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
You can check out last week’s question by clicking on the link here.
In this episode of “YOUR QUESTIONS ANSWERED” I want to answer a question from one of my clients Megan, as part of my 1:1 consulting and advocacy service! Megan’s brother is not waking up in ICU and Megan is asking about their plan of getting her brother out of the induced coma.
My Brother is Not Waking Up in ICU. So What’s their Plan in Getting Him Out of the Induced Coma?
“You can also check out previous 1:1 consulting and advocacy sessions with me and Megan here.”
Patrik: Okay, just give me a sec. I’m just on their site now. And Critical Care is not coming up under C. Let me have a look under I, it should be under me under Intensive Care or ICU. So, just give me a… No, whoa. Oh, they’re hiding. So, nothing under C and nothing under I, however-
Megan: Nice.
Patrik: However, sometimes ICUs have standalone websites, sometimes. What I’ll do is I’ll just… Just let me have a look at whether there’s something.
Megan: Okay.
Patrik: Oh yeah. It comes up. It comes up. Nope. No, there is a website-
Megan: Alright, Patrik.
Patrik: Pardon?
Megan: I’m here.
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Patrik: Can you hear-
Megan: I can hear you now.
Patrik: Okay. Sorry, sorry. So, they have a website I found… Oh, hang on. I found the website and…
Megan: So, the name of the director sounds like it could be the woman who’s on today.
Patrik: Right.
Megan: Sounds similar.
Patrik: I’ll send you the link. I’ll send you the link.
Megan: Lovely.
Patrik: It says, “Meet the team,” but then there are only two names.
Megan: Ah. That’s the team that you meet, the two of them. But we don’t know about…
Patrik: That’s right.
Megan: That’s all they’re admitting to.
Patrik: That’s right.
Megan: They’re keeping them under wraps.
Patrik: That’s exactly right.
Megan: Oh dear.
Patrik: So-
Megan: Okay. Oh Patrik, what a carry on, eh? You think they’d be more transparent.
Patrik: Absolutely. Absolutely. It makes you wonder what they’ve got to hide, you know?
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Megan: It does, really.
Megan: Because even with my mom, I’m sure I was able to even find the email of the nice professor and email him personally, you know? It was much more open. It was just professional in the ICUs charming with my mother. A completely different culture to this. This is really, really a hostile environment. Not the nurses, as I’ve said 100 times, and they’re very sweet. But the doctors are quite something else.
Patrik: That’s really bad. But at least you know what you’re dealing with and you know what you need to pay attention to.
Megan: Yes. Yes.
Patrik: And-
Megan: So, I’ll go in today and ask them about the sedation to be absolutely sure they’re not giving him anything at night. I could say, “I’ve been thinking that you’re giving him propofol. Are you sure, because this would account for all of this?”
Patrik: Yep. Yeah. You can ask. You can ask. And you’ll gauge by their reaction whether they’re telling you the truth or not. I mean, I would be really horrified if they were lying. I mean, if you ask them, “Hey, are you giving any sedation?” And they say, “No,” but they actually do it. I mean, that would be horrible.
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Patrik: Do you think that could happen in there?
Megan: Yes I do.
Patrik: Right. Okay.
Megan: I think it’s possible.
Megan: But Patrik, they see me. They see the sort of person I am.
Patrik: Sure. Yeah, but there’s nothing wrong with that. You are what you are, I mean… There’s nothing wrong with it.
Megan: Hello? Patrik?
Patrik: Hi Megan. It’s Patrik here from Intensive Care Hotline. Good evening. How are you?
Megan: I’m not sure how should I be feeling right now. My brother is intubated now and they have not informed or notified me of this thing they did to him, what happened and what could be the reason for this?
Patrik: That should be standard practice to notify the next of kin and the medical power of attorney.
Megan: But because I noticed that my brother had a lot of sputum recently. Do you think that can be a reason for this?
Patrik: With a lot of sputum, that could’ve been one of the reasons why they intubated him. That would be my first guess.
Megan: They’ve also got his sputum for investigation.
Patrik: Now, when you’re saying they’ve got some sputum, do you know whether they’ve done a bronchoscopy? You know what I mean by that? What a bronchoscopy basically means is once he’s got the tube in his throat and he’s on the ventilator, they put down a video camera, through the tube, to have a look in his lung. Do you know whether they’ve done that?
Megan: They have not told me anything about it.
