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 one of my clients and the question in last week’s episode was
You can check out last week’s question by clicking on the link here.
Francis has her diabetic father transferred in the Intensive Care due to delirium caused by alcohol withdrawal. In their stay in the ICU, her father had been given a lot of sedation and he was in a prolonged induced coma. Now, they are planning to do a tracheostomy for her father.
I think the ICU is giving too many sedatives that is preventing my father from waking up. Will he need a tracheostomy?
Patrik: Oh hi, is that Francis?
Francis: It is.
Patrik: Hi Francis, it’s Patrik speaking from Intensive Care Hotline. How are you?
Francis: I’m hanging in there. How are you?
Patrik: I’m really good, thank you. Is this a good time to call you?
Francis: Yes. Yeah.
Patrik: Ok well, thanks, thanks for your voice message, and I also received your email. Thank you for being a client, I highly appreciate it.
Francis: Yeah absolutely, thanks for helping me. I have a pretty good grasp on everything that’s transpired, so did you get a chance to look at that video.
Patrik: I did have a look at the video. I did have a look at the video. So…
Francis: Okay, I mean, yeah go ahead.
Patrik: No, no, you tell me, you tell me first, you tell me first.
Francis: I mean I, one thing I may have left out of the email was that, you know, he’s diabetic, as my uncle was saying he was reading something in one of his Mayo books about how that can contribute to a coma. But when he was originally admitted into the first hospital they were all focused on alcohol withdrawals. They gave him, I think, quite a lot of Ativan, propofol, and then also fentanyl. That has me a little concerned, but I’m thinking that he lost his oxygen because that would have shown up on the MRI. So now, here we are, six days or so, five, six days with midazolam and propofol shut off, he’s still getting fentanyl because they’re perceiving that he’s still experiencing some pain. And originally, it was like a little more flashing leg movements and arm movements and then now, it’s become more pronounced to what I showed you in that video. And that facial movement that you see is just every 20 seconds. That’s just, I mean, to me that looks like someone dying in a vegetative state, and…
Patrik: Hmm… just, no to me, he doesn’t look like he’s dying. What I can see in the video really is, you know, I mean, the situation like that I’ve seen probably hundreds of times, right? When patients are dying, they often don’t move it all.
Francis: Mm-hmm (affirming).
Patrik: Right? It’s a…
Francis: But when I look at the symptoms of a vegetative state, it’s exactly the same as he’s exhibiting there’s peeling in his eyes, he has that movement he has all of that.
Patrik: Mm-hmm… (affirming) There is certainly some of that, but you see, one of the challenges in intensive care is that people often mix up the symptoms between a vegetative state and coming out of an induced coma. What you see, there’s definitely overlaps between both.
Francis: Mm-hmm (affirmative)
Francis: Mm-hmm (affirmative)
Patrik: But it’s not, it’s not the same. What families haven’t seen in intensive care is people coming out of a coma, I mean, you wouldn’t have seen this sort of situation before would you?
Patrik: Right, right and that’s the challenge, you know, just by looking at the video it’s, it’s a patient coming out of a coma, right. And it’s your dad…
Find more information about induced coma:
Francis: That’s what your opinion is? Yeah.
Patrik: Absolutely, absolutely that is what my opinion is. And so, you know…
Francis: Well, the doctors are acting like they’re really puzzled by why he’s not awake, because they say everything underlying is good to go except his kidneys are in full failure, but they’re dealing with that with dialysis, I’m not worried about that. But so they’re still, they seem, they’re like, “We’re puzzled.” So obviously they’re getting neuro-consults set. But, I mean, is there any chance that there could be some kind of brain damage that’s not showing up on an MRI, or a CAT scan, or an EEG?
Patrik: How long ago was the MRI, again, or the CAT scan? How long ago?
Francis: They did them all in the last two days.
Patrik: Yeah, okay. And obviously, as you said in the email, the results are not, basically it’s negative. It’s not showing anything.
Francis: Right. Yes.
Patrik: Yeah, okay. So then, so they’ve ruled that out the answer is probably no. You know, if he’s still not waking up in three days or in four days, they probably will have to do another CAT scan or MRI. They should definitely look at a neuro-consult. Now, patients, you see one of the challenges in intensive care is everybody wants patients to wake up very quickly. Now the reality is patients will wake up in their own time, that’s number one. Number two, the withdrawal from alcohol and probably then using a lot of sedation initially will not help the situation, right? So he will have more sedation onboard still, especially if they use the Midazolam or Versed, compared to propofol, and I need to explain that distinction because it’s very important. So…
Francis: Yes, I heard that in your video, and I understand it.
