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 week’s episode of “YOUR QUESTIONS ANSWERED” I want to answer questions from one of my clients Nestor, as part of my 1:1 consulting and advocacy. Nestor’s wife has a tracheostomy in ICU and he is asking if mobilizing his wife will help to wean her off the ventilator.
My Wife Has Tracheostomy in ICU & Is it True That Mobilizing Her Helps to Wean Her Off the Ventilator?
“You can also check out previous 1:1 consulting and advocacy sessions with me and Nestor here.”
Nestor: Okay. All right. So, I guess, I’ll talk to the doctor and let them know.
Patrik: Yeah, I’ll have a listen to the recording and hopefully that’ll give us more insights as well.
Nestor: Okay. All right, but you said it’s okay to go ahead with the trach.
Patrik: You can consent to the trach, don’t consent to the PEG.
Nestor: Okay.
Patrik: And they will probably keep pressuring you. Just to be prepared. Don’t let them. That’s all I can say. Just stand your ground.
Nestor: Okay. I will not. Thank you. I appreciate your time.
Patrik: It’s a pleasure.
Nestor: I really do. I’ve been telling people about you and passing on your information for sure.
Patrik: Right. I appreciate that.
Nestor: All right. I think I’ll go back and talk to the doctor.
Patrik: eah. Okay. All the best for now, Nestor.
Nestor: Okay. Thank you.
Patrik: Thank you. Bye.
Nestor: Bye-bye.
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Patrik: Hi Nestor! Any updates about your wife?
Nestor: Hi Patrik! There is a problem again. So, she’s still tolerating the trach, but it ended up with some type of bacterial growth.
Patrik: Okay. Can you tell me more about it?
Nestor: I guess when they tested the sputum or whatever, it had some type of bacteria growth.
Patrik: Okay. Is it in the chest or at the insertion site?
Nestor: They didn’t say, but she has pneumonia now as well.
Patrik: Okay. Very likely then, right.
Nestor: They said they did a tracheal aspirate culture and I think that showed Gram-negative…something like that.
Patrik: Okay. Basically, that’s one of the risks of a trach, that it’s easier for bacteria to travel down the lungs because it’s an incision site.
Nestor: Right.
Patrik: But I would imagine now. Is she off all sedations now?
Nestor: No. They just gave her some Ativan.
Patrik: Ativan?
Nestor: I’d suppose they give it to her once every six or eight hours because her heart and breathing rate are faster than the ventilator. She was tachycardic. I don’t know if she is. She has tachypnea as well.
Patrik: Alright. Is she getting more awake?
Nestor: Honestly, yeah, when she’s not sedated. She hasn’t really been sedated today, so she’ll open her eyes. She’ll open his eyes. She’s moving her mouth because I started helping with the suction and because she’s got some secretions orally and it’s really, really thick. So, she moves her mouth. She’s chewing where I put the catheter in there to suction the secretions out, and then she yawns. And then she blinks and moves her eyes.
Patrik: Okay. Is there anything that you would describe as purposeful movements?
Nestor: I think the eyes are sometimes reactive to light. She blinks when the light is in her eyes and her pupils are reactive. She coughs. She reacts to the suctioning. She literally tries to move away. It irritates her. You can tell because that’s when she starts breathing fast.
Patrik: Right. Right. But with the eyes, is she making eye contact with you?
Nestor: Only if I get on her level.
Patrik: I see.
Nestor: At one point, it was like a gaze, but it’s not like a gaze. It’s like she’ll look over to where I am.
Patrik: Right.
Nestor: And if someone comes on the other side, then she’ll look over to where they are. But she doesn’t move her head. The only time she moves her head is when she’s trying to get away from the suction.
Patrik: Right. I see. Okay. If you’ll grab her hand and you’ll ask her to squeeze your fingers, would she do that?
Nestor: No.
Patrik: Okay. From a ventilation point of view, is she making progress?
