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 the questions from one of my clients Caroline as part of my 1:1 consulting and advocacy service, whose fiancée is in the ICU and ventilated but the ICU team is rushing him into a tracheostomy.
The ICU Team Keep On Insisting Charly To Have A Tracheostomy. Why Not Wean Him Off The Ventilator First?
Patrik: Hi. It’s Patrik here from Intensive Care Hotline.
Tom: Yes, can you hold? I’m going to put you hang on the phone.
Patrik: Thank you. Thank you.
Tom: Patrik is on the phone with us.
Tom: Patrik’s on the phone. He called back.
Patrik: Yes. Can you hear me?
Patrik: Okay. Number one, I thank you so much for being a client. I really appreciate it. We can get on to resolving some of the issues straight away. I think the first most pressing question, and tell me if I’m wrong, would be the issue around tracheostomy, whether that would be appropriate or not.
Caroline: Yes, that was the question.
Patrik: There are two very important things to understand here. Number one, a tracheostomy has its time and its place if ventilation can’t be weaned, okay? You are correct that the two-week mark is sort of the cut-off where people need to decide if a tracheostomy is the right thing to do or not, but the number one priority with a tracheostomy should always be not to use it. It should be a last resort and the goal should always be to wean somebody off a ventilator in the first place and wean the breathing tube and the ventilator. That should always be the goal, okay?
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Patrik: Now I don’t know whether that has happened or not and-
Caroline: They haven’t done that at all.
Patrik: Right. Why do you think they haven’t done that? Have you got any indication?
Caroline: I don’t know. They keep saying that they believe that they should do a tracheostomy. That’s what the nurse just told me earlier. That’s why I particularly wanted you to speak to me. They said that they think that his brain is now gone, that his lungs could breathe so they think that the tracheostomy is the best thing to do.
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My grandmother was in ICU three weeks ago and we asked them could we have the weekend to give her a little bit more time and when they did the extubation, she would be … They were weaning her and then they were able to do the extubation, so I don’t understand why they haven’t tried to do that in this case to see if he can breathe.
Caroline: He’s been breathing on his own. He’s been breathing. His number is 20 on the vent so-
Patrik: Right. Have they started to mobilize Charly? Have they started to get him out of bed, for example?
Caroline: No. No, they haven’t done anything. They just move him, shift him occasionally. They keep massaging on his feet. They haven’t tried to have him out of the bed or at least sit him up in a chair, something like that.
Caroline: He’s just been in the bed this whole time.
Patrik: Okay. Do you think he could be mobilized?
Caroline: I think he can be but when he is moved, his blood pressure does go up. Then they’ve been giving him, every time it goes up, they give him Ativan, Ativan, Ativan.
Patrik: Um-hmm (affirmative) and that’s knocking him back.
Tom: What do you mean by mobilize. I don’t know what you’re talking about.
Caroline: They could put him in a different position, right?
Patrik: Yeah, I think the goal is, with getting somebody off the ventilator and the breathing tube, it’s always number one, through physical therapy, physical therapy for the chest in particular, number two, getting them out of bed if they can, sitting them up, stimulating them, all of that. If getting him off the ventilator and breathing tube can’t be achieved, and in some instances, it can’t be achieved, but obviously, they need to try their very best to achieve that. Then a tracheostomy might be appropriate. However, here is another question. Have they mentioned anything about long-term acute care?
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Caroline: Not yet, no. I think that the goal is once they do the tracheostomy, that would be the next conversation.
Patrik: That has been brought up as a point of discussion, has it?
Caroline: Very, very frustrating, but I will say physical therapy was here about five days ago and I asked them if they could do something for him. All he did was shout, “Charly! Charly!” He didn’t do anything. It was very basic. I even asked if accupuncture would help him in some kind of way or something and he said, well no, he didn’t think Eastern medicine would work at all. That’s the last time I saw him.
Patrik: That’s terrible because the physical therapy should be a daily thing. That’s very disappointing that the physical therapist comes and says, well, they don’t think they can do anything. That’s terribly disappointing.
I’ll tell you what I’ve experienced over the years and that’s really important to understand. The tracheostomy is often a vehicle for an ICU to empty their ICU and get on to long-term acute care. That, from my perspective, is not the best way forward because … Do you know what happens in long-term acute care? Have you got any ideas?
Caroline: Well, isn’t that just a way to put you in a facility to wait for you to pass?
Patrik: No, not necessarily, not at all. The goal is always to wean somebody off the ventilator but the problem is you’re going from an ICU with ICU doctors, ICU nurses with respiratory physicians, all of that, or respiratory therapists. You’re then going to a long-term acute care facility where there’s one doctor for 30 patients and no ICU nurses.
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Caroline: Oh, no. Yeah.
