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
How Will I Know if My Brother Can Already Come Off the Ventilator?
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 Joyce, as part of my 1:1 consulting and advocacy service! Joyce’s sister is still with a tracheostomy, on a
ventilator, and has developed severe pressure sores. Joyce asks if she needs to sue the ICU team for medical negligence due to her sister’s severe pressure sores.
Should I Sue the ICU Team for Medical Negligence Due to My Sister’s Severe Pressure Sores?
Joyce: I’m good, how are you?
Patrik: Very well thank you. How is your sister?
Joyce: Well, can you believe it, it’s five months?
Patrik: Five months.
Joyce: And she just recently on … I would say maybe three days ago, I think a day before, she’s been off the ventilator. I had a very … I had a traveling nurse through the hospital, very aggressive old-school one, and kind of like same philosophy as you, anyways, she was very, very
aggressive, she went and … she’s the one that really weaned them off, she told the doctors to have different criteria, and she changed the criteria and everything for my sister to really be weaned off, so she’s off, right? So she got to six, and then they weaned her off, and she hasn’t been … you know, knock on wood, she hasn’t needed it back.
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Joyce: Now I kind of want to tell you where we are now, okay.
Patrik: Is there someone else coming in? Brent.
Joyce: Oh is he coming in?
Patrik: Up to you.
Joyce: Yeah he’s now with my sister. Let him in. He’s actually at my sister’s. I told him to zoom because he’s at my sister’s room right now.
Patrik: Okay.
Joyce: Oh there he is. Oh okay. His audio. Okay. Brent, are you there? Oh okay.
Well he’s at my sister’s room because I wanted you to see my sister’s room. Okay.
Oh there’s my sister. Okay. But put the meeting on mute. Brent put the meeting on mute, I don’t want her to hear it. Do not put it on … you have it on mute? She cannot hear us? Okay good. Okay so where we are right now is she currently still had the tracheostomy, she has a humidifier going in because she has quite a few
secretions.
Joyce: I kind of pressed for the talking valve because we’re all so eager to hear her, but they were very reluctant, but I had a good respiratory therapist who really was like egging on, so we tried it for right … like we just tried it like a half an hour ago, and her saturation decreased really fast, it dropped into the 80s, so I assume that she still has a lot of … I want to actually answer why she desaturated a lot, I have like a
sneeze not coming out. Anyway so she desaturated pretty fast through the talking trach, so he let it for maybe one minute and then he put it back on.
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Patrik: So that was the very first time she was on the speaking valve? Very first time?
Joyce: Very first time. Like the very, very first time, and like right now, just so …
she has a really high white blood cell count, like 23, there is an infection, they can’t figure out where it’s at, they just did a CT scan to see if maybe she has an infection in the bladder of some sort, but I tried to decode it and I don’t … I’m not really sure. They took a culture from the lungs, that hasn’t come back yet so we don’t know. So basically we’re getting kind of the discussion again about sub-acute, obviously.
Patrik: Just remind me, where is she at the moment? Which facility?
Joyce: She’s at her home hospital.
Patrik: In ICU or?
Joyce: No, DOU, she’s in DOU because what’s keeping her there right now is the stage four bed sores. She has stage four bed sores, she has a wound vac on it, so now she’s very, very, very alert, like 100% herself, she’s actually very … she’s right now very angry at us and very moody and doesn’t want our … you know she likes to shake our hands off and she’s very upset with us.
Patrik: Yes. DOU stands for Definitive Observation Unit and this unit is for patients who are less critical than ICU patients and where patients who need very close observation.
Joyce: It’s a step-down from ICU.
Patrik: Yes.
Joyce: So what we have on our plate is this, she’s on trach with a humidifier at the moment, she’s not on the ventilator, saturating pretty nice for three to four days now. She has the bed sore and she has secretions, those are kind of like our two things on our plate. They are talking about sub-acutes, we’re not aggressively there because she has not been discharged, because there’s always something, there’s always an elevated infection, so
you know … but that being said, the purpose of today’s phone call is I want you to tell me … oh and then they’ve been putting her in the chair, right?
Joyce: So now they have an order every day to put her in the chair for two hours.
Patrik: Great.
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Joyce: I have … the only problem is I’m still find the physical therapy a hot mess. Physical therapy keeps discharging her because she’s not following command, and if she doesn’t follow command they discharge her. So the only thing she’s getting right now is range of motion, which I advocate for the nurses to do. My other sibling has been trained to do range of motion so he’s there doing what they taught him to do, in addition to what
I’m advocating for the nurses to do. She’s able to move her hand a little bit from the pillow, she’s able to move fingers and shake, she’s able to shake her toes, but that’s kind of where we’re at. Very slow movement.
