My Mother Had a Cardiac Arrest and Her Level of Consciousness is Not Improving. Help!

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

My Mother Had a Cardiac Arrest and is on a Ventilator in the ICU. Are We Losing Her?

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 Stephanie as part of my 1:1 consulting and advocacy service. Stephanie’s mother is a post cardiac arrest patient in the ICU and Stephanie is asking if her Mom is just sleeping or already brain dead.

My Mother Had a Cardiac Arrest and Her Level of Consciousness is Not Improving. Help!

PART 13

Mikael: Okay.

Patrik: As far as I can see. Would you agree with that?

Mikael: Once again, she’s been here for since the 10th. Right. I don’t know for how long she was down, and that normally is one of the reasons why someone would take time before they wake up.

Patrik: I understand, but it’s a good sign that she’s not having any more seizures at the moment because I believe that’s been a concern in the beginning. Some of the Keppra and Dilantin seems to work then but on the other hand she’s not waking up.

Mikael: Correct.

Patrik: Yeah and now the next step potentially is a trach. It sounds like that might happen in the next few days and then she can hopefully have more time to wake up if that’s going to happen, so are there any other concerns? She’s being fed, she’s absorbing her feeds? There’s no issues there?

Mikael: What did you say?

Patrik: Is she absorbing her enteral feeds?

Mikael: Oh yeah. She has zero residuals.

Patrik: Right, Right

Stephanie: Wow! Wow!

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Patrik: So, She’s hemodynamically stable. Oh, and does she have a central line still? An arterial line or-

Mikael: No, we have removed both.

Patrik: Removed central line as well as arterial line?

Mikael: She has no A-line. She has only peripheral line.

Patrik: Right, Right, so if you have no A-line that means you’re happy with ventilation settings and you don’t feel the need for doing any more blood gases at the moment.

Mikael: If she’s hemodynamically stable, and she is not fighting the vent, right.

Patrik: Right, so if she was to have a trach would she be able to go on a collar straightaway or not there yet you think?

Mikael: I would not answer that question ’cause I’m not good at vents.

Patrik: That’s alright.

Mikael: That would be something I’d leave for providers, yeah.

Patrik: That’s fine, thank you, thank you. Look Miranda, I think that’s more than enough to-

Mikael: The main thing is the family should have a meeting. There should be a plan of care meeting on Monday in the books. Miranda, are you meeting the doctors on Monday?

Miranda: Yes sir.

Mikael: I would suggest you write as many questions down as you can so that you don’t forget anything. Yeah. Come with open mind, and make sure you get as much information as you can.

Patrik: Yeah, yeah. That’s wonderful. Look, I really do appreciate your time, Mr. Mikael. I know you’re probably on a busy night shift and I know how tough it is. Thank you so much.

Mikael: Sure, Miranda do you have any other questions for me?

Miranda: I feel you know, we just still believing and earlier when I talked to you, you said you earlier and agreeing with us.

Mikael: Yeah, just keep trusting. God gives God takes away. Just trust the will of God, Okay? Alright. You have a good morning!

Miranda: You too!

Stephanie: Thank you.

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Patrik: Thank you so much sir! Okay-

Stephanie: Miranda are you back?

Miranda: I’m here.

Patrik: That was good. It really concerned what we suspected that the main issue is she’s not waking up. That’s the main issue. It does concern me that her Glasgow Coma Scale is still only a three. That really does concern me. Right, because that’s the lowest score. But at the same time, it is still early days, I believe day 12 is still too early. They need to stop the Phenobarbital as far as I can see to get her more awake and then see whether her Glasgow Coma Scale will be changing. It’s good that she’s off vasopressors. It’s good that her kidneys are working. It’s not so good that there are signs of infection. I’m not clear why they’re not giving antibiotics. He didn’t want to sort of answer that question.

Stephanie: What he said, what Doctor Reynolds said yesterday “With us giving her a round of 10 days of antibiotics there shouldn’t be any infection in her body.” But as far as I’m concerned they didn’t take a test, the fact that the white blood cell count shot from 22,000 to 44,000 whatever it is. That’s a sign that there’s an infection. That’s a no brainer. He said it could be inflammation which may be true, but to me that’s a sign of something.

Patrik: Yes. Yes. Yes. Look, some ICU’s are really almost aggressive with giving antibiotics. As soon as there’s a sign of infection they are really aggressive with giving-

Stephanie: I see.

Patrik: Right. And they might have a different approach there. When I asked him about ventilation. When I asked him whether she could go straight to a collar. Do you know what I mean by that when I said a collar? Do you know what I mean by that?

