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
Why Does the ICU Doctor Tell Me to Just Let My Dad Pass Away? 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 Irene, as part of my 1:1 consulting and advocacy service! Irene’s dad is with a
breathing tube and on a ventilator in the ICU. Irene is asking if her dad will benefit more from a tracheostomy rather than a breathing tube.
Will My Dad in ICU Benefit More From A Tracheostomy Instead of A Breathing Tube?
“You can also check out previous 1:1 consulting and advocacy sessions with me and Irene here.”
Part 1
Irene: And when he go on bed and lay down and then it’ll go the opposite way down his throat and coat his trachea. And I would have to suction him at home sometimes four times a day. And I would suction him with a needle tracheal suction through the right nares using a 14 French. I would run the 14 inches, and as I’m pulling it back out, it would go really wild right here in the last three inches, right at the sinus opening and this fill up
the sinuses, will just fill up the suction like three or four feet a white cloud repeatedly. That’s what’s going on with the infection. It’s a chronic fungus infection that we just can’t get rid off. And we just get into the cycle, he’s home for a month and then he develops it again. And the weather’s cold. He’d go back to the emergency room. That kind of thing.
Patrik: Yeah. Okay. So I feel like the sooner a trach the better on the one hand, on the other hand, I don’t know whether we discussed that on our last call. If they end up doing a trach, they definitely want to send him out then. Did we speak about that? I think we did.
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Irene: Yeah. I did talk to them about the LTAC and the doctor, the attending says, “Well, maybe we can get it done at your house.” Like that service that you
mentioned.
Patrik: Yeah.
Irene: And he said, “I’m going to work with the case manager. And we get back with you to see if we can keep him away from COVID and away from…” I said, the main thing LTAC is if you call 911, and ambulance picks him up. The state have restrictions on
ambulances now. They tell them if they can’t start a person’s heart in three minutes, then don’t take them to the emergency. And then they’ll tell them if the person’s over a certain age, you don’t have to take them to the emergency. And then they’ll say if at a certain point, they do go to the emergency and there’s a line, then you have to keep the patient in your ambulance, till the emergency opens the door to allow them in. And so I really don’t want to get him on the back of an ambulance at
LTAC because I don’t have any control when dad’s sick at home. I can get someone to help me. I can put him in the car and I can take him to my choice, ER or hospital.
Patrik: Hospital.
Irene: Yeah. If you’re in ambulance, and you’re at the mercy of the government where they’re going to send that ambulance, sometimes they go to these out, these hospitals away from the city that just been open up, and you don’t know how equipped they are, what kind of ICU situation, how much COVID they have, those real bad place for an elderly person, it’d be in nursing homes right now getting sick or LTAC, any of these places if you have to
call 911.
Patrik: Yep. Yep. Look home care, I’m all for home care, but setting it up is not a straightforward process. You can set it up, but it takes effort preparation and the right staff, right equipment, all of that.
Irene: Yeah.
Patrik: Right. I can’t remember, I don’t know how much research you’ve done. We are running a service here in Melbourne intensive care at home .
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Irene: Yeah. I read about it.
Patrik: Right. So we basically providing tracheostomy care and ventilation care at home. If I was in your area, no problem. But it takes preparation… It’s a unique skill set.
Irene: Yeah. Well, I’m not sure how that would work, but the doctor said he was going to look into it and never heard back from him.
Patrik: I tell you what you could do as a first step. There is a nursing agency that we have referred some of our clients. Sometimes they are too busy, sometimes they say they don’t have nurses, but I know they have helped some of our clients that we referred.
Irene: Okay. Thank you.
Patrik: Oh, pleasure. Pleasure.
Irene: Great. So they might be able to do trach management at home?
Patrik: Absolutely. Absolutely.
