stuff, I’ve seen it. It’s still quite thick, Patrik, but it looked much less yesterday. Obviously I don’t know how many times they do it, but they got out in that syringe thing about half an inch of thick stuff.
Patrik: Right. Okay. And she said it’s not too bad. And I think that’s all right. That would be the bottom line. Once he’s off the ventilator, the question is, can he, not only breathe, but also can he manage-
Suggested links:
Megan: Cough.
Patrik: … cough. That’s right. The other thing that I asked is, and the first sign that he would be exhausted on CPAP, if he’s breathing too fast and his volumes would go down, but she’s denying that he’s breathing too fast and that his volumes are down. So, that’s all good.
Megan: Yes. Because yesterday, I can report, I was watching very closely on that ventilator and the breaths per minute were about 20 to 22, but when I started talking to him, they’d go right up, 27.
Patrik: Okay.
Megan: Because he was trying to speak back, and all this. And I said, “Be calm, Ryan.” Then I just leave him and not speak. And then everything would calm down.
Patrik: Yeah. Look as long as he’s not going above 30 with his breathing rate consistently, it’s fine. But if he’s going above 30 consistently that would definitely be a concern.
Megan: Yes.
Patrik: Right. And also his volumes would go down.
Megan: Yes.
Patrik: Right. So both goes hand in hand. So then the other thing that I asked was is he tolerating his feeds because that’s enough. So he’s tolerating his feeds, which is good because they should be checking that every so often as well. I asked about the PICC line again. I don’t think
there’s anything devious really.
Megan: You don’t?
Patrik: No. I don’t think there’s anything devious because as I said, there’s no inotropes/vasopressors, like for low blood pressure. No. It just seems to be their preference and that’s fine.
Megan: Yes. And the only other thing I would add there is I saw Ryan’s arms and they’ve been putting these cannulas in. That’s what they’re called, isn’t it, cannulas? And they’ve been creating these big, red, angry lumps with scabs on. And so he’s not been getting all well with these. And she said, “Look how sore it is. That’s why we’ve done it,” she said.
Patrik: No, that’s fine.
Megan: She said, “We can’t keep doing this because he’s had so many of these and they keep getting sore.” And I think it’s also because Ryan’s started to also get quite active with his arm. So he’s trying to take things, he’s not trying to take things out, but he’s moving around more than they want, which I think is good, actually, that he’s moving. But he’s going off to the tracheostomy a bit, which I think it’s probably natural. He wants to
know what it is.
Patrik: Yeah. Look, it’s funny that you say that. I do remember when I first started out in ICU, I was always wondering how can people live with a tracheostomy? Is it painful? Now, I have to say, because I’ve been seeing many patients over the years with tracheostomies, most of them just get on
with it. It seems to be painless. Even when patients wake up, they tend to not pull it in most of the time, there’s always the exception to the rule. But most of the time they’ve almost like it’s not there.
Related articles:
Megan: This is good. It makes me feel more, less…. What’s the word? Because obviously I think about it all the time and I think, “Oh, how uncomfortable that must be?”
Patrik: No. It’s not uncomfortable. No. I can assure you it’s not uncomfortable. I can tell you what we do. We look after kids at home with tracheostomies. They just get on with it. Look, there’s always the odd kid who’ll pull it out the tracheostomy, don’t get me wrong, which is why we’re there in the first place. But they just get on with it.
Megan: Yes. It’s not as painful as it looks is what you’re saying?
Patrik: No. It’s not painful at all.
Megan: No. And the other thing he hasn’t done and has never done, but he did on the ward. He was pulling it off, all sorts of things, but he hasn’t done it on their thing. On the ITU. He hasn’t tried to pull out the nasal, the NGT. He hasn’t tried that at all.
Patrik: Good. Usually people pull that out before they pull out the tracheostomy.
Megan: Tracheostomy. Which, to me, it looks like he’s kind of wanting to know, he’s kind of trying to find out what’s going on and he’s trying to feel around. That’s how it looks. And also it’s a kind of natural progression. If you’ve got your arm out and then you turn your hand back, it’s going to come straight at your throat. If you’re lying there and you bring your hand up, your arms out, it comes to that area. And that’s what he’s doing. He’s
moving his arms a lot, which I think is great.
