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 last week was
You can check out last week’s episode by clicking on the link here.
In this week’s episode of “YOUR QUESTIONS ANSWERED“, I want to showcase how I can answer many questions in a short period of time when helping clients directly over the phone or via Skype.
I therefore showcase another conversation with one of my clients Vanessa in a 1:1 phone/Skype counselling and consulting session.
This is another great case study where I can leverage your time, get down to your most pressing questions and most pressing issues very quickly and therefore help you to get the outcomes that you want, need and deserve for your Mom, your Dad, your husband, your wife, your sister, your brother, your grandmother, your grandfather, your aunt, your uncle, your niece or your nephew!
I can show you very quickly how you can improve the care and treatment for your Mom, your Dad, your husband, your wife, your brother, your sister, your niece, your nephew, your Aunt, your uncle or your grandmother or grandfather!
It all comes down to asking the right questions and it all comes down shining the light on the things that you don’t know and looking for a solution that Intensive Care teams often hide away from you!
CASE STUDY: My Mom has been in ICU ventilated with a breathing tube in an induced coma for 5 days, is a tracheostomy too early?
Patrik: Hi Vanessa, thank you for being a client, I appreciate you! Tell me more about your Mom’s situation!
Vanessa: Well, it’s kind of hard to explain the scenario. My mom had respiratory distress so she was intubated and now they’re finding it hard to get … It’s past the recommended amount of time to have the tube in. They want, sorry, me to consider doing a tracheostomy. But the thing is they’re saying she could still, she has the capacity to breath still. It’s not like she’s had brain damage or anything. She has the capacity but she has a mass on the right side of her lung. Kind of close. Like some of the airways on the right. But her left is still functioning good. It makes it just difficult for her to breath and I don’t what to do. If I should have the tube taken out and see how she does or I don’t know if that’s a dangerous option?
Patrik: I can definitely help you with that. Let me ask you just a few questions that I fully understand your Mom’s situation. How old is your mom?
Vanessa: She’s 69.
Patrik: 69. How long has she been in intensive care now?
Vanessa: Intubated I think Thursday night. Last Thursday night so Friday, Saturday, Sunday, Monday, Tuesday.
Patrik: Five days. Five days. Okay. What got her intubated (Intubation= insertion of breathing tube) in the first place? Was that the mass on her lung?
Vanessa: Well, they’re saying that’s what caused … the chest x-rays showed a partial collapse of the right side, some of the airways on the right side of her lung. But that’s not what she came in for. Actually this is like an episode, something that happened while she was being treated for general pain in the hospital.
Patrik: Okay. Okay. All right. Five days of intubation and already talking about a tracheostomy is too early for my experience. Now I don’t know how much research you’ve done on our website. There’s numerous articles around when patients should have a tracheostomy or a trach, whatever you want to call it. Usually the time range is between 10 to 15 days after intubation (intubation= insertion of a breathing tube) if you think patients can’t get extubated. Then one might consider a trach.
But you’ve made a very good point in terms of probably aiming for a trial extubation (=removal of the breathing tube). Trial extubation basically means taking the breathing tube out. Having the staff on standby and making sure they can react if your mother can’t breathe. But I personally think, and from my experience as well, patients should have a trial extubation in order to avoid a tracheostomy in the first place.
Vanessa: The thing is, yeah, go ahead. I’m sorry.
Patrik: There are a number of parameters that need to be looked at, whether that’s an option. I would need to know a lot more to guide you with this. Hospitals can be very quick. Hospitals are intensive care units. They can be very quick in suggesting the next steps. But they can also be very quick in sometimes removing life support when it’s inappropriate. You always have to read between the lines. By that I mean what’s their goal? Are they pushed for beds? Do they want to do a tracheostomy because they want to move her onto long term care? What are their goals? Their goals should always be the wellbeing of their patients but we also know that’s not always the case.