Patrik: I’ll make a note because I will send you an email when we come off this call, just with anything that we think needs to be addressed. The reason I’m bringing it up is when patients get tubed, especially when they have pneumonia and they’re trying to get up sputum from a bronchoscopy, I’d say for 40% out of patients has a bronchoscopy at the same time. It’s possible. And also, it’s great that they got sputum, but again, there’s a high chance that you don’t get any sputum straight away; however, you always get sputum in a bronchoscopy, always.
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Megan: Alright. Is it going to be beneficial for my brother?
Patrik: Look, it depends. It’s beneficial for some patients, but again, it’s a procedure. It’s a procedure, it’s an invasive procedure. He needs more anesthetics for it. As I said, some… There are downsides to it, but then, at the same time, there is often a chance that they can clear some of the crap out on the lungs. What else then? So you had a chat through the doctor, but you think that was a junior doctor. Is that what you think?
Megan: Yes I did but unfortunately it didn’t turn out to be the way I was expecting. He was a junior doctor, seemed to be mean.
Patrik: So you’ve spoken to the doctor. Yeah, right. Do you know how many beds are in this unit? Is it big?
Megan: 12-bedded unit
Patrik: That’s fairly average, yeah. Fairly average. Okay. Because that’s interesting. Normally, what happens with the consultants, they usually change once a week, but…
Megan: I felt the doctors there are being unsympathetic.
Patrik: So when you saying he was unsympathetic, do you feel like that’s across the board there, including the nursing staff?
Megan: Not all of them but most of the doctors seem to be unpleasant.
Patrik: Right. Okay. I’ve seen it millions of times. Not another one. And you see, the reason I’m asking all of these questions, how big is this unit, a 12-bedded unit, from my experience, is a smallish unit. And the smaller the unit, generally speaking, the nicer; generally speaking, right? The bigger, the less personalized. I’m a bit disappointed to hear that even in that smaller unit that your first sort of experience is their not very nice.
Megan: And I don’t even get the chance of talking to the consultant and explaining the health status of my brother.
Patrik: You see, here is where it gets interesting. This is often the approach that the doctor’s take. They send the junior staff, they tell them what to say. The reality is that if things were to take a turn to the worse even, what they will do next is they will then ask for a meeting with you and then they will break the bad news. All of a sudden, there’s this hurry because they want to push for the withdrawal of treatment and all that and then they’re in a hurry.
Megan: Yes. I feel they are up to it.
Patrik: So because you’ve seen this before, my advice is always… Let’s just take the worst-case scenario. You get a phone call and say, “Look, you’ve got to come in. We got to meet, blah, blah, blah.” My advice in a situation like that is nine times out of 10, they only want to meet with you to break bad news, right? And if they want to meet with you, don’t go there until you have the meeting agenda in writing. Right? Because what they do, nine times out of 10 is they ask for a meeting, families are falling all over themselves to get there as quickly as possible and they have no idea what’s coming. And they know what to say, they know how to say, they know when to say and they know what not to say to get what they want. They’re doing it every day, all the time, right? Every day.
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Megan: Yes I think they are already used to it.
Patrik: And that’s why I just say if that situation was to occur, don’t go there. Just get the meeting agenda in writing and then you can see they’re going there or not, right? This is always a tricky question. Obviously, they’ve intubated your brother obviously, without your consent, right? Do you know whether they had his consent? Do you know that?
Megan: They might. I’m not sure. But if they had, they should have put that in writing.
Patrik: Right. Yes, true. Okay. So can they do something with your brother… Again, let’s just look at the worst-case scenario for a moment. The worst-case scenario is that they call you for a meeting, you don’t go there because you want the meeting agenda first and then they would withdraw treatment, your brother might pass away. That would be the worst-case scenario.
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Megan: Right.
Patrik: Now, you look at cases like Alfie Evans. They did withdraw treatment, right? But after a lot of back and forth, obviously, right? So on paper, legally, yes, they can withdraw treatment against family or next of kin or medical power of attorney consent, but as we know from experience, it’s not a quick process if family’s object. Right? I’ll tell you, I’ve worked with a client in New Zealand just in the last few weeks, where we bought a lot of time. The patient ultimately passed away, but we bought a lot of time to make sure there was no stone left unturned, right? But your positioning for whatever’s coming from them is going to be very important. What I always say is you can’t control what they do, but you are 100% in control of how you react, 100%.
Megan: Yes I think it is very important that I should learn how to be in control of my responses in a situation like that.
