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!
Ther is another episode of “YOUR QUESTIONS ANSWERED“ and in last week’s episode I answered another question from our readers and the question was
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, Albert, as part of my 1:1 consulting and advocacy. Albert’s sister is in ICU, and he is asking why the doctors are discussing direct nursing facility transfer from ICU.
Is it Safe to Transfer My Sister to a Nursing Facility Directly from ICU? Help!
“You can also check out previous 1:1 consulting and advocacy sessions with me and Albert here.”
Albert: Yes. Last week. She was off last week sometimes for three hours, sometimes for five-
Albert: Seven hours before, because of the fluid. When the fluids come back because of her heart. And then they will take the fluid and they have to take chest X-ray. And then after they took the x-ray, they took off the fluid and then she will be fine. Otherwise, when the fluid comes, it’s hard.
Patrik: I see. I see. So, with the-
Val: One thing I wanted to mention, we didn’t mention. So, one of the things, because of her lungs, she does have fluid buildups. Okay? So, a couple times they have to use a needle to drain out the fluid. So, now what she has is, she has chest tube on the side. That’s how they’re draining the fluid out. But now, lately the fluid has been lower and lower.
Patrik: Okay. Why do you think that is? Why do you think the fluids are getting less?
Val: From my understanding, could be couple reasons like these little improvements from her lung. And the other one is, I remember before they put that on, sometimes when you put these PleurX tube in, sometimes they stick and they hold back the fluid. That’s my understanding.
Patrik: Yeah. And are her kidneys working? And, I’ll tell you in a minute why I’m asking that question.
Val: Okay. So, her kidneys are working right now. At one point, though, because for whatever reason she did have dialysis for two weeks. But never since, though. That was back, I believe, in October.
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Patrik: Okay. Good. That’s fine. I mean, we were probably just scratching the surface here, but just with what you’re sharing with me, I would argue she’s definitely not a candidate to go anywhere else. Because if she was to go to rehab or to LTAC, she would bounce back probably in no time. So, what I would like to focus on next, unless you think there’s anything else you need to share that is of importance, is how can she come off the ventilator? That’s number 1. Number 2, with her heart, is there a cardiologist involved?
Lorie: Yes, there is. They do have cardiologists visiting all the time there. And I just wanted to mention one thing is, what they’re trying to do right now, is force us, not even to rehab. It’s more into a nursing home, where they don’t have any capabilities to handle her, let alone just another hospital. Right? So, that’s what is having huge concerns for us.
Patrik: Yeah. Absolutely. Are you getting pressure from the hospital? Or is the health insurance putting pressure on you, saying her time is up in ICU? Is that part of the discussion?
Val: Well, it’s not.
Lorie: It’s more the hospital trying to say, “Okay, she’s fine, she has to go to rehab,” and so on. And, of course, as a family we want her to do better. We want her to do well.
Patrik: Of course.
Lorie: But, realistically, right? And for your question about the cardiologist, many times when we have meetings, when we try to ask about the heart situation, they say, “We got to deal with the lung first.”
Patrik: Yeah. It’s a chicken-or-egg question and I think I can explain that to you. She had a heart attack, which means her heart muscle has sustained a weakness. Okay? With that weakness, it’s more difficult for the heart to pump blood around the lungs, which means some of the fluid buildup in the lungs is a result of the heart being weakened. Okay? So, that’s what I’m saying, it’s a chicken or egg. Yes, the lungs would be damaged too by the pneumonia. So, if they can’t control the pneumonia, yes, that’s causing trouble too. But, by having sustained a heart attack that’s pushing more fluids onto the lungs, which makes things more difficult for her to be weaned off the ventilator, most likely. Now, have you heard of the term “ejection fraction”?
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Val: Say that again.
Patrik: Ejection fraction.
Val: Yes.
Patrik: Have you heard of that term?
Val: No, I haven’t myself.
Patrik: No. That’s okay. So, ejection fraction is quite an important term in this situation, I believe. So, when someone sustained a heart attack and they have a weakened heart muscle, the contractility, the pump function of the heart, which is also called contractility, is diminished. Okay? And the doctors would’ve done an ultrasound of the heart by now, I’m very certain about that. They would’ve done an ultrasound of the heart and they would’ve determined the ejection fraction.
Why is this important? An ejection fraction ideally should be above 60%, roughly speaking. After a heart attack, the ejection fraction goes down from 90% to, depending on the damage of the heart muscle, goes down significantly. If the ejection fraction is less than 60%, I would argue a cardiologist needs to have a very good look at what is the treatment of that diminished ejection fraction. A diminished ejection fraction often keeps patients in ICU. It keeps pushing fluids onto the lungs, if a fluid balance is not managed correctly. What do I mean by that? Anyone with a weakened heart muscle, you need to manage fluid balance quite closely. What that means is, you need to look every 24-hour period, how much fluids are going in, how many fluids are going out, because if you’ve got two liters more going in every day than going out, you’re pushing fluids into the lungs.
Val: Oh, I think I know what you’re talking about. And this was a while back, though, when we had a meeting with the doctors, with the ejection fraction. They were talking about, her was around 30.