Vanessa: Yeah. And I kind of feel like … Now that I think about it, she was in since the Thursday, it has been not a week yet but it’s been, I mean it’s not two weeks yet. It’s been since the 16th or 17th. I’d say about the 17th with the tube in. I kind of feel like they hadn’t really been … I don’t know what their protocol is. I kind of feel they haven’t really been exercising her every single day.
Patrik: Yeah. Yeah. Absolutely. Absolutely. In fact, it’s something, in order to build somebody up for extubation (removal of the breathing tube) they need to do some physiotherapy and you know by saying, “We need to do a tracheostomy next week or in a few days,” without having built your mother up to give her the best chance to get her off the ventilator in the first place is what I would consider not best practise.
Vanessa: Yeah, now I’m like, I don’t know what to do. I don’t know-
Patrik: Are you feeling pressured by the hospital?
Vanessa: Yeah. I am actually, I am. To make a decision. They were saying if she gets this tracheostomy and connected to another ventilation it’s like she goes to some other facility. Acute, whatever they call it. She doesn’t go home.
Patrik: Yeah, long term acute … That’s exactly right. That’s exactly my point. Where I’m wondering … You see there’s four avenues in a situation like that as far as I can see. The first avenue would be to do a trial extubation (removal of the breathing tube). Okay, to build your mother up with physiotherapy, breathing exercises, to get her off the ventilator and when she’s off the ventilator, get her out of ICU. That would be number one and it would be the preferred option.
Number two, do a tracheostomy and wean her off the ventilator and the tracheostomy while she’s still in intensive care.
Number four, do a tracheostomy and move her onto long term acute care. From my perspective if the first option hasn’t been given the best go that they could ever provide, the other three options shouldn’t be even looked at if that makes sense.
Vanessa: Yes, and to tell you like the truth, my very first day, when she was just intubated I was talking to the doctor like a day after, one or two days after, he told me back on day one or day two that he didn’t have any confidence that she was going to be able to be taken off of the ventilator. This was like one or two days after just being intubated.
Patrik: Yeah, what they’re basically doing is they’re trying to position your mother’s case in what I would believe is convenient for them. From my experience, eight or nine patients out of ten do come off the ventilator without a tracheostomy. But the reality is that most doctors in ICU are negative and they are negative for a number of reasons. If they would tell you, “Oh look, we get your mother off the ventilator and no questions asked. It’s all going to happen,” and then they don’t they could be in big trouble.
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For them it’s much safer to say, “Oh, your mother will never come off the ventilator.” It keeps their options open. What’s also important to know from an intensive care perspective, they are most likely pushed for beds, meaning their demand for beds is higher than the number of patients they can accommodate. They know that once they intubate a patient, if they can’t get that patient off the ventilator in a timeframe that is convenient for the ICU, for them it’s easier to do a tracheostomy and send her off to somewhere else. That’s the reality in intensive care and that’s what you’re dealing with probably. A mass on the x-ray, is that a new diagnosis?
Vanessa: No, it’s about maybe a two year, one or two year old diagnosis. She’s been getting radiation treatments prior to this and then …
Patrik: This is what I can see in your situation. The reason why we’re working with clients 1:1 all the time is because we’re dealing with situations like that all the time.
Vanessa: You have a lot of good information.
Patrik: When we come off this call I will send you some articles around when patients should have a tracheostomy. I’m sure you have done some reading already. The other option that we can provide, and this goes back to your initial question, we’re always happy to have a chat, we would be very happy to work with you and talk to the doctors and also advocate for your mother and help you to get the outcomes that you want. It’s simply a matter of asking the right questions! You simply don’t know what you don’t know!
By us asking the right questions, the dynamics will change very quickly, because the Intensive Care team will have nowhere to hide!
At the moment they haven’t even told you half of the truth and they haven’t even told you all the options! Once I speak to them, I will change all of that!
Vanessa: I see. You would call in and kind of push for things.
Patrik: Absolutely. Also, you’ve given me now an understanding of what you’re dealing with but I have worked in intensive care for nearly 20 years. I could help you with asking more questions and the right questions and once you have given me authority I will ring up and ask those questions. But we could help you one way or another if you like. Whichever way you want to go about it of course.
