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
Should I Get Access to Medical Records for My Husband while He is in Intensive Care? Live Stream!
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, Lloyd, as part of my 1:1 consulting and advocacy service! Lloyd’s mom is critically ill in the ICU and he is asking if they should agree with the tracheostomy ASAP for his mom after they reintubated her.
Should We Agree with the Tracheostomy ASAP After they Reintubated our Mom in ICU?
Patrik: Hi Lloyd! Patrik here from Intensive Care Hotline. How are you and your mom?
Lloyd: Hi Patrik! This morning they came in. I called for a family meeting for this afternoon to see if I could get the doctors and everyone in my family together so that we could see what’s going on and what the plan is. But I told her this morning that we wanted to try to do the breathing test first and see if we could do another extubation.
Patrik: Yeah.
Lloyd: And then go from there, instead of going straight to trach.
Patrik: Yes, definitely. There is someone else coming in.
Lloyd: Yeah, my wife. She is supposed to come in.
Patrik: Okay. All right.
Lloyd: My wife is the one who found you.
Patrik: Oh, okay. Right.
Lloyd: Yeah.
Patrik: Okay.
Lloyd: And then my brother might be dialing in.
Patrik: Okay, great, great.
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Lloyd: Oh, you were asking me about the Glasgow coma score. She’s seven, I was told.
Patrik: Right, okay. Have you looked at the Glasgow Coma Scale? Have you familiarized yourself with it?
Lloyd: Yeah.
Patrik: Right. Okay, so you’ve got a basic understanding of what that looks like.
Lloyd: Yes.
Patrik: And that is off sedation?
Lloyd: I don’t know. I could tell you when she is off the sedation, she recognizes us. I think she understands us.
Patrik: Okay.
Lloyd: She can look left, right. She’s breathing on her own. When they do the pain thing, she withdraws on her feet and one hand. The other hand also, but very light. She used to be able to move everything on command, like her feet. And she used to be able to squeeze the hand before the first extubation, and now she can’t. I don’t know why, because they put the stent in her artery so that there’s blood flow to the brain.
Patrik: Okay.
Lloyd: So, I don’t know why she’s not progressing in the other direction.
Patrik: Right. So, she had a carotid stent?
Lloyd: A stent in her basal artery.
Patrik: Okay.
Lloyd: Yeah, left low. Because her right side was weak.
Patrik: Right. Has the right side improved since?
Lloyd: Well, she’s lying down, so we can’t tell. I mean, well, when she first got into the hospital, she was able to move her hands, to squeeze her hand, and the nurse’s hands. And that was when they were treating her with medication in the beginning. And that was Friday morning. We brought her in around 11. And so she was able to squeeze, she was able to swallow an aspirin. She was able to do all the commands. Then I noticed on Wednesday that she wasn’t progressing her right leg. Her right side was getting weaker. I was told that the stroke had progressed, and that’s when they said that she had to go for surgery and get the stent in, otherwise we would lose her.
Patrik: Right.
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Lloyd: We went in and then she didn’t wake up for, I think, 12 hours after surgery. She woke up at 4 o’clock in the morning. She might have gone to surgery around 12:00 or 1:00 in the afternoon.
Patrik: Sure.
Lloyd: And then she woke up at 4:00 in the morning. Her eyes were open, so that was a little concerning. And then that was Wednesday. And oh no, when was that? I’m trying to remember the days. I know Wednesday they extubated her, so that must have been …
Belle: The surgery was on Sunday.
Lloyd: Oh yeah, the surgery was on Sunday. That’s right. The surgery was on Sunday. Then they tried to extubate her on Wednesday.
Patrik: Right.
Lloyd: And then here we are. And then they kept pushing going to tracheostomy right after that. But what they didn’t do when they first extubated her is they didn’t go to BiPAP or CPAP right away. I think she had labored breathing during the night after extubation. So, that’s why they said that they had to reintubate her because they thought that she was going to give out. And then a couple of days later she had the same belly breathing, but she had a lot of fluid in her lungs that they had to suction out. I don’t know if it’s in her lungs or in her throat, so they suctioned out and that subsided. I don’t know what’s the reason why she failed the first extubation. Was it because she had fluid in her lungs and they didn’t suck it out, or fluid down her wherever? Because now that she’s on a tube they suck out the mucus with this tubular contraption.
Patrik: Of course.
Lloyd: So that’s, I think, in a nutshell ideally.
Patrik: What stopped them from proceeding to the tracheostomy straightaway?
Lloyd: You mean straightaway, instead of doing the first extubation?
Patrik: Yes.
Lloyd: I don’t know.