Stephanie: Yeah. It’s a ventilation collar. I’ve heard about them probably from reading your stuff. A ventilation collar is just like air-

Patrik: Yeah, It’s just like air-

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Stephanie: It’s just like it’s not-

Patrik: Air going to the trach. It’s not ventilation. It’s just air or oxygen going to the trach. So I wasn’t sure whether he was trying to avoid answering that question.

Stephanie: I think he was. I think he was.

Patrik: I think so too.

Stephanie: Aha. I caught it! I’m on it, I think. He was trying to avoid it because he said “That’s something you have to ask the doctors”, right?

Patrik: That’s right. That’s right. He tried to avoid some of the issues. He can’t look after Carmen not knowing about ventilation. That would disqualify him from looking after her, you know what I’m saying?

Stephanie: Yeaah!

Patrik: He’s saying oh he’s not good with ventilation. I don’t believe that. It would almost disqualify him to be in that role.

Stephanie: Right, right. Um hmm. Yep. So we just listened. We don’t antagonise. We take in the notes. We read in between, what you said read in between the lines!

Patrik: Yeah, yeah, yeah.

Stephanie: He was trying to avoid that question.

Patrik: Yes.

Stephanie: She probably could. She probably could, and he just you know.

Patrik: Because if she’s breathing above the ventilator, that’s a sign she’s breathing up, that’s a sign she’s doing something.

Stephanie: Yeah!

Patrik: Right!

Stephanie: Yeah!

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Patrik: And that’s why my next question then is automatically what if she had a trach could she come off the ventilator quickly. That’s where I was going with this and he was trying to avoid it.

Stephanie: Patrick, you got some information there didn’t you? You were digging! Very nicely, very carefully!

Patrik: Yes, exactly. I got some information there.

Stephanie: That’s why he had to ask you, “Who am I speaking to?”

Patrik: Yeah, and that’s okay. That’s okay. But my biggest concern is that she’s still a Glasgow Coma Scale of three, and they need to stop that Phenobarbital and see what happens then.

Stephanie: It’ll knock you out!

Patrik: Yeah.

Stephanie: Yep. Yep. Yep. See what you want to do. See what Monday is going to tell us. Yep, Yep! We found out some information. That makes you more equipped to deal with them on Monday and if we need to call, hey if we need to call again tomorrow night I think night time’s a good time to call. Don’t you?

Patrik: Night time’s a good time. Absolutely! As I said, I hope it’s been very non-confrontational … we asked, that’s absolutely fine. It’s really about getting as much information as possible to be prepared for the meeting.

Stephanie: You did it! Go ahead Miranda.

Miranda: So when we was talking to the Neurologist and they was talking about in the meeting the difference between the Dilantin and the one you all keep saying that you all want to take her off. They was basically saying when they took her off she started having the seizures again. They was saying that’s the method of medicine that they use.

Stephanie: The Phenobarbital.

Patrik: Look. I have only seen Phenobarbital being used in traumatic brain injuries. That’s the only time I have seen Phenobarbital being used, for whatever reason, they seem to have a different approach there. I personally don’t like it because to me the Phenobarbital has always been a last resort drug. Right?

Stephanie: They did say that. They did say that. They said “It was our last resort.”

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Patrik: I don’t like that the Glasgow Coma Scale is still only a three. I don’t like that either, but again it’s early days and again we gotta hope, take one day at a time-

Stephanie: You’re just wondering. One day at a time but you’re just wondering if they removed the Phenobarbital would that change her scale.

Patrik: Yeah absolutely.

Stephanie: And when I asked that lady at that meeting what her numbers were, for her to tell me that she doesn’t have any numbers was a lie.

Patrik: Yeah. Sure, sure! Yeah, yeah of course.

Miranda: How do you come to a meeting without the numbers? They’re so unorganised. I don’t know what you would say Mr. Patrik but we need to probably ask somebody higher. They’re not doing what’s right.

Patrik: Say that again.

Stephanie: Well it’s necessary … she said that she feels as though they don’t have it together, they’re disorganised or what have you, and she’s saying that we need to go higher than the people that we’re talking to, and I’m about to call her. She’s on the job, so I’ll just talk to you so I do know that if you feel the need to speak to someone higher than you’re going to ask that.

Patrik: Yeah. Yeah sure, and he really gave us the option.

Stephanie: Yes he did.

Patrik: Right. But I can tell you the only other question that I would have had to the doctor is probably the antibiotic part and the other question I would have had is the Phenobarbital. Those are the two questions he couldn’t answer, right? And those would have been my most pressing questions. Right?

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Stephanie: Should we ask those tomorrow?

Patrik: I think so. Ask the question if they expect if they took off the Phenobarbital if the Glasgow Coma Scale would change or if they expect that she would start seizing.

Stephanie: Right. They do, I think they do.

Patrik: Probably. But if that’s the case then they have to work on the Keppra and the Dilantin.