Patrik: He will take a lot more time to metabolize and also get rid of those drugs in his body system, right? Because of the liver and the kidneys not working 100%. So…
Francis: Mm-hmm (affirming)
Patrik: Right, I know this is not very nice to watch for you. I mean, this is just a nightmare probably that never seem to end for you, however you need to give it more time, and they need to give them more time, as well. How old is your dad?
Francis: He’s 69. Was fully healthy before this, I’ve never even seen him hospitalized, except for diabetes.
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Patrik: Right, right. And when you’re saying he’s a drinker, how heavy was that drinking? Like, sort of, because that can play a role as well, and I’ll tell you why.
Francis: Yeah, we think it was pretty heavy for many, many years. He was a very functioning alcoholic.
Francis: A smart individual, a business man, successful, but we do think he was drinking morning and evening a little bit. For a good bit.
Patrik: Okay. The reason I’m…
Francis: Completely functioning.
Francis: You never saw him stumbling on the floor or anything like that.
Patrik: Yeah, yeah. Mm-hmm (affirming) So, the reason I bring that up is when patients come out of an induced coma, they can be delirious, okay, because of the side, because of the induced coma, because the side effects of the drugs. It’s pretty much like somebody knocks you out for days on end and then you’re waking up. So that’s one side of the coin, that patients can be delirious and often are delirious when they come out of an induced coma.
Now for somebody going through withdrawal, potentially, on different alcohol and drugs, that delirium can be exacerbated.
Francis: Even though we’re a couple weeks out from that, 14 days at least?
Patrik: Oh yeah, oh definitely, definitely.
Patrik: And the reason, again, waking up from an induced coma after critical illness is not straightforward. So, it’s not straightforward to simply, people are, besides the side effects of the medication people are very sick. So the combination of…
Patrik: The combination of the critical illness and the induced coma is huge. It has a huge impact on the body, right? Waking up after an induced coma is not like switching on a light with a switch, it’s like switching on a light with a dimmer.
Francis: Right. And sometimes it flickers maybe even and I mean that’s what we’re… So that video of his movement is every 15 seconds, that’s not concerning to you something? Is that something that you’ve seen and then they just pop up one day?
Patrik: Oh absolutely, absolutely yeah, he will wake up. I have no concerns that he won’t wake up. He will wake up in his own time, and it could be another two weeks, he just needs to be given time. But it’s a process.
Francis: Okay. Really?
Patrik: It’s a process, it’s not an event.
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Patrik: The other thing that…
Francis: Okay, wow.
Patrik: The other thing that’s important to know is you know your dad as a functioning individual, okay and now he’s in this situation and you simply can’t comprehend, and that’s only fair enough. So for me as an intensive care professional, I see, I look at this video and I think okay well you know that’s just the situation your dad is in, and he’s just trying to wake up, that’s the way I look at your dad right after having seen patients like this hundreds if not thousands of times. So our view is very different, if that makes sense, and that’s important to understand. You are looking at your dad…
Francis: I mean I wonder why the doctors, why do you think the doctors here are not, I’m mean they’re just saying oh… it’s kind of puzzling. We expected him to be woken up by now. I mean, I know the very doctor…
Patrik: Yeah look, the challenge with the doctors well is they want him to wake up too, of course. The other challenge with the doctor is, the doctors are looking after, I don’t know 20 patients. How big is that ICU, do you know?
Francis: It’s big, yeah.
Patrik: 20 plus beds?
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Francis: Mm-hmm (affirming) Yeah.
Patrik: Yeah? Okay, so you’ve got the doctors in there. They are looking after 20 plus patients, right? So they have a high workload, and they basically do their rounds, they go from bed to bed, they don’t spend more than probably 20, 30 minutes with one patient, right? As a nurse, and I’m an intensive care nurse, I’m not a doctor. As a nurse, you spend your whole shift with a patient.
Francis: Right, that’s right. Mm-hmm (affirming)
Patrik: You know, you see the trajectory of a patient, if you’re working three, four, five days in a row, you often look after the same patient. You have seen that, I have seen that, right? Whereas, for the doctor, he’s, I’m not saying he’s just a number for the numbers, but he’s more of a number for a doctor because he has a higher workload or a different workload, let’s put it that way, compared to a bedside nurse.