It’s a matter of asking the right questions and also challenging them. Again, you simply don’t know what you don’t know!
They’re also not used to being challenged. Most people don’t do their own research. They don’t look at other avenues. They just knock everything off without looking, “Okay, what’s really happening there? What’s the ICU’s goal, what are their frustrations or what are their constraints?” I should say. Their constraints generally tend to be the number of beds that they have. The number of staff. There’s huge pressure on intensive care beds in general.
- Why The Doctors In Intensive Care Are Looking For A Solution For Their ICU And Why You Are Looking For A Solution For Your Critically Ill Loved One And How To Get What You Want In This Power Struggle!
Vanessa: I see. I wonder if I didn’t make any decision within their timeframe, what would they do then? If I go past their-
Patrik: Yeah. That’s a very good question. My advice, or our advice generally to families is that if you are uncertain and you feel pressured to make a decision, to not make a decision at all. They have a duty of care for your mother and they also have a duty of care towards you and whoever else might be involved from a family point of view if you have any siblings or whatever other decision makers there might be. They have a duty of care towards your mom and towards you. They can’t pressure you to make a decision. They would like to of course. We know all of that. But at the end of the day, my advice would be not to get pressured at all and say, “Look, I’m not ready to make a decision. I’m talking to a few other people.” Also, sometimes not respond to their questions.
Families feel pressured all the time but the reality is she’s in a safe environment and while it’s not ideal to be on a ventilator if you need more time to make that decision, you should take that time. What could well happen is you might go there tomorrow and they might say, “Oh, can we have a family meeting tomorrow at 3pm or whatever and can you come? We want to make some decisions.” If you’re not ready to make decisions, don’t go there until you’re ready and comfortable to make the right decisions.
Vanessa: Yeah. It’s really, I hate to go back over but I can … My mom, she’s always had a few, almost like an asthma attack. Difficult breathing. I’m sorry, I’m going back now. We came into the hospital when she had general pain. They’re treating with pain medicine, Morphine and different things. My mom actually caught me, she asked if they gave me an overdose. This is when she’s on the fifth floor just being treated for pain. I remember the nurse coming in asking, “Do you want more morphine?” Being really, I thought it was maybe a little too free.
Patrik: Okay. Do you know the main side effect of Morphine is respiratory depression? Do you know what that means?
Vanessa: I do. I do.
Patrik: The main side effect of Morphine is respiratory depression. That means if you give somebody too much Morphine, they stop breathing. In some cases, that gets people on a ventilator. I’m glad that you mentioned that.
Vanessa: Yeah. It’s like now what do I do? If I want to go up and see, “How much Morphine did she actually take?” Even when I was there-
Patrik: You should ask for that. You should ask for that. You should definitely ask for that. Don’t be, other advice that we would give is don’t be intimidated by anyone. Don’t be intimidated. It’s the worst thing you can do, be intimidated. Ask for the medical notes and it’s bargaining power for you.
Vanessa: I see. I guess I just have to talk to the right people to get those results?
Patrik: You just ask for the medical records. Ask for the medical records from whatever timeframe. You can do that under the Freedom of Information Act. They have to give you that information.
Vanessa: Okay. That was one thing I didn’t want to think like maybe because actually the night before with my mom she had an episode like that and I gave her two puffs of a Salbutamol inhaler and she pretty much, it was like laboured breathing but she calmed down and everything was good. The next day I wasn’t there and she calls me. She’s like, “I feel like I got an overdose.” Then all of a sudden she started, she had an amount of time talking back and forth with the nurses before the onset of this breathing episode came on. The first thing I know, they’re taking her. They intubated (=insertion of the breathing tube) her and put her on ICU.
Patrik: If your mother is on Salbutamol, is she having also COPD or asthma?