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Irene: Okay. I just wanted to tell you, I’ve made a request for him to be transferred to the big hospital, the main one, where they have neuro ICU. And then I was told today that my dad is too unstable to be transferred to the neuro ICU, yet an hour later, I got that call saying, “Oh, we’re just going to discharge him and put him out on the street to another unit.” So on the one hand, they’re saying he’s too unstable to go to their main ICU,
neurologic ICU. And now on the other hand, “Oh, you’re just going to have to take him to another facility because this hospital is not going to take care of him anymore.”
Patrik: So I guess the question then is if they want to send him to… Is that a sister hospital, does the money keep flowing within their system?
Irene: Yeah. The big hospital is a community hospital. So this facility is just like an overflow sometimes for the big hospital and a big hospital has all these special ICUs. Sometimes from Australia, they bring them into this hospital. It’s amazing what they can get done major procedures like transplant at that main hospital.
Patrik: Right.
Irene: Yeah. That’s kind of… It’s a world-class hospital and they do specialized surgeries there that you don’t see anywhere else.
Patrik: Right. Okay. Yeah. Sure. Have you been in contact with that hospital?
Irene: Yes. I have been. I was trying to get dad transferred over there. So if they can’t convince them to take dad there, and the main reason why they can’t because he’s too unstable to transport over there, and we have a dilemma because he’s too unstable to leave the hospital any way.
Patrik: I don’t agree with that, Irene. I don’t agree with that. The reason I’m saying that there are air retrievals all the time for very unstable patients. I can’t see why your dad can’t be transported. Have you heard of ECMO?
Irene: Yes.
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Patrik: People are being airlifted on ECMO. I don’t think that your dad is too unstable to go to another hospital. I don’t think he is. Is there a risk? Yeah, sure, there’s a risk, but it’s all about risk management. I think there’s politics at play. I don’t think it’s a case of your dad not being stable enough.
Irene: Yeah. I agree. It’s definitely politics.
Patrik: Definitely politics, what needs to happen usually for a patient to go from one hospital to another is a vacant bed, a bed that’s available, a doctor that’s willing to take him, and a referring doctor. That’s the three ingredients. It’s fairly straightforward. However, in the last few weeks probably since late last year, we are finding that transfer to another hospital is very, very difficult because of COVID, very, very difficult, is
not impossible, but very, very difficult.
Irene: Yeah. And the other thing is, I want a patient experience office to help me because they advocate for the patients in that location, so I brought it up to them to see if we can get him transferred, but he warned me the very beginning. He says, “Irene, the big hospital has a lot more COVID cases. And your dad’s COVID free, and so are you.” So he kind of warned me about that.
Patrik: You got to weigh up the risk. You’ve got to weigh up the risk.
Irene: It takes four days to get in from an ER into a floor of that hospital. In the other hospital, you go straight from the ER to the floor. And in this hospital, it takes an average of four days, you’re waiting in the ER before they find you a bed.
Patrik: Oh my goodness. So that I’m almost saying… I don’t like the word impossible, but in this situation, it sounds like it’s going to be very, very, very difficult to organize that transfer.
Irene: Yeah.
Patrik: Yeah. Plus the risk that even if you can get a bed, plus the COVID exposure.
Irene: Yeah. Dad’s picked an acquired pneumonia in that hospital last winter.
Patrik: Right.
Irene: He’s getting cured for her primary pneumonia. Then he picked up hospital acquired pneumonia.
Patrik: Right. So there you go.
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Irene: Yeah. There’s a lot of disease there. Lot of different population, a lot of international people coming in from the airport to go there. They have the big helicopter pads on the roof. So they bring in people from all over, out of state, upstate, out of the country.
Patrik: Right. Irene, in your email you’re also asking, can you push your dad out to 30 days without a trach, with a breathing tube? You can but, it’s very uncomfortable. You’ve seen your dad on Zoom, have you?
Irene: Yeah. He only tossed his head back and forth like this a little bit. And then his whole face turned red from secretion as they get past the gag reflex. And then the breathing tube picks up the secretions. But to get from up here to down there, his whole face turns beet root red. He’s very uncomfortable.