Francis: Mm-hmm (affirming)
Francis: Yeah we had a really sweet nurse who made us feel comfortable, and then she left to go on vacation for a little bit, so it’s has been a little difficult. But I mean, so you I mean you… I guess what keep getting me stumped is I keep looking at these symptoms of vegetative states, the eye-watering, these movements and everything, and I’m thinking that they meet the criteria, but you’re saying right he still going to wake up?
Patrik: Absolutely. And if for whatever reason he’s not going…
Francis: Because the…
Patrik: If for whatever reason he’s not going to wake up right there is something else going on that they haven’t found out, but if the CT of the brain is negative, and if the MRI of the brain is negative, you know, I am very positive he will wake up. I don’t know, how long have you been looking at our website, if I may ask? Days or weeks or just a couple of days?
Francis: Well, just a day or so.
Patrik: Okay, yeah. Your biggest asset when you have a loved one in intensive care is patience, being patient. That’s one of your, that’s one of the biggest, that’s the biggest focus you can have. It’s a process, it’s not an event.
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Francis: Let me ask you this, we were in, and just let me know if it comes time for…
Patrik: Yeah, yeah that’s fine. I’ll tell you, I’ll tell you.
Francis: If it comes time. We were at a hospital by our home when a hurricane came so we got evacuated…
Patrik: Right, right, mm-hmm (affirming)
Francis: Do you think it would be best to keep him where he is now, which we think is actually a much better hospital, until he wakes up, is there really any value in moving him anywhere else?
Patrik: Right, so how far away from, so basically your whole your dad got evacuated because of the hurricane, and how far away from home is that?
Francis: It’s about 90 miles.
Patrik: 90 miles. So basically, you are traveling 90 miles every day to the hospital?
Francis: We’ve been living in a hotel here, actually.
Patrik: Right, okay. Have they given you the option of going back?
Francis: Well, they gave us the option of going back to the original hospital, but the original hospital is really a regional hospital. This is a, this is University of Florida Teaching Hospital with all of the staff that’s here. We have a Mayo Clinic in Jacksonville where we live, so we thought about that as a possible option, but maybe just giving him a little more time here because, you know like you said to wake up, to fully stabilize.
Patrik: Right. Yeah, yeah yeah. Yeah, look I have personally always worked in major metropolitan ICUs, so I can’t really speak about more regional ICUs, but what I do know obviously having worked in many metropolitan ICUS, most sick patients come from regional ICUs, right, because they often don’t have the skills, the experience to deal with really sick patients. So, you know, I know it’s probably very inconvenient to…
Francis: Yeah, we just want what’s best for him, that’s all we care about.
Patrik: Of course, of course, right.
Francis: I don’t think leaving him and then in an ambulance with…
Patrik: How many days has he been in this ICU, now?
Francis: He has been in this, what’s today? Friday? He got here last Friday. They have gotten all the underlying issues under control and everything like that it’s just waiting to function now that is a concern.
Patrik: Yeah, yeah. No, absolutely, absolutely. Look I, my experience is more the metropolitan ICUs, but it’s, yeah I would say they would’ve seen this more and more often. Now just quickly asking about the doctors as well, do you think you’re dealing with experienced doctors or mainly dealing with junior doctors? Especially if it’s a teaching hospital, there would be many junior doctors there.
Francis: I’ve been dealing with the attendings. I’ve been dealing with the attending physicians.
Patrik: Right, they would, they would probably be fairly young?
Francis: No, no, no, the attendings are the most senior.
Patrik: Okay, okay.
Francis: Then they have fellows, and then residents, and interns, so we have been getting the attention of the most senior doctor.
Patrik: Yeah, yeah. But I can tell you this is not the vegetative state. He’s opening his eyes, and he’s yawning, that’s what it looks like in the video anyway. And there is nothing…
Francis: Do you think that’s pain from the respirator? Is it pain or…
Patrik: Yeah, look. The breathing tube (endotracheal tube) would be uncomfortable. There’s no doubt, no. But what I like about the video is his opening eyes, right, that to me is a good sign. That to me as a good sign.