Belle: When it failed. I think he means when it failed, correct? After the first extubation failed, they re-intubated instead of the trach.
Patrik: Yes. But didn’t you say, did I understand correctly that they were trying to push for the trach straight away, or do I understand this incorrectly?
Belle: They treated her as an emergency. After they reintubated her, that was kind of an emergency. And then after that they came and had a chat with us.
Patrik: I see.
Belle: Said it doesn’t look good. That’s when they started talking.
Patrik: Right.
Belle: Doing the trach. And had not been a week yet at that point.
Patrik: And what was your response to them trying to push for a trach?
Lloyd: I think we were basically saying that we wanted to try to have her breathe on her own first. And then she was saying that no, I mean, they don’t see any changes from a few days ago to now, and that would make anything different. And so I wanted to talk to this other doctor who put in the stent, just because he seemed like he was more positive. The attending is very negative. And he was saying maybe they took it out a little too early. Even the respiratory therapists were saying they thought that she was extubated a little bit early, too early. Not knowing that, I don’t know if they’re aware of any of the other history. I forget what it was, when they first took the extubation they put a tube up her nose so she can breathe better. And it was fine, she was able to breathe.
Belle: The extubation, I think you need to stress that fact that the extubation went very well. When they first called me and said the tube was out, it sounded like she was doing great. She was propped up, sitting up, and she could go for six hours without the tube.
Lloyd: Yeah.
Belle: It wasn’t like it failed immediately. She was doing great. It was only when she was laid down to sleep that she had labored breathing.
Lloyd: She was laying down flat overnight.
Patrik: Oh, I see. And that’s when she was struggling to breathe?
Lloyd: Yes.
Patrik: My goodness. That’s ICU nursing 101 to sit up a patient that’s struggling to breathe, unless there’s any contraindication why she can’t sit up. But it doesn’t sound to me like there is, you know?
Lloyd: No, no, because she’s sitting. I mean, she’s at, I think, what, 30 degrees right now, 40 degrees, so I don’t know.
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Patrik: Now, talk about aspiration before the second intubation?
Lloyd: What’s aspiration?
Patrik: Like-
Paul: The water in the lungs.
Patrik: Yes.
Lloyd: Oh, like water in the lungs.
Patrik: Water in the lungs or food in the lungs?
Lloyd: No, nothing. When they did the extubation everything seemed fine. She did have mucus, but that’s one of the criteria I guess they said she shouldn’t … For her to get extubated they wanted to make sure she didn’t have a lot of mucus. But I don’t know if it’s possible that mucus developed after and that’s what was causing her labored breathing or her belly breathing. But I understand that they could have sucked it out. I don’t know.
Patrik: Yes, they could have-
Lloyd: They didn’t know that they needed to.
Patrik: They could have. And who was saying that she was having, or she should have had the BiPAP or the CPAP after extubation? Someone was mentioning that.
Paul: It was the respiratory therapist who were coming in to check his ventilator.
Patrik: Right. Well-
Paul: It was a respiratory therapist who suggested that.
Patrik: Right.
Lloyd: Yeah, but he told us on.
Patrik: He told you on?
Lloyd: In confidence.
Patrik: In confidence. I see, I see. Well, again, I argue this is ICU treatment 101 that if someone is struggling after extubation you put them on BiPAP or on CPAP. Again, unless there is a contraindication such as fractures in the face. But that doesn’t seem to be the case.
Lloyd: Yeah. Well, they put her on CPAP after she was struggling and laying down. They put her on CPAP for a little bit, but they didn’t put her on CPAP right after extubation. They just put her on CPAP after she was having the belly labored breathing.
Patrik: Right. When they took out the breathing tube, she must have been able to follow commands?
Lloyd: I think so-
Paul: That day they were doing PT (physical therapy) with her. They took her out of the bed, and they put her on a chair.
Patrik: Yep. And if you had asked her that day to squeeze your hands or move her feet, she would have done that?
Paul: Lloyd when she was sitting down, was she able to squeeze her hand when they were working on her on with PT?
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Lloyd: Yeah, that was before extubation. She was able to squeeze hands before extubation.
Paul: No, no. When they took the tubes out, remember they did PT? They did PT on her, and they put her on the chair? That was with or without the tubes, right?
Lloyd: No, without the tubes. Yeah, because she wasn’t, they said it was great, because she wasn’t distressed. And that was without the tube.
Paul: Was she able to squeeze her hand on command?
Lloyd: I think so. I think at that point, I can’t swear for it, but I think at that point she was.
Patrik: She must have been. She must have been.
The 1:1 consulting session will continue in next week’s episode.
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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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