Patrik: And 99% in life, you can’t control, but focus on the 1% you can control and you’re way more powerful than you think you are. And no one can force you to attend a meeting. No one can force you. Just because they want to… But you know what to do if that situation comes up. Let’s not dwell on it because I think it’s going to be way more important that we look at, “Okay, what do they need to do to get your brother out of there alive?”
Megan: Yeah. That is the thing that they should be working on, on how to get my brother to recover from his current condition and live.
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Patrik: Absolutely. Correct. So what are they predicting for the next 24, 48, potentially, 72 hours?
Megan: They have not told much but currently, they put him on antibiotics, on Erythromycin and Meropenem. But the nurse is telling as well that his infection marker decreased.
Patrik: Yep. Erythromycin, yep. Meropenem. Okay. So just one comment there with the markers down, that the nurse is probably referring to the white cell count, which is the infection marker in the blood. So that’s a good sign. That could be a sign that the antibodies are working already. Do you know whether they’re giving steroids?
Megan: Yeah I think so but I’m not sure. Is it IV meds or through a feeding tube?
Patrik: Yep. Okay. If he was to have steroids, I’m 99% certain that they would give it IV, but you never know. Well, he might get prednisolone or through the feeding tube, but most of the time, in a situation like that, if they do give steroids, it’s most of the time, it’s IV. But that’s okay.
Megan: I can see names of meds here in the pump, wait a sec. He’s on fentanyl, noradrenaline, propofol, IV fluid and that’s it.
Patrik: Okay. Okay. That’s it? Just let me make a note. Just give me one sec. I’ll just write this down fentanyl and noradrenaline. Yeah. Correct. So for example, with the antibiotics, this is what they told you or have you seen that on a drug chart?
Megan: I’ve been seeing them running those antibiotics via the pump.
Patrik: Okay. Because for example, if he was to have steroids like hydrocortisone IV, it would be going in twice a day for 10 minutes. You wouldn’t see it in the pump. No. So that’s something to be mindful of. Have they used the term sepsis? You know what I mean by that?
Megan: I have not remembered them saying that.
Patrik: The term sepsis is everywhere in ICU. It’s everywhere. Do you know the primary admission diagnosis? Have you seen that in writing? Do you know the primary admission diagnosis?
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Megan: They said he’s got bad lungs, that he’s got pneumonia but they have not explained how he got it? But I remember there was a time where he vomited. And after that, his condition worsens.
Patrik: Okay. He’s got a pneumonia. So if he vomited, he might have aspiration pneumonia. Do you know what I mean by that? Okay. So if somebody vomits, especially when they’re sick, there is a chance that they might get some gastric content, some stomach content into the lungs and that would be what’s considered aspiration pneumonia and that could be the cause of his pneumonia.
Megan: Right.
Patrik: Right. So that is a question you should be asking; whether they know the origin of pneumonia. Right. When did he vomit apparently? Okay. Look, if somebody aspirates and… Let’s put it that way. If a healthy person vomits because of food poisoning or whatever, it’s unlikely that they aspirate. But if somebody is weak already, the risk for aspiration is high. So the questions then really are, do you think that on Sunday or on Saturday, or whenever it might’ve been, do you think your brother was weak already so if he did vomit, that he might not have been able to protect his airways?
Megan: Yes I think so.
Patrik: Sure. Right. Okay. Look, I think it’s a question you should ask; if they think he had aspiration pneumonia and that could well lead to septicemia. That could well lead to septicemia, so let’s just then, quickly look at the noradrenaline, the propofol, and the fentanyl. When somebody’s induced into a coma, they need propofol for sedation and they need fentanyl for pain. It’s good that they use propofol because propofol is short-acting. That means when they switch it off, he should wake up fairly quickly. That’s a good thing. That’s a good thing; however, the fentanyl is very potent, which means… The fentanyl is a pain reliever. It’s very strong pain relief, but it can also stop people from waking up quickly. It’s working extremely well to relieve pain but yeah, it’s also stopping people from waking up sometimes.
Megan: Alright. But I think they have been putting him on minimal sedation to wake him up.
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Patrik: Good. That’s good. They need to keep trying to wake him up. That’s all good. That’s all positive. So then the question is why is he on noradrenaline? Or before I go there, have they told you when they want to wake him up properly? Have they given you a timeline?
Megan: No.