Patrik: Right. Right. Well, I can tell you that if she’s got COPD and they’re giving her Morphine, you should certainly avoid Morphine for anybody with a chronic airway disease. It just increases the risk for intubation. Does that makes sense so far?
Vanessa: It does, yeah.
Patrik: What I can do as the next step is I can send you some links to some articles that will evaluate a bit more when patients should have a tracheostomy. That might be a next step. As you know, we work with you and help you get the outcomes that you want. It’s not just a counselling, consulting and advocacy service,(7) we want to be accountable for how we can help you if that makes sense.
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Vanessa: I see. Is it almost, just being represented. Not really legal.
Patrik: No, we’re not legal people. We’re not legal people but we are advocates and because we have so much ICU experience we can, if we can only ask five questions to a doctor it’ll change the dynamics in your favour immediately. It’ll change the dynamics immediately in your favour because they know we know what we’re talking about. You don’t even know what questions you need to ask. We’re just scratching the surface here. The minute they know they’re dealing with a professional, the dynamics change completely.
Vanessa: I see, yeah that makes sense!
Patrik: There’s no one size fits all but we tend to find that this tends to be a good arrangement for our clients when we start talking to doctors, nurses and sometimes social workers! But, it sounds to me like by everything we’ve talked about so far, this sounds to me like it could be a short-term problem where the goal would be to get your mother off the ventilator as quickly as possible to avoid any future complications such as a tracheostomy.
That’s what it sounds like to me but again, if I was in front of a decision maker or in front of a doctor and I could ask them, “Hey, what’s happening with the chest x-ray, what’s happening with the blood gases, why are you not doing physiotherapy, what sedation is she on?” Sedation in terms of, “What are you using to keep her in the induced coma?” If they’re still giving Morphine for example, Fentanyl, well, she’s not going to wake up anytime soon. Those are the type of questions that I-
Vanessa: That was my concern actually, yeah.
Patrik: Those are the type … For example, the combination of Morphine and not doing any physiotherapy is not getting your mother off the ventilator.
Vanessa: I can say since she’s been down in the ICU on the ventilator they haven’t given her Morphine as far as I know but she is connected to Fentanyl.
Patrik: Fentanyl is similar to Morphine. It’s just as bad. Morphine and Fentanyl are extremely good for severe pain. Works very well. But it’s detrimental to getting someone off the ventilator because the main side effect of Morphine or Fentanyl is respiratory depression.
Vanessa: I see and I didn’t know that. You know when they do a trial, actually I’ve found that I’ve had to push for the trials. I’m like, “Okay, when is my mom going to get her trial?” Then the nurse would talk to the respiratory therapist and then they’d be like, “Okay.” Then I’ll ask her again and she would turn off the Fentanyl for maybe, I don’t know, 30 minutes. I don’t even know if that’s a good amount of time. Then she would come back. She would turn it back on and I’d have to say, “Okay, I thought you guys were going to do her test? Her waiting trail.” And she’s, “Oh, okay.” It was really weird. It was almost like I had to …’
Patrik: And that’s exactly where I can help. We could number one, speak to them and ask them and number two, we could give you a series of questions where they would immediately know that you know what you’re talking about and that you want the best for your mom.
Patrik: Okay. Okay. I’ll send you a couple of articles. You know where we are if you need help. I think I’ve given you certainly some starting points in how you can try to manage the situation yourself. Also, if you keep browsing our website, there’s numerous articles and we’ve consulted clients in the past in similar situations where you might find some articles around that.
If people spend time on the website, they can find enough information to manage those situations themselves if they do more research and spend some time using us a shortcut of course. But at the same time, there’s hundreds of articles on our website where we helped families in similar or even more difficult situations. Yeah, you can use all that information of course. It’s there for you. But you’ve chosen the best and quickest option by hiring me for 1:1 counselling, consulting and advocacy!
Vanessa: I see. So you’re going to send me the emails that’s next!
Patrik: Yeah. Exactly.