Stephanie: Now we have to find out what levels did they use before. Did they have a high dose? Or were they concerned that if they went any higher that it would affect her liver or whatever.

Patrik: That’s right. And also there’s two sort of thoughts I have: number one she could be a Glasgow Coma Scale three because of her brain injury but I think it’s way more likely at the moment that she has a Glasgow Coma Scale three because of the Phenobarbital.

Stephanie: She’s breathing on her own, her other functions … the brain is controlling the rest of her functions.

Patrik: No, no you’re right! It must be a minimal dose. It must be a minimal dose of Phenobarbital but still I’m trying to find-

Stephanie: It’s like ten, ten kilogrammes or whatever the math. You did the math didn’t you?

Patrik: Yeah. So my question is why is she still a Glasgow Coma Scale three? Is she over sedated or is it a result of the brain injury?

Stephanie: Right.

Patrik: Right. That we don’t know and they probably don’t know either at this point in time. They do have a theory, of course.

Stephanie: They say she’s in that grey, right in the middle

Patrik: That’s right. So those are the questions. And then also you remember I asked him about doing the trach and then potentially getting on the collar straightaway because once she’s on the collar and can stay on the collar for more than 24 hours she basically doesn’t need any ventilation anymore which is another-

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Stephanie: Right, she can breathe on her own!

Patrik: Right! One layer of complexity taken away.

Stephanie: But then they would really want to ship her out of there fast!

Patrik: Yeah but then … okay, let’s just say she doesn’t need ventilation. It’s good if she wouldn’t need any ventilation, right? But then maybe the next step is Neuro rehab.

Stephanie: But you know what, yeah, where are we going to find that at?

Patrik: Look, let’s cross that bridge when it’s there.

Stephanie: Got it! We know that Kurtland, write this down! Check them out! Kurtland, K-u-r-t-l-and Annapolis, Maryland. Kurtland is extremely good for Neuro rehabilitation, however, they have to be able to respond to commands. But that’s one that I know that we have.

Patrik: Again, let’s cross that bridge-

Stephanie: Cross that when we get to that. But I just thought I’d throw it out there, keep that in the notes. If you need to ask me again, of course…

Patrik: So we’ve got some information and from my perspective the next step is to talk tomorrow when you have the family meeting, when you have the family deal. Did you have any other pressing question?

Stephanie: No, no. The two things I’m taking away, I’m concerned about the arterial line. You tell me about the arterial line. We don’t need it? I heard you ask him a question about that.

Patrik: I’ll tell you something. He avoided the answer in regards to the trach collar. If somebody has no art line, no arterial line, they’re pretty close to coming off the ventilator, right, because the only way-

Stephanie: That’s because they’re not using the suppressors right?

Patrik: No. no, no, no. Not at all, not at all.

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Stephanie: Vasal, Vasalpressors?

Patrik: No, no, no. It’s got nothing to do with the Vasopressors. The A-line can be used to gauge the vasopressors but the A-line is way more important to measure the effectiveness of ventilation.

Stephanie: To measure what? What about the ventilation?

Patrik: Yeah. So basically when you take an arterial blood gas, it’ll tell you straightaway whether ventilation is good or not.

Stephanie: Got it! Got it! Because it tests the oxygen in the blood.

Patrik: Correct. Correct. Oxygen, Carbon dioxide in the blood, right?

Stephanie: Got it. Got it!

Patrik: So because they’ve taken that away, they don’t see the need for it.

Stephanie: Okay, probably because she’s breathing over the ventilator.

Patrik: Yes and again that-

Stephanie: No. Yes and no.

Patrik: Yeah, yeah. Look, it’s great that she’s breathing above the ventilator and it sounds like it’s adequate, but if they’ve taken out the A-line I would hope they don’t need it, they don’t see the need for it, and that’s all positive, right?

Stephanie: She has a hematoma there. She has a hematoma. Should we worry about that or that will dissolve on its own?

Patrik: Probably dissolve on its own, I would hope.

Stephanie: Yeah, my Nana had one.

Patrik: We can ask that tomorrow.

Stephanie: Okay. Got you!

Patrik: But we’ve got enough information. We’ve got enough information for now.

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Stephanie: Okay. Sounds good. Well, I don’t know if Miranda’s on the line but she’s not we’re gonna go ahead and end the call and we’ll reconvene tomorrow evening.

Patrik: Yes. Yes. Please give me enough time

Stephanie: I’ll give you well enough notice. I will give you well enough notice. There will be at least an hour.

Patrik: Okay, Okay. Wonderful!

Stephanie: I appreciate you so much. Thank you so much Patrik. I think we’re a good team.

Patrik: I think so too. Thank you so much!

Stephanie: Goodnight.

Patrik: Goodnight, bye.

The 1:1 consulting session will continue in next week’s episode.

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