Patrik: No? Okay. All right, okay. Let’s look then at the noradrenaline. There are two reasons why he might be on noradrenaline. One could be the septicemia because the biggest sort of thing you see in septicemia is low blood pressure. Sorry. And the noradrenaline is basically increasing the blood pressure. Noradrenaline is considered life support, okay?
Megan: Okay.
Patrik: So when somebody has low blood pressure, a dangerously low blood pressure, I should say, they get started on noradrenaline. It’s a drug of choice, okay? But just like ventilation… Ventilation is life support. Noradrenaline is considered life support as well. Right. So why is he on noradrenaline? Potentially, because of the sepsis, but the propofol… the main side effect of the propofol is low blood pressure, right? So a lot of patients who go on propofol in an induced coma and who are not septic, end up on noradrenaline because their blood pressure drops. So the…
Megan: Yeah. I noticed that when they started him on propofol, his blood pressure drops.
Patrik: Yeah. No doubt about that, yeah. The question is, is the blood pressure down because of the propofol or because of the sepsis? That’s the question. So that then… Then there’s a very good chance he’s on the noradrenaline because of the propofol. There’s a very good chance for that, but you’ve got to ask what they think it is. So then the next question is what’s their plan in getting him out of the induced coma? So with pneumonia, there are some schools of thought around how long should you keep somebody on a ventilator with pneumonia. Three, four days; if pneumonia clears, then you should wake up a patient if you can and get them off the ventilator.
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Megan: I still need to ask them about their plan.
Patrik: Okay. Now, if pneumonia doesn’t clear, you’ll probably need a few more days, but at the same time always, you want to always minimize the time on a ventilator, of course. It’s a no-brainer. That’s why you need to ask what their plan is.
Megan: Every time I ask them, they keep on telling me that it is still the same as before.
Patrik: Yes, sure. No, I understand that. That’s sort of a standard answer, which doesn’t mean anything. And sometimes they don’t know. Sometimes you got to wait a few days to see whether the pneumonia is clearing up or not. You can see that. They can see that in the chest X-ray, okay? So you would have a daily chest X-ray for now. And they can also see it… Have you heard of an arterial blood gas? Am I making sense there?
Megan: Yes. And I noticed that they are changing the setting of the ventilator each time they have the result.
Patrik: So they can see there, how effective ventilation is. So when they reduce the support and the gases stay the same, that could be another sign that the pneumonia is clearing up, right? Do you know how much oxygen he’s on at the moment?
Megan: I think he is at 60% then down to 50%.
Patrik: 60%? Good. Okay. Probably something, again, you should be asking; how much oxygen he’s on. 50% is a fair bit. 50% is a fair bit. Room air, the air you and I are breathing at the moment is 21%. Right. So 50%… Again, in pneumonia, it’s not a particularly high number, but it is definitely a concern. Sometimes patients with pneumonia are ventilated on 100% of oxygen. So it’s just a matter of keeping an eye on that.
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Megan: Alright.
Patrik: Okay. Have they done any other interventions as far as you’re aware? Have they done a CT of his chest, for example?
Megan: Yes. I will include this on the list of things I need to ask them.
Patrik: So those are the things to look for, in terms of outlook, have they been positive? Have they been negative? Have they been neutral?
Megan: The truth is, I’m feeling that they tend to be negative about my brother’s current condition. As per the story, I have been telling you regarding their plan for my brother. It always seemed to be on that perspective.
Patrik: Yeah. And I agree with that. At the moment… So when again, just remind me, when was he intubated again?
Megan: Just yesterday.
Patrik: Okay, so it’s basically, 24 hours. So if it’s 24 hours, they should hopefully, have a better idea after they’ve done an X-ray and even this morning, he would’ve had an X-ray, chest X-ray. So even then, they would have an indication of what the chest X-ray today looks like, compared to yesterday, compared to the day before and so forth. That’s a really good indicator of where he’s going.
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Megan: Okay.
Patrik: So then, do you know how much noradrenaline he’s on? Do you have a number? Yeah. And you know what you could also get? You could also get a picture of the ventilator if you can. Look, I think at the moment, from what you’re sharing, I really think it’s way too early to see where this is going. And obviously, panic is the worst thing you can do. The most important thing really is just to stay calm and stay collected. That’s really important. And just to be prepared that…
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- How to ask the doctors and the nurses the right questions
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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!
Make sure you also check out our “blog” section for more tips and strategies or send me an email to [email protected] with your 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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