Nestor: She was. Before the pneumonia, she was definitely making progress. Yesterday, the doctor turned the ventilator off for like three minutes and allowed her to breathe on her own. She breathed on her own, but then they cranked it back up because she was struggling with the pneumonia again.
Patrik: Okay. The next step should be, as far as I can see, they should start mobilizing her. They should start getting her out of bed.
Nestor: Can they do that without her being alert and able to follow commands?
Patrik: Absolutely. When I say get her out of bed, it means … there’s special chairs. She probably is not in a position to strengthen her upper body, but nevertheless, especially with the pneumonia, if she stays in bed, she’ll decondition further.
Nestor: Right.
Patrik: Right? Whilst it might not be feasible for you at the moment that she can get out of bed, I can tell you she can. If they tell you that she can’t, then they’re complacent.
Nestor: That’s what I think they’re doing. Instead of treating the infection first, all I can hear is about LTAC. I mean, we have an immediate problem here. But like I told the doctor today, she’s still critical and you’re trying to send her out the door, because she wanted to know why I didn’t want her to have a PEG. I said, “I just don’t want her to have one.” She said, “We need to send her to LTAC.” And I’m like, “She’s too sick.” She’s like, “Well, she can’t stay here. How long you think can she stay here?” “Until you get her well.”
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Patrik: Absolutely. Did she say anything else? Did she say anything about health insurance? Somebody they might be starting to talk about the health insurance will only pay for so many days in ICU. Did they say anything about that?
Nestor: They mentioned that when she was in the CCU. They were saying they couldn’t justify having her down there because she no longer needs all of the machines to support her life. That’s the first thing, they were trying to push her out to LTAC, but they ended up sending her to another ICU.
Patrik: They want to send her to another ICU?
Nestor: Yes, they did. She’s in Medical ICU now from Cardiac Critical Unit.
Patrik: Right.
Nestor: Medical ICU.
Patrik: Yeah. Right. Okay. But that’s a different ICU compared to couple of weeks ago, is that what you’re saying?
Nestor: Right. She was on the cardiac critical unit.
Patrik: Yeah. I see. Right. Okay. Does she have a different team there?
Nestor: Totally a whole different team.
Patrik: Right. For how many days has she been in that unit for?
Nestor: This is Day 2.
Patrik: Day 2. I see. I think I mentioned that when you first reached out to me, when I said, “Imagine she’s going to another facility. There’ll be a whole different team that needs to get to know her. Do you want to go through that again?” I mean, you can see why this possibly complicates the situation if there’s a new team coming every so often.
Nestor: Mm-hmm. It’s a totally new team but they are pretty much saying the same thing. LTAC. The new doctor came upstairs to try to, I guess, to check her up and to make me consent, and I would not. I told her, “You guys couldn’t even pinpoint where the infection was coming from and you’re going to send her to LTAC?” They couldn’t do anything. They wouldn’t be able to care for her in LTAC like here. She has pneumonia. She probably would just decline there.
Patrik: Yeah. Decline or she would bounce back into ICU pretty quickly.
Nestor: Right. I was just telling her LTAC wouldn’t be able to do this for her.
Patrik: I’ll tell you how they’re trying to “sell LTAC to families”. They’re trying to sell LTAC to families that … LTACs are specialized in weaning people off the ventilator. They’re specialized in rehabilitation. And unfortunately, my experience is that none of that is happening in LTAC.
Nestor: Right.
Patrik: That’s my experience. That’s not to say there may not be the odd good one, but my experience is 9 out of 10 it’s going from bad to worse. The problem in ICU that you’re facing at the moment is that their focus is more on the acute side of things, which she’s still very acute, but as patients come out of the acute phase the focus in ICU is probably less on physical rehabilitation, right? They’re telling you that this is what she will get in LTAC, but in reality, they don’t. LTACs are, from my experience, it’s a better version of a nursing home.
Nestor: Right.
Patrik: It’s built and designed to save money. It’s not built and designed for clinical need.
Nestor: Right.