Joyce: So we’re seeing some progress, so I kind of want to … kind of like let’s kind of see where we’re going to go, because there’s lots of questions. I mean I definitely want to … the end of the conversation just to map it out, because I’d like to maybe possibly talk about home care, but let’s right now kind of tell me where I’m at, and I also sent you … did you see I sent you her arterial blood gas.
Patrik: Yes I was going to come to that in a minute. Let me ask you a few questions. How many days has she been off the ventilator now?
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Joyce: I would say … Let’s see.
Brent: 72 hours.
Joyce: No it’s more than that-
Patrik: So 72 hours?
Joyce: It’s more than that because they restarted. How many days is 72 hours?
Patrik: Three days.
Joyce: I would argue maybe four, but okay.
Patrik: Okay. All right. How much oxygen is she on? Is she on any at all or is it just room air?
Joyce: Yeah she’s on 28.
Patrik: 28? Okay, and how often do they suction her?
Joyce: Very often.
Patrik: Hourly? Two-hourly?
Joyce: I would say about every two hours or so.
Patrik: Every two hours.
Joyce: She’s been pretty … she’s been … like it all depends, she’ll have a cough episode, so it’s either the nurse does it, or the respiratory. When we’re there she … you know, we’re not there 24 hours but pretty often and he is getting some pretty thick secretions at the moment.
Patrik: Right. Okay, and when you say thick secretions, also are we talking about yellow secretions?
Joyce: I mean they looked … I didn’t look at the color.
Patrik: Right, well if she does have an infection and the secretions are yellow, she might have a chest infection.
Joyce: Could be, I mean that’s why they took a-
Brent: It’s greenish. It’s kind of greenish.
Patrik: Right.
Joyce: I mean they did take a culture so we’re waiting for it to grow. So I’m sure they’re monitoring it.
Patrik: Right okay. It sounds to me like she’s still a bit away from decannulation, but you would say she’s neurologically intact?
Joyce: 100%. Like so 100% of who she is, now she’s actually … to be honest with you, this last week she’s just pissed off. She’s like pissed, which she would normally be pissed. Like severely pissed. Like really upset with us, and she’s actually trying to mouth, she’s like really, really trying to talk, and she’s getting very frustrated with us not knowing what she’s trying to say.
Patrik: Right. That is … okay. Okay what are they saying are the next steps? What are they saying?
Joyce: Well the doctor’s right now are monitoring why her white blood cells are so elevated, and this is why they’re kind of keeping her in. We did get a call from the case worker telling us get ready for the sub-acute. We had a family next door from us that we’ve been speaking with and they actually took their sister off home on a ventilator, which I didn’t know was an option, but I guess they don’t tell you, but home care is an option,
where they give you some support from the hospital and you have to pay for some, so we haven’t really like opened that door because the doctors haven’t aggressively like done it, because there’s always something going on with my sister.
Joyce: There’s always an infection, plus the bed sores are so severe, and they don’t know if a sub-acute will dedicate the two hours, it takes an hour and 45 minutes to change the dressing for the wound vac, somebody needs to accept that, and if a sub-acute doesn’t, then we don’t even know who will even accept her in that aspect.
Patrik: Yeah of course.
Joyce: So we’re like … we don’t know, we’re like not there yet because we’re still having some concerns and I’m going to … yeah.
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Patrik: But you can see the progress obviously on a respiratory, mental level? You can see the progress?
Joyce: Mental she is there, she is pissed off, I mean I’m not going to tell you that I’m like … she’s mad, and emotionally somebody is always with her. We have done like … now that the hospitals have been a lot more relaxed, this particular hospital are letting us visit, so we have around the clock somebody’s with her, except night time, so we literally … someone’s from eight, I did my three hours, he’s about to do a couple of hours,
and we’re always sitting next to her, because obviously we’ve been waiting for this day for quite some time.
Patrik: Okay. Look I have … to map out the lay of the land so to speak, right? Going home without a trach would be the easiest, if for whatever reason she can’t have the trach removed, you should be looking at home care of course, but it’s not a simple task, and I would argue yes, the hospital want your sister out and will argue they give you some level of support, but I would argue from experience that the level of support they’re giving you
is not enough, you would have to look at additional resources. It has to be safe, right?
Joyce: Yeah no and that’s the thing, like you’ve got to remember, because of the stage four pressure sores … listen, none of us have been able to see it, it’s really severe. They showed us a little bit and I couldn’t sleep for days. I decided that I cannot look at them, it does not benefit anyone, and all of them have been pushing us to see it just to like … we don’t want to see it. They’re bad, extremely … he said it’s down to the
bone.
Patrik: And this is sacrum?
Joyce: What’s sacrum?
