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Hi, it’s Patrik Hutzel from intensivecarehotline.com with another quick tip for families in intensive care.

Today, I have an email from Heather who says, 

“Hi Patrik, 

My dad has a foot wound on his heel that was previously surgically drained, biopsied, and debrided, and treated with IV antibiotics. He had a wound VAC (vacuum assisted closure) and then the wound was dry. Nothing growing in the cultures taken.

He was transferred and finished his course of IV antibiotics for blood infection. When I noticed the foot bandage was not being changed and checked each day, I asked the nurse about it. She showed me that her directions were to only change if the bandage appeared dirty or there was a bad smell coming from it.

I spoke to the doctor and got assurance that the wound care physician was changing the bandage every two days and monitoring it because they didn’t want to disturb new skin growth. We were assured that there was no infection, no drainage, and no need for it to be escalated to a surgical consult.

Then the wound care doctor met with my elderly mother alone and said the wound doesn’t look good and part of it looks soft and they will debride but probably can’t handle this type of wound and someone else will need to, and the doctor made a chop motion.

This was right after a family meeting where they assured us, he would have access to a foot ankle surgeon if needed, that wound care was communicating with the infectious disease doctor. I can’t now take my father to see his podiatrist foot ankle specialist surgeon because after entering an LTAC (long term acute care) and aspirating, getting pneumonia, he needed to be put on a ventilator and then finally had a tracheostomy surgery on the 14th of February and is in the process of weaning. The weaning is going well. He’s breathing on CPAP (continuous positive airway pressure) for about 7 to 8 hours per day at a very low-pressure rate and respiratory therapy has recommended that he starts on a T-piece or T-bar. 

I don’t want to set back his weaning process. I can’t ignore the possibility of bone infection and it’s not being monitored and him being taken off of IV antibiotics too early. How should I best ask both to be addressed?

All of this is complicated by this facility refusing to give me the doctor’s orders, progress notes, and nurses’ notes. My mother and I are supposed to be satisfied with the nurse explaining to us verbally if they have time. I have asked for the notes and offered to pay. They have updated me that if I pay for the pages, I can have a bring down, but it will be weeks afterwards. 

Best. 

– Heather.” 

Thank you, Heather for sharing this difficult situation with me.

Here is what I would do next. First off, it’s good that he’s making progress with the weaning and I’m surprised that he’s making progress in LTAC because as you probably know, I don’t have anything good to say about LTAC in general.

However, here’s what I will say. Given it might go well with weaning, but it certainly doesn’t go well with wound care and with wound care specialists in particular. I’m not surprised even that your dad is in LTAC. In an ICU or in the hospital, he would be getting the weaning and the pressure area care. He would be getting both.

You also haven’t shared whether he’s got a stage 1,2,3 or even 4 pressure sores. So, it would be good to find out what stage pressure sore he has, but that’s also why it’s important that you get access to the medical records because that would all be documented in there.

Let me clarify this. First off, you absolutely have the right to access medical records. That’s not a privilege. That is a right. So, make no mistake here and keep the pressure on and don’t let them get away with that. Often what it takes is either a second party to come in and put pressure on them like we do here at intensivecarehotline.com or we write a letter to hospital or LTAC executive and that will turn the needle 100%. 

So, it is important also that you check obviously the wound daily. They need to check the wound daily but even you can request that you can have a look at the wound daily. What is it that they have to hide?

So, what is difficult here is if your dad can’t get mobilized because of the foot wound that might set him back with the weaning, but I would also hope that the foot wound won’t delay him in weaning and won’t delay him getting out of bed.

So, it is important though that they take the pressure off his foot all the time and do the dressing changes every day and not only when it’s dirty like you refer to. That’s not very professional, that’s almost ridiculous, and a dressing needs to be changed either daily or there are some dressings where you can leave them 2, 3, sometimes even seven 7 for hydrocolloid dressings but it really depends on what the wound looks like.

So, those are your options here in terms of, first off, get access to the medical records. Once again, it’s a right, not a privilege. You need to put the pressure on. Set deadlines, tell them you need access to the medical records tomorrow at three o’clock. You don’t need to explain yourself. You just ask for what you want and hopefully your dad can also stay on the CPAP overnight, I believe, now, at the moment, it’s during the day.

What’s also important is for your dad to get in a good day and night rhythm because that will help him to be strong during the day and wean during the day and hopefully you can rest at night and that will hopefully give him more and more time off the ventilator during the day. That is really important. 

Once he has more time off the ventilator during the day, maybe they can start a speaking valve trial, maybe they can also try a tracheostomy capping to see what they can breathe without the tracheostomy. I know it sounds a little bit far-fetched at the moment if he’s still fully ventilated overnight, but those should be his goals. Plus, the mobilization. Plus, changing his dressing regularly and not only when it’s dirty and that is not good practice. So, I hope that helps and I hope that answers your questions, Heather.

Now, I’ve worked in critical care for nearly 25 years in three different countries where I worked as a nurse manager for over 5 years. I’ve been consulting and advocating since 2013 here at intensivecarehotline.com.

I can confidently and without the slightest hint of exaggeration say that we have saved many lives as part of our consulting and advocacy. You can verify that on our testimonial section at intensivecarehotline.com. You can also look up our podcast at intensivecarehotline.com where we’ve done client interviews, and you can vouch for our work.

That’s also one of the reasons why we created a membership for families of critically ill patients in intensive care. You can become a member if you go to intensivecarehotline.com if you click on the membership link or you go to intensivecaresupport.org directly. In the membership, you have access to me and my team, 24 hours a day, in the membership area and via email and we answer all questions intensive care related.

You also have exclusive access to 21 e-books and 21 videos as part of the membership that I have personally written and recorded, sharing all my nearly two and a half worth decades of ICU experience with you and your families.

I also do one-on-one consulting and advocacy for families in intensive care. I talk to you over the phone, Skype, Zoom, WhatsApp, whichever medium works best for you. I talk to you and your families directly. I hand hold you through this once in a lifetime situation that you can’t afford to get wrong. I also talk to doctors and nurses directly. I ask all the questions that you haven’t even considered asking but must be asked when you have a loved one, critically ill in intensive care. I also represent you in family meetings with intensive care teams and all with the goal of making informed decisions, have peace of mind, control, power, and influence, making sure your loved one gets best care and treatment.

We also do medical record reviews in real time so that you can get a second opinion in real time. We also do medical record reviews after intensive care if you have unanswered questions, if you need closure, or if you are suspecting medical negligence.

All of that, you get at intensivecarehotline.com. Call us on one of the numbers on the top of our website or simply send us an email to [email protected] with your questions.

If you like my videos, subscribe to my YouTube channel for regular updates for families in intensive care, click the like button, click the notification bell, comment below what you want to see next, what questions and insights you have from this video.

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If you want your email done, quickly, read out quickly and your questions answered quickly, you can leave a donation here with the super chat button and I will answer your question in email in the next couple of days. I have email sitting in my email in box from early this year or late last year even and I’m still catching up with the emails. If you want to leave a small donation anyway, to support our work, so we can help as many families in intensive care as possible all around the world. I appreciate that.

Thank you so much for watching.

This is Patrik Hutzel from intensivecarehotline.com and I will talk to you in a few days.

Take care for now.