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 Dad in ICU has a Fighting Chance to Survive but the ICU Team Thinks Otherwise. Help!
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 Bob as part of my 1:1 consulting and advocacy service! Bob’s dad
is critically ill in ICU and Bob is asking why the ICU doctor is suggesting withdrawal of treatment if he is saying that his job is to advocate for his dad.
The ICU Doctor Says He is an Advocate for Dad, So Why Is He Suggesting Withdrawal of Treatment Now?
Part 1
Hello Patrik,
Thank you for putting this together. I’ve responded to a few things below.
Based on the GCS rating, I’d say Dad is about a 6/15. Although He looks like he is trying to talk, but can’t make any sounds. I see his mouth and Uvula move.
Unknown for the ABGs, it was something that came up in rounds and an IV drip was installed yesterday. They are doing routine suctioning of Dad and provide daily counts over 24hours. He had 9 suctions in the last 24 hours. 7 the day before and 5 on the
15th.
Also they think that the ventilator is pushing the secretions into his lungs and when they trach cradle it brings them up.
I don’t think dad is getting any chest physiotherapy. I’ll ask as I wasn’t aware this is a thing.
To my knowledge no cardio consult has been put in. Yes my dad has medication for blood pressure. Norepinephrine via IV drip and an oral medication Midodrine to use less Norepinephrine. To prevent his heart from going Afib he is on Amiodarone which is administered orally.
He’s been getting bladder scan once a week. Unknown if any other tests are being done. He originally had some Sodium Bicarbonate given orally to try and improve kidneys according to the doctor. Now that is given by IV starting yesterday.
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Dad is on an airbed and is being turned every 2 hours. I will inquire into those questions. Dad’s skin in general looks pink and healthy.
Agreed that there was negligence really and will ask today about cultures. I will ask what their treatment plan is. White cell counts was 20, 20, 17, 17, 21 over the last five days.
I was told that they don’t want to mobilize dad because they want to keep blood flowing to his vital organs. Having him moved around moves too much blood away for the moment. That came from the head physiotherapist.
Regards,
Bob
Hi Bob,
I’m responding to your email.
So you’re saying that IV drip was installed yesterday, they’re doing routine suction of dad and provide daily counts over 24 hours.
He had nine suctions in the last 24 hours, seven the day before and five on the 15th.
You think that the ventilator is pushing the secretions into the lungs and when the trache cradle, it brings them up. You’re probably right there, the ventilator is pushing down secretions but that’s why it’s also important that they keep doing the regular suctioning and they also need to start a regular nebulizer such as normal saline nebulizers, could also be some ventolin in the mix or atrovent, but definitely nebulization to mobilize secretions.
You’re saying that you don’t think that your dad is getting chest physiotherapy. You weren’t even aware that this was a thing? Well, he definitely will need chest physiotherapy daily. He would have lost a lot of muscle strength during this time in ICU and he needs daily physiotherapy or physical therapy.
You’re saying that with the cardiac issues, AF and so forth. To your knowledge, no consult has been put in. Yes, your dad has medications for blood pressure, norepinephrine via IV drip and an oral medication midodrine to use less norepinephrine to prevent his heart from going Afib.
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He’s on Amiodarone, which is administered orally. So that’s good. It sounds like they’re doing all the right things in order to get norepinephrine down. A midodrine is a good drug to have and with preventing AFib, amiodarone is the drug of choice.
So that sounds to me like they’re on the right track there. Bear in mind, one of the side effects of amiodarone can be kidney failure.
You were saying that your dad has been getting bladder scan once a week unknown if other tests are being done. You’re originally had some sodium bicarbonate given orally to try and improve kidneys according the doctor.
Now it’s given by intravenous yesterday. Okay, well, it’s getting sodium bicarbonate intravenously, that’s to be a different concern, I guess depends on how much he’s getting.
With a bladder scan once a week, how much? How much are they scanning? Do you know how much urine is in his bladder after the bladder scan? That would be a good indication whether his kidneys are working or not.
Then you’re saying your dad is on an air bed and is being turned every two hours? You have to question that. You know whether he’s got pressure sores, you’re saying that your dad’s skin in general looks pink and healthy and they mustn’t neglect that.
But please keep asking those questions what they’re doing in terms of pressure sores, and pressure area care. The last thing your dad needs is another pressure sore.
White cell count, it was in the 20, 17, 17, 21 over the last five days. Normal white cell count is 4 to 11. So that’s a sign of an infection. You should also ask for his temperature obviously. You should also ask his CRP, you should ask how they’re treating the high white cell count. Is he on IV antibiotics have they screened for an infection again? Are they treating the right source of infection?