Patrik: So I’m just looking through your file. I’m just looking at the latest ventilator settings. As far as I can see, she’s still not doing a lot of work herself. She’s still, by the looks of things, getting all the support from the ventilator.
Nestor: Is that the picture that I sent you?
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Patrik: Yes.
Nestor: I think that was maybe four days ago.
Patrik: Right. Okay. Then it would be good if you could send an updated one because it might’ve changed then.
Nestor: Okay.
Patrik: I’ll tell you why it might’ve changed. So now that she had the trach, and she’s more alert, chances are she might be breathing up more.
Nestor: Okay.
Patrik: So now the focus needs to be, quite naturally, to focus on weaning her off the ventilator and mobilizing her. One goes with the other.
Nestor: Okay.
Patrik: Picture this. She’s been lying in bed for how many days now? Two weeks? Three weeks?
Nestor: 15, 16 days. Yeah.
Patrik: 15, 16 days. Imagine you’re lying in bed for two weeks. So now is the time to stimulate her. And by getting her out of bed is one way of stimulation. Not the only way, but it’s one way to begin with.
Nestor: They put the wedges in to move her, kind of like move her body from side to side.
Patrik: Right.
Nestor: They’ve done that. They raised the head of the bed up toward her because she was struggling to breathe. She was struggling to breathe so she raised the head of the bed up. It’s like she could breathe more because they had her kind of like not totally flat but almost flat. You could hear her struggling.
Patrik: Right. When she was lying flat?
Nestor: Right.
Patrik: No surprises. No surprises. That’s what I’m saying. She needs to sit up.
Nestor: So she needs to sit up? Because when I tell them, when I ask them to mobilize her, and I say, “Get her up in the chair or sit her up in the bed … ”
Patrik: What’s their response?
Nestor: No, no, I’m asking should I ask?
Patrik: Yeah. Absolutely. If you type into Google “Mobilizing ICU Patient with Tracheostomy Images”, you will actually see that mobilizing patients is possible. It takes work. It takes people to do that. But it’s possible. You can’t wean someone off the ventilator without mobilization.
Nestor: Mm-hmm.
Patrik: So, with your wife’s brain injury, she needs stimulation.
Nestor: Okay.
Patrik: She’s not getting enough stimulation if she’s lying in bed. I understand that it might be difficult for you to picture that at the moment, because you haven’t seen it before. But as I said, it is possible.
Patrik: As far as the PEG is concerned, have you read some of the articles that we published around PEG versus nasogastric tube? Have you seen some of the articles?
Nestor: I’ve watched your videos.
Patrik: Right. Good.
Nestor: I have also seen one of your images. They have this gentleman; he looks like he’s unconscious, but he has a belt where they lift him. Anyway, Patrik, is there something that they should be doing and they’re just not doing it?
Patrik: Absolutely. So I’ll tell you when you can’t mobilize a patient in ICU. For example, your wife, after the cardiac arrest, the first few days you wouldn’t want to mobilize someone because they’re often unstable. Right? But now she’s stable.
Nestor: Right.
Patrik: Okay? She’s stable. She’s had the tracheostomy. They’ve minimized her sedation. I would even ask them why she is still getting the Ativan. What’s the point in keeping her sedated?
Nestor: Well, they said the reason why is because her breathing is going fast. She has tachypnea and tachycardia.
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Patrik: Okay. Fair enough. She’ll probably transition through a phase now where she needs to adjust to sort of waking up, able to talk. She might be uncomfortable coming from this place of being unconscious and now sort of slowly transitioning to more alertness. And because she can’t talk, that’s probably her sign of adjusting to this new situation. But bear in mind, Ativan, again, any sedation should be minimized as much as possible. Ativan is also a benzodiazepine. And benzodiazepine are addictive.
Nestor: Okay.
Patrik: Right? So the longer she gets the lorazepam, there’s a risk of her getting addicted to it.
The 1:1 consulting session will continue in next week’s episode.
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This is Patrik Hutzel from INTENSIVECAREHOTLINE.COM and I’ll see you again next week with another update!