Patrik: So the other thing that would probably be important to know, so what is he getting for sedation at the moment nothing at all? Or…
Francis: Nothing, he’s just getting the fentanyl to manage the pain.
Patrik: Do you know how much fentanyl he’s getting?
Francis: I want to say like 175 or something.
Patrik: An hour?
Francis: I don’t know. I don’t know.
Patrik: Okay look, I would, if they can stay away from the fentanyl I would suggest to do that because fentanyl just like, fentanyl just like morphine and Midazolam or the Versed, making people very sleepy, okay that’s number one. The other thing is, and that would be another conversation to have, they obviously do want to get him off the ventilator at some point, okay, and the fentanyl, right, the fentanyl, the main side effect of the fentanyl is respiratory depression do you know what that means?
Francis: Mm-hmm (affirming). Well, they said that they won’t take out the breathing tube until he wakes up because of orientation issues.
Francis: He’s breathing up over the breathing tube. He’s breathing on his own, but they won’t remove it because of orientation issues, so we’re going to have to put on tracheostomy him in a couple days because it’s just been too long.
Patrik: Okay, okay I get that, I get that, and he may need a tracheostomy, but there’s two things. Number one, I do believe they need to stop the fentanyl. Fentanyl, the main side effect of fentanyl is respiratory depression. Respiratory depression basically means it’s inhibiting any spontaneous breathing efforts, right.
Francis: Mm-hmm (affirming). Right.
Patrik: Your dad, to me, in the video looks comfortable, right. The breathing tube is irritating, but he looks comfortable in the in the video, okay. That’s a sign it’s probably about time to stop the fentanyl and see what’s happening, right. And the challenge is, especially with kidney and liver failure, if they do stop the fentanyl, he still probably won’t wake up straightaway. Also, if he’s had fentanyl now for many weeks, again it takes time for the body to process.
Patrik: Okay, so especially if he’s not breathing above the ventilator, I do believe they need to stop the fentanyl rather sooner than later. The other thing that I would be curious to know is, they’ve stopped the propofol, they stop the Midazolam, or the Versed, do you know whether they’re getting anything like haloperidol, like quetiapine, like diazepam, do you know whether they’re getting any of that?
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Francis: They’re not here. He had that initially, he had Ativan at the first place to, kind of, treat what they thought was the alcohol withdrawal symptoms, but not since he’s been here.
Patrik: Okay, are you sure?
Patrik: Okay, okay, right. Look, in terms of tracheostomy, what I’ll do is, that would be a whole another conversation to have. What I can do as a starting point is, I can send you some links to articles and videos, when to do a tracheostomy, okay, if he’s not waking up then, which there’s a good chance he will need a tracheostomy, but you still want to do your research. I sent you some articles about that, you can have a look at what the next ups are. Obviously we can talk about it as well, if you like in our next consulting and advocacy session tomorrow.
Patrik: And also, with the 7-day package, you can use that at your own pace. It doesn’t have to be seven consecutive days you can use that.
Francis: Seven consecutive days, okay.
Patrik: No, no. No, no it doesn’t, it doesn’t. You can use it at your own pace.
Francis: Right. Okay that makes sense.
Patrik: Right, you use it when needed.
Francis: Okay. Okay. Yeah let me, I appreciate your service so much, My step-mom was listening for minute, but then she had to walk back because I think she wants to meet with the neurologist. So I will find out the fentanyl amount and start suggesting that they leave him off of it, and then I will get you back probably with you to at least talk about the tracheostomy and everything
Francis: Okay, okay. Well, I’ll just call back to that number, and if I need to leave a message again I will and we could set up another 60 minutes tomorrow.
Francis: I’ll go ahead and start looking on your website more. I was only looking from my cell phone, but I’ll get on my computer this evening and look.
Patrik: And look to finish off, all of your questions are answered on our website, you know, if you have the time to do the research, there’s hundreds, hundreds of articles, right. Talking to me is just a shortcut.
Francis: Okay, yeah exactly, okay.
Patrik: But for people who have the time you just research our website there’s hundreds of questions answered. It’s all there, and if you want to talk to me that’s there as well, of course.
Francis: Okay, okay, great. Okay, thank you so much, and I will definitely be in touch. I appreciate this.
Patrik: You’re very welcome. You’re very welcome. All the best for now, Francis.
Francis: OK, thank you bye-bye.
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- How to ask the doctors and the nurses the right questions
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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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