Patrik: Back, sort of upper bottom, between-
Joyce: Yeah he’s saying it’s like kind of where the butt hole is, to the right, to the left. Huge. He said it’s like-
Patrik: You should sue the hospital for that really, I mean-
Joyce: Oh I’m going to, I’m actually going to … because I guess like she also came with a really bad trach cuff, like the person who admitted her to this hospital said she came in really bad shape, so I’m actually looking to sue the hospital because it’s negligence to the fifth degree.
Patrik: Negligence.
Joyce: Yeah.
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Patrik: In terms of home care, I just again probably need to educate you a little bit on that.
Joyce: But before we … Patrik, before you talk to me about home care, can you tell me the blood gas and where we’re at?
Patrik: Oh yeah, the blood gas.
Joyce: And how far do you think we..
Patrik: So this blood gas, is this on a ventilator or just on the trach collar?
Joyce: This was today. This is on a trach collar.
Patrik: Oh this was today? 28% of oxygen?
Joyce: Yeah, this is today.
Patrik: And is this an arterial blood gas or a venous blood gas?
Joyce: Yes. No this is an arterial.
Patrik: How … I can’t see that verified that it’s-
Joyce: Hold on, I’m going to go to the app right now. Hold on, because this hospital..
Patrik: Please.
Joyce: Hold on.
Patrik: Because I-
Joyce: Hold on. Messages. Here, this is the test I gave you … it says the blood gas with oxygen saturation.
Patrik: Yeah, but that doesn’t … look I do believe it’s arterial, but I would need to ask the question, if it’s arterial, it’s okay, the PO2 is good, 77, what concerns me is the PCO2 which is 54, you can see that it’s elevated, you can see it’s outside of range.
Joyce: Right, and what does that mean? What’s that?
Patrik: So what it means is her respiratory drive is probably not quite where it needs to be, probably not quite.
Joyce: So how do we get that down?
Patrik: Yeah. So you could get it down potentially with a cough assist, I’ll text that to you.
Joyce: What does that mean?
Patrik: A cough assist, so you could get it down two ways, okay? The first way is to put her on overnight ventilation just a little bit to give her a bit of a break, and don’t see that as a setback, she might just need it for a few more days to get the numbers within the right range, or they could try and use a machine called a cough assist, I’ll text that to you.
Joyce: Yeah.
Patrik: Cough assist machine, some hospitals use it, some hospitals don’t, we find it very, very effective, and it’s basically-
Joyce: Okay send it to me, I’ll ask for it.
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Patrik: Yes, ask them, but I can’t see any other way besides using a little bit of ventilation, whether it’s overnight ventilation or whether it’s daytime cough assist.
Joyce: Okay.
Patrik: But you know, I mean you can see the positives. If she needs to go back on a ventilator overnight for a few more days it’s not the end of the world.
Joyce: I’m just scared to do that and then they’ll just..
Patrik: I know.
Joyce: I’m stuck because I’m so … you know like I’ve got to be honest with you, if it wasn’t for this amazing miracle person, she would have never been off, they would have kept the criteria so high that she would have never been able to meet it, and there was this person … I can now understand the struggle of why this is a cat and mouse game, because I had a horrible respiratory therapist where I argued with her and she set her back, she put
her on pressure support, way back, and I said, “No I want spontaneous,” and she’s like, “No she can’t handle it.”
Joyce: And literally four days later she’s off the ventilator, so how do you explain that?
Patrik: Yeah look … no look, pushing is good, but when I look at the … I’m all for pushing, but when I look at the blood gas, you know, you’ve got to look at this in context, maybe she just came out of … I don’t know, of a deep sleep after this blood gas. You know maybe if they had taken this blood gas at 11 o’clock in the morning when she was wide-
Joyce: They probably did, I’ll tell you when they took it. They took it at … I mean they took it early because they take-
Brent: Do you want an update? He gave me an update right now.
Joyce: Okay.
Brent: So they think that her infection is coming from the wound, so the infectious doctor said that it’s probably from the wound, and now they’re starting her on antibiotics again.
Patrik: So they must have taken a swab from the wound and they must have gotten the result back.
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Joyce: Is this from the CT Brent? Is this the result from the CT?
Brent: Yes.
Joyce: Wait, they have-
Brent: She says … but the doctor called her and she told her that she probably has an infection from the wound most likely because she talked to the infectious doctor.
Joyce: And this they saw on the CT?
Brent: She will probably call you today or tomorrow to let you know.
Joyce: Doctor … okay.
Brent: But she’s starting antibiotics again.
Joyce: Okay, so I guess Patrik this is from the wound, and I guess they saw the infection through the CT. I don’t know if you can see an infection through a CT, but it’s that severe.
Patrik: Yeah.
Joyce: So..
Patrik: Have they surgically intervened with that wound?
The 1:1 consulting session will continue in next week’s episode.
Kind regards,
Patrik