Patrik: No surprises. No surprises.
Val: Yeah.
Patrik: So how long ago was that?
Val: That was about a month ago.
Patrik: Month ago. Did they tell you at the time how they would treat that?
Albert: Her heart?
Patrik: Yes.
Val: Yeah. They are giving her medication to control. That’s all I know. Yes.
Patrik: Okay.
Albert: Sorry. And then, they say they cannot treat her now, because of the lungs and they can’t do any kind of surgery. That’s what they say. And from 60, Patrik, it goes like, how much they say? 25, about her heart?
Val: They said 25 to 30. Around there. That’s what it was.
Albert: Yeah.
Patrik: Right. No surprises. So, okay. Look, a low ejection fraction doesn’t necessarily get fixed with surgery. It may get fixed with surgery, but after a heart attack you often need to do surgery within hours or days to fix it. I think that time has almost passed. Right? So now, their option to, “fix or treat the heart” is with medication. So, she might be on medication, such as dobutamine, dopamine or milrinone. If she’s on that, she would definitely not be a candidate for rehab. There may be other medications she’s on for her heart failure. Right? So, the medications that I just shared would be intravenous medications. But she might be on other medications for heart failure via tablets, such as maybe she’s on digoxin, she might be on amiodarone, she might be on Verapamil. That’s why it would be important to find out a bit more on what they’re currently doing.
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Albert: I can send you the medication too.
Patrik: That would be very, very helpful.
Albert: Yeah.
Patrik: The other reason I asked about the kidneys earlier was, if her gut fluid buildup on the lungs and her kidneys wouldn’t be working, that would contribute to fluid buildup. She may be on what’s called diuretics, such as Lasix. Have you heard of Lasix?
Albert: Yes.
Patrik: Right. She’s probably having some of it. I’m sure she is.
Val: She is on diuretic.
Patrik: She’s on diuretics. But then you’ve got other issues. If someone is on diuretics, you’ve got other issues, such as potassium levels might go down. If potassium levels go down and they’re not followed up, your heart might go into an irregular heart rhythm. Now, they might have all of that under control, I couldn’t tell you. But the challenge is, the minute she leaves ICU, losing control of that is very easy.
Val: Mm-hmm. Mm-hmm.
Patrik: So, I would argue with the limited information that you’re giving me, that the heart almost needs to be taken care of first, before the lungs, unless she still has a pneumonia. Does she still have a pneumonia?
Albert: No. She doesn’t have a pneumonia. But you ask a question earlier and then I just want to answer it, before I forget, because you ask, is there a problem with a payment for insurance? She has a standard. Everything’s covered. She has no problem.
Patrik: That’s good. And as long as you haven’t heard from the health insurance putting pressure on you, I wouldn’t worry about it. But, sometimes in other cases, the health insurance might call you and might say, “Hey, your sister only has two weeks left in ICU. She needs to move on.” If that’s not the case, I wouldn’t worry about that.
Albert: Yeah. And I just want to know what we do from this step, from the next step is they told us to go. And then can we just go to hire a lawyer and fight, and then to keep her over there?
Patrik: Yep. Yeah. You can do that, but I don’t necessarily see the need for that as yet.
Albert: Okay.
Patrik: What I would do as a next step, I would be very happy … If you give me more information I can draft a letter or an email and just point out the clinical argument. Okay?
Albert: Okay.
Patrik: Point out the clinical argument. That’s number 1. Number 2, the hospitals have discharge policies. You got to keep in mind, everything in a hospital comes with a policy. Everything. Mopping the floor, cleaning the window, everything has a policy in a hospital. Okay? And that includes discharging a patient, it has also a policy. Most of those policies are clearly stating that you need to give consent when it comes to, or your sister if she’s in a position to, to go somewhere else. Now, the exception to that is, obviously, if she was well enough, if she was off the ventilator, and if she would be walking, she could be discharged home. Right? And it would be very difficult for you to challenge that. But I think with everything that you’ve shared to this point, I do believe there’s a clinical argument.
Now, by the sounds of things, she’s also representing what I refer to as their worst-case scenario. What is their worst-case scenario? Their worst-case scenario is to have a patient in ICU indefinitely with an uncertain outcome. That’s their worst-case scenario. And it sounds to me like your sister fits that scenario for them. Right? For them, it’s well, given she’s been here for six months already, we don’t have space for another six months, let’s move her on.
Albert: Yeah. That’s what it is.
Patrik: That’s what it is.
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Albert: And then one time, you know what they say, Patrik? And then they say they can go to the court and take away our … Yeah.
Patrik: Okay. I’m glad you mentioned it. Are you the power of attorney?
Albert: I did the power of attorney. We went to the bank last time. And then my brother-in-law, he has care of proxy, but we wrote our name and then I went to the bank and then I did the power of attorney. But can I bring that one to them?
Patrik: Yeah, so, if she needs surgery, let’s just make up a scenario, let’s just say she needs surgery and she can’t give consent herself. Are you the one giving consent?
Albert: Yes. Yeah.
Patrik: Okay.
The 1:1 consulting session will continue in next week’s episode.
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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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