Also then mobilization, you were told on that they don’t want to mobilize your dad because they want to keep blood flowing to his vital organs. Having him moved around moves too much blood away for the moment and that came from the head physiotherapist.
Look, given that he’s still on norepinephrine and some midodrine, they may have a point in not mobilizing him, but it really depends on how much norepinephrine he’s on. If he’s on high doses, absolutely no to mobilization, if he’s on low doses, I’d say they can be very carefully mobilizing him but very carefully.
So I hope that helps Bob. Let me know if you need anything else and we’ll go from there.
Take care for now.
Regards,
Patrik
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Hello Patrik,
Another thing that raised my alarm bells really is regarding the medication that the creepy nurse said to my Mom. She told her before I give him the medication, go look at Dad’s face and see his face how you’d like to remember seeing him. She then went on this tirade speech about nothing is healing on my dad and nothing would ever heal.
After objecting to the new medication I asked my mom to go take a walk and talk to discuss this. As soon as we walked out of the room the doctor appeared to start the family meeting. They sat us in a room and disappeared for 15 mins. I told my mom it’s a power play. I also discreetly recorded the conversation.
They came in and gave a very doom and gloom thing about how everything is much worse with dad than it was when the initial was here 3 weeks ago. Suggested withdrawing support from Dad.
He said his job was to advocate for dad. I told him very firmly his job is to heal dad and our job is to advocate for dad.
The doctor told us at how dad’s esophageal tissue was falling apart and that even with the stint they put in Dad is too infected to heal. I challenged him on that. The CT scan done showed nothing was worse and the other doctor said it may even be a bit better than the previous CT scan. They said the stint put in blocks things and they have no way of actually looking to verify. I asked the doctor and said without a new CT scan how do you know it’s falling apart
and not healing up? He didn’t provide an answer and said there is no way I can look at it.
I also raised my concerns to the doctor about the new medication and he implored it was just for pain management to make him comfortable and that they should try it to see what happens.
We were also told in the meeting how bad my dad’s lung function is that he couldn’t get off the ventilator, but when asked about his Pseudomonas infection progress. I was told his lungs are now clear of secretions. He was breathing with 99% O2 today with minimal ventilator support.
Regards,
Bob
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Hello Bob,
So let’s break this down a bit further step by step.
The nurse or any one of them is not in any position stating that your dad will not recover from anything. You can always say “No” if they are suggesting withdrawal of support for your dad. They should not be controlling your decisions, but rather control them with what you think is right for your dad.
Intensive care teams generally speaking are overtly negative. They often pay a doom and gloom picture for families in intensive care. And if you don’t know how to challenge that if you don’t know how to ask the right questions, it’s very difficult for you to get the outcomes that you want.
And also, how come they told that the esophageal tissue of your dad was falling apart when the result of the last CT scan showed nothing was worse and even better than the previous CT scan? The doctors should be explaining to you in full detail the results of any diagnostic studies for your dad. And how come the stent they put in your dad became too infected? Are they giving the correct antibiotics for your Dad?
Any referral to the Infectious Disease Consultant. If so, what are their plans? What antibiotics your dad is getting right now? Is it given via IV or via tube? Have they done any blood or wound cultures in particular? What are the results? Getting anything “too much infected” would have been prevented if they have given your dad the correct antibiotics and if they have provided the correct clinical management for your dad.
It is good to know that he has a good oxygen saturation (99%) with minimal ventilator support, but it is important as well to note that he needs to be negative of any bugs (Pseudomonas) if he became positive before.
To know if he already is, they should have done a follow up of tracheal culture again and repeat chest x- ray and not just say from their observations that his lungs are now clear of secretions.
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Getting off a ventilator takes a while, especially if your dad has been on sedation for quite a long time and if he’s still on it up till this time. There’s going to be parameters to know if your dad is already ready for extubation, or for the breathing tube to be removed, and he should have undergone a weaning process.
Weaning means gradually reducing the support the ventilator is providing for your dad, until minimal parameters have been reached so that your dad can breathe by himself so it is important that he is out of any medication that would cause any
respiratory depression.
Other factors should be, if your dad is: awake and cooperative, adequate oxygenation, adequate ABG (arterial blood gas) – An arterial blood gas (ABG) test measures oxygen and carbon dioxide levels in your blood -, sitting up in bed and presence of spontaneous cough.
I hope this helps. Still any questions further. Please don’t hesitate to ask.
Kind regards,
Patrik