Patrik: Yeah, absolutely. So then… Yeah. Sorry, go on.
Megan: No, just to say a few days ago he was absolutely lifeless. His hands were just literally lying. He was lying, his hand was just limp.
Patrik: Right.
Megan: But now he seems to be regaining a lot of strength.
Patrik: Right. And that’s what I asked her. I said, day and night dreams, so I asked about sleep. So she’s saying he’s getting a good rest at night. Apparently. That’s what she said.
Megan: Yes. They’ve all reported this, which is why the sleepiness was such a mystery.
Patrik: And it could have just been a one off, you know?
Megan: Yes. The other thing is that his doctor at home gives him sleeping tablets. So I said this to you before, he has problems sleeping. I wonder if they’re still giving him those tablets.
Recommended:
Patrik: I asked them. They’re denying, if there is a sleeping problem, the other thing you can ask for to begin with is melatonin. Have you heard of melatonin?
Megan: Yes.
Patrik: It’s a natural product.
Megan: Yes.
Patrik: It’s a natural product. And it’s often being given in ICU before you go in with the big guns.
Megan: Right. If there is a problem, I can ask for that.
Patrik: For melatonin, yeah. And often it takes a few days to kick in. If you started today, it might not work before Monday. And in some instances it doesn’t work at all. But from my perspective, it’s definitely much better than any of the temazepam or diazepam or, you know?
Megan: Yes. They’re so strong and they’re so…
Patrik: Addictive? They’re addictive.
Megan: Addictive. Horribly addictive. Yes.
Patrik: Right. So, it’s not ideal by any means. So then I asked about his kidney function. She says it’s his kidney function is so-so at the moment and that’s when she got a bit funny and that’s when she said, “Oh, I’m not sure how much I can share with you.” And that’s when I said, “Look, you are aware I’ve identified myself appropriately. You are aware that Megan has given me authorization to call.” And then I said to her, “Do you have anything
to hide?” And then she said, “No, I’ve got nothing to hide.” So then I said to her, “Okay, so then you can tell me about kidney function, can’t you?”
RECOMMENDED:
Megan: Yes. Well done. I think you’re doing well getting this out of them because with me on the phone, they’ll say to me, “We’re not going to go into detail with you. Wait till you come here. “So you’re doing well. I think it’s their policy not to say too much over the phone.
Patrik: Yeah. But I go down a list and I will actually send you that. I basically ask the way I would ask if I was getting handover as a bedside nurse.
Megan: Handover. Yes. By the way I was there at your handover last night.
Patrik: Okay. And did they kick you out again?
Megan: Nope.
Patrik: No. Good.
Megan: No. I sat there. The whole time.
Patrik: Did they want to send you out?
Megan: No.
Patrik: Good. Because what are they saying that you can’t hear? That’s, you know?
Megan: What I can’t hear? What’s all this secrecy about?
Patrik: That’s right.
Megan: If what they’re telling me is the truth, what are they going to hide?
RECOMMENDED:
Patrik: Correct. Yeah. The only thing they probably would like to say in a handover when you’re not there is probably, “Oh yeah. We’re dealing with a difficult family.”
Megan: Watch out for the sister.
Patrik: That’s right. That’s part of the handover.
Megan: Yes.
Patrik: Well, I’ve been around long enough Megan…
Megan: To know that one.
Patrik: … to know that. And by the way, we’ve got a very difficult family here.
Megan: Yes. And they’re asking…
Patrik: That’s right. And they’re asking all these questions and they don’t want to leave for handover and all of that.
RECOMMENDED:
Megan: Yes. And all of that.
Patrik: So that’s all right. It’s a good sign.
Megan: That’s fine.
Patrik: That’s fine. Just ignore. So, yeah. And I’m definitely getting all the information that I want and she was nice, but she did in the end… Because I don’t know how long we spoke. Maybe for five, seven minutes. And then I know she got busy. She said, “I have to leave now because the doctors are coming and doing their round.” And I said, “Yeah, go. Fine.” But I wouldn’t say she got suspicious, but you just said, “Oh, I’m not sure.” Because I
said, “Look, I’m an ICU nurse myself. We can talk about…” And then basically the deeper that I was digging, she said, “Oh, but I’m not sure how much I can share with you.”
The 1:1 consulting session will continue in next week’s episode.
Kind Regards