Patrik: And that’s why, I would say yes, you can push people out to 30 days, but this is why, you try to do it as quickly as possible if you can, especially with the Glasgow Coma Scale of 7 or 8. And just remind me how many days of ventilation
is it today?
Irene: Today is on the 20th day going 21.
Patrik: Is 12 days. 12 days. So yeah. So, I’m almost bound to say, you can probably push it out a couple of more days, but he will be much more comfortable.
It’s also easier to mobilize him with a trach. It’s a more stable airway. And once he can be mobilized, his Glasgow Coma Scale might improve.
Irene: Yes.
Patrik: Right. So-
Irene: He’ll wake up more.
Patrik: You you’d hope that would be the case.
Irene: Yeah. We hope. Yeah. He might be more arousable.
Patrik: Yes, correct. Just making the mobilization part easier and also safer will help, I believe in improving on his neurological condition.
Irene: Okay.
Patrik: Right. So the trach is a risk, it’s a procedure, but if you can’t wean someone off the ventilator or if there’s a real aspiration risk, then a trach is the right next step.
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Irene: Yeah. That would also include a feeding tube that will be put in his stomach.
Patrik: Yeah. I tell you my thoughts on the feeding tube, especially in your location. The trach goes hand in hand with a feeding tube. Not so much here. Here the feeding tube gets pushed back. I do believe pushing the feeding tube back, I like it, and I’ll tell you why I like it, he would have a nasogastric
tube at the moment.
Irene: No, it’s part of the intubation, yeah, oral.
Patrik: Orogastric. Okay. Okay. So, okay. If they take out the tube, put in a trach and not do a feeding tube, they would put in a nasogastric tube. Okay. I tell you what I don’t like about PEGs. PEG tube is a feeding tube in the tummy. Have you
heard of it?
Irene: Yes. Yes. I do.
Patrik: Right, right. I’ll tell you what I don’t like about it. It’s got a permanency about it-
Irene: Oh.
Patrik: that the nasogastric tube doesn’t have.
Irene: Yes.
Patrik: And the permanency or the perceived permanency of the PEG makes people I believe lazy and complacent, not the patients, but the staff.
Irene: Oh, I got it. Okay.
Patrik: Right. Whereas if you have a nasogastric tube, well, that could always come out. And then you got to look at, okay, can your father start eating, drinking.
The PEG is almost like… Or once you’ve got a PEG, it’s like, that person will never eat or drink again.
Irene: Oh, yeah. Yeah.
Patrik: It’s got these perceived permanency and I don’t like it.
Irene: Right. Right. Okay. That’s a good point. He had a nasogastric tube last month when he’s in ICU and he got better in the bed, he’s waking up. He pulled it out.
Patrik: Yeah. Yeah. That’s the risk. That is the risk. But if he pulls it out, that’s probably also a good sign, that he’s realizing what’s happening.
Irene: Right.
Patrik: But I do know, the push to do a PEG simultaneously with a trach is always there. It’s part of the hospital culture, ICU culture. Not so much here.
Irene: Right.
Patrik: Right.
Irene: He’s a dance teacher. So, he likes dancing in the water. As he gets better, I have him at the local state college and they have him in the pool. It’s a physical therapy pool. We lower him down in the water with a wheelchair ramp. Or he walks down the ramp with a walker. And the students work with him in the pool walking and getting him ambulating better. And he doesn’t have to worry about falling and breaking a bone while he’s in the
water. If he had something in his tummy, that’s not going to work.
Patrik: No. It’s not going to work. Bear in mind, bear in mind if he has a trach that won’t work either.
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Irene: Right. Right. Exactly. So hopefully they would close the trach and they close the trachs up pretty commonly, right?