Vanessa: Yeah, I really, it’s really stressful. I’m not really sure what to do. Then it’s like, “Okay, we take the tube out. Does that mean,” … Some that I talk to say, “Okay you take the tube out, we’ll make her as comfortable as possible.” I’m like, are they saying, the doctor did agree. She agreed that, “Yeah, she can breathe on her own.” It’s weird. “Yeah, she can breathe on her own.” I’m like, taking the tube out wouldn’t be… it seems like an important thing to me!
Patrik: I can tell you that as long as she’s on Fentanyl it’ll be very hard for her to breathe by herself. The Fentanyl and I believe physiotherapy, getting rid of Fentanyl and starting some physiotherapy from my perspective, just by everything that you’ve told me so far would be the first steps to avoid the tracheostomy.
Vanessa: Yeah. Do you think that just stopping it, say it’s running and they just stopped it. Is there a certain amount of time or they should just get rid of it altogether.
Patrik: It depends how much, it depends how much she’s on and it depends, you were mentioning earlier that she might have gotten some Morphine before she got intubated. It really depends on what her tolerance towards that is. If I had some numbers. If somebody would tell me, “Oh yeah.”
Vanessa: I have them.
Patrik: Right. Right. You know that would give me an indication of, “Okay, how much is she on now. How long has she had it for? Was she on Morphine or anything else like Oxycodone or Oxycontin before intubation?” That would give me an indication, “Okay, how quickly can they wean it and what else do they need to give to avoid the Fentanyl if she’s in pain,” for example.
Vanessa: Yeah. They have actually, it was at 250 micrograms per hour I think and then now they went down to 150 and now when I came back today it’s at 50. It’s the lowest I’ve seen it but they’ve also added, they added Midazolam.
Patrik: Midazolam. Not a good sign. Not a good sign. Midazolam is long acting. It’s a long acting sedative. Not good.
Vanessa: I’m not really sure how they’re making the decisions on these.
Patrik: I don’t know why they’re giving Midazolam. There’s two sedatives. Again, when I send you an article you will see that in the article. There’s two main sedatives. One is Midazolam which is a long acting sedative and the other one is Propofol, which is a short acting sedative.
Vanessa: She was on that first.
Patrik: Right. If you want to get somebody off the ventilator you use Propofol, not Midazolam. Propofol is short acting.
Vanessa: I kind of feel like, yeah, she was on Propofol. They cut it down and they stopped it. Now I feel like, when I came back today it’s almost like everything’s full force again. Almost like they had already set her up to fail almost.
Patrik: Absolutely. That’s what it sounds like to me. Especially with the Midazolam. But again, there may be other reasons why they are using Midazolam. Those would be the type of questions that I will ask.
Vanessa: Yeah. Okay. All right.
Patrik: Okay Vanessa!
Vanessa: Thank you.
Patrik: You’re most welcome. I’ll send you that email in a moment and you’ll get back to me when you want me to talk to the doctors.
Vanessa: Yes, probably tomorrow, I will call you! Thank you.
Patrik: You’re most welcome. Take care.
Vanessa: You too.
Patrik: Bye bye.
How can you become the best advocate for your critically ill loved one, make informed decisions, get peace of mind, control, power and influence quickly, whilst your loved one is critically ill in Intensive Care?
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- How to ask the doctors and the nurses the right questions
- Discover the many competing interests in Intensive Care and how your critically ill loved one’s treatment may depend on those competing interests
- How to eliminate fear, frustration, stress, struggle and vulnerability even if your loved one is dying
- 5 mind blowing tips& strategies helping you to get on the right path to making informed decisions, get PEACE OF MIND, control, power and influence in your situation
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- How to stop being intimidated by the Intensive Care team and how you will be seen as equals
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- How you need to manage doctors and nurses in Intensive Care (it’s not what you think)
Thank you for tuning into this week’s YOUR QUESTIONS ANSWERED episode and I’ll see you again in another update next week!
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This is Patrik Hutzel from INTENSIVECAREHOTLINE.COM and I’ll see you again next week with another update!
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