Patrik: Look, I don’t have any numbers to be honest with you. I do believe with everything that you’ve shared so far, I do believe your dad has a good chance to come off the ventilator, whether he’s got a good chance to have the trach removed because of aspiration risk, I’m not sure.
Irene: Okay. Well, you know what? We don’t want him to aspirate again and keep going back to the hospital. So we have to weigh that.
Patrik: What’ll happen is at some point, if he can come off the ventilator, speech therapy should do some swallowing tests, as well as a speaking tests, speech tests. But that can only happen if he can come off the ventilator.
Irene: Okay.
Patrik: Unfortunately he won’t be able to talk on a ventilator at all.
Irene: Okay.
Patrik: So that’s what I can see with the information you have shared so far.
Irene: Okay. All right. That’s very nice. Very nice. Would you be willing to call the hospital tomorrow during business hours?
Patrik: Yes, I can. Oh yes, I can.
Irene: Okay. I think that would be good.
Patrik: You know what we could do Irene, I can call you and I could then call the hospital so you can listen.
Irene: Okay. I can just put it on speaker.
Patrik: Yeah. Absolutely. And who do you think we will be talking to?
Irene: You can ask for the attending doctor that attends to my dad, or you can ask for the case manager.
Patrik: Is the case manager a clinical person.
Irene: It’s a civilian person, administration..
Patrik: I would like to talk to a clinician.
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Irene: That would be the doctor MD.
Patrik: Or even to the nurse, because we’ve got information, but it would be good to verify it and things change. The administrator wouldn’t know what clinical things have changed.
Irene: Yeah. Okay, great.
Patrik: So we’ve got some time left. What time do you think is a good time?
Irene: They do their rounds late morning. And usually by 2 o’clock they finish up talking with family. So I would say between probably 11 and 2 maybe or 10 and 2, something like that.
Patrik: Yeah. Let me just… Yep. Just give me a second, 2 o’clock I’m just trying to work out the times, yeah, 2 o’clock, yeah, that would be fine. Sort of 12, hang on 12 is… Yeah. Anywhere between 12 and 2 should be fine, but it can be later as well.
Irene: Yeah. I would try to go earlier, between 12 and 2, probably better.
Patrik: All right. I’ll call you tomorrow at 12 and then we’ll call the hospital.
Irene: Okay. We can just dial to the ICU directly. And then from there you can talk to the charge nurse.
Patrik: Exactly.
Irene: And then from there you can request the attending doctor for my dad.
Patrik: Exactly.
Irene: And they might call you back.
Patrik: Look, oh, I tell you something, even if we can’t get the attending doctor, I know I will get information even from the nurse looking after your dad.
Irene: Okay.
Patrik: Great if we could talk to the doctor that would be preferred, but I know I could get… As long as the nurses are friendly and cooperative, which most of them are, look at the information from the nurse as a worst-case scenario.
Irene: There’s also a charge nurse too.
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Patrik: Yeah, absolutely. Absolutely. So ideally, yes, we talk to the doctor, but if not, there’s the charge nurse and there is the nurse looking after your dad. There could also be the respiratory therapist, potentially.
Irene: Yeah. This hospital, I asked to talk to the RTs, but they don’t talk on the phone.
Patrik: Oh, interesting.
Irene: Yeah. So, but you can get the settings from the nurse. She just has to look harder, she just has to look harder because it’s not her specialty.
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Patrik: I don’t get that. Yeah, sure. I don’t get how an ICU nurse doesn’t want to know about ventilation, but yeah. I’m not going there.
Irene: Yeah, I know.
Patrik: Okay. Okay, Irene, look, you’re happy with that. I’ll call you tomorrow at noon, 12 o’clock your time.
Irene: Okay.
Patrik: Okay. Thank you so much. And we’ll talk tomorrow.
Irene: Yes Sir.
Patrik: Thanks Irene. Bye. Bye.
The 1:1 consulting session will continue in next week’s episode.
Kind regards,
Patrik