Patrik: The drop in skills is significant and therefore, yes, tracheostomy again has its time and its place, but many ICU’s use it to send patients out of intensive care as soon as possible without actually looking at the clinical needs. That’s why it’s so important that patients get weaned off the ventilator in the first place and avoid the tracheostomy. The reality is the minute somebody has the tracheostomy, they often line up the patient in long-term acute care a few days later. That’s from my perspective, is inappropriate.
Patrik: Has Charly’s dad, has he even consented to the tracheostomy already?
Caroline: We didn’t want him to so he said no. They asked me again tonight and I said, “I don’t know what’s going on, so you can stop asking me about it.”
Patrik: Right, right, so no consent has been given yet.
Caroline: No. They’re asking me now so that they can pull his feed.
Patrik: What do you mean by pulling his feed? What do you mean by that?
Caroline: They said that they’re trying to find out from the father if they can go ahead with the surgery, so they can turn his feeding off.
Patrik: Oh, sure, sure. I see now. I’m with you. I’m with you. Okay.
Caroline: I said, “I don’t know. I don’t know, so they can just, keeping the feeding on.”
Patrik: Yeah, sure. That is what happens before they do a tracheotomy. They do stop the feed for 12 to 24 hours prior, but then if Charly’s dad hasn’t given consent, there’s not much they can do, either.
Tom: Charly’s dad maybe hears what we have to say also.
Patrik: Okay, good. No, that’s good. From that perspective, another question is do you know if Charly is still on any sedation or not?
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Caroline: No, he hasn’t been on sedation for a few days now. They took him completely off of that.
Patrik: Right, and what about the Ativan? How often do you think they’re giving that?
Caroline: It seems as though they’re giving Ativan whenever they see him shaking. The last he’s had Ativan in the last 12 hours in time.
Patrik: Right, okay. Any change in his response to you since we last spoke?
Caroline: Well, last night when I was here … I stayed over at the hospital, so I was here the whole time. I noticed that … I took a pin to his foot, from the bottom to the top and he moved it a lot. He has never done that before. He has never done that before at all.
Patrik: That’s good.
Caroline: I was holding his hand and he grabbed my hand twice, not like a jerking motion. It was like he was holding my hand twice. Then his fingers moved and then it stopped. Then I also noticed that … His eyes right now are closed, right? There was one point in time where one eye opened and then the other eye opened and he kept them open for two minutes straight and one eyeball looked like it was moving very little to the left, now very little, so he had his eyes opened for two full minutes. I counted, and I recorded with my camera. He made so many foot movements yesterday, I have at least 15 minutes of video where he moved his foot at least 12 times.
Patrik: That’s great. That’s great. That’s good.
Caroline: That’s why I think that he is trying. I know that we’re in a situation where I don’t want to be rushed, but I do want to do what’s best for him.
Patrik: Yep, absolutely.
Tom: Let me ask you a question, Patrik. If stimulation, if you take something like a small device and you run it on someone’s foot and he is in a coma, will it cause him to move or is that something that he has to have feelings for?
Patrik: No, he doesn’t have feelings for this device. You see, when patients are in a coma, there are no hard and fast rules because individuals are very different. It also depends on how much brain damage there is. There may be no brain damage. I remember you mentioning last week that there potentially is brain damage but the biggest problem is that the ICU wants Charly to recover in a time frame that’s convenient for the ICU, right? The reality is Tom will need time or any other patient, for that matter, needs time. People are people. They are individuals. No amount of pressure will get Charly to recover quicker.
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Caroline: Yeah, I agree.
Patrik: As you know, Charly, yes, he’s moving now his legs. In two days’ time, he might move his arms. There’s no textbook around how long it takes for a patient to recover in a situation like that. Nobody has a crystal ball to say, “Yep, this is going to take two weeks, two days, two months.”
Tom: What do you think should be done at this point?
Patrik: Say again?
Tom: What should be done at this point?
Patrik: Yeah, I’ll tell you what-
Caroline: I’m sorry. Hold on one second. I’m sorry. The doctor is here now. He has been trying to call him, too.
Patrik: Okay, well, if you need to interrupt, let me know and I can call you back.
Caroline: Yes, can you just give me a call right back, please? I’m sorry.
Patrik: Yeah, sure. I’ll call you back. Sure.
Caroline: All right. Thank you.
Caroline: All right.
Patrik: Hi,Tom. It’s Patrik again.
Tom: Okay, shall I put him on you right now?
Patrik: Yes, yes. Absolutely.
Caroline: Yes, hello?
Patrik: Yes, I can hear you.
Caroline: Oh yes, sorry. He was looking for me, asking me again.
Patrik: Right, right. So I think the last thing that you asked, Tom, was what should happen? So to put this in a nutshell, number one, they should maximize their chances to get him off the ventilator and the breathing tube. And if it can’t be achieved, fair enough, let’s do a tracheostomy. But even if he ends up with the tracheostomy, it’s then to be prepared for the next step, which would be to stop them from going to long-term acute care.
The reason why I feel so strongly about not going to long-term acute care is the reality is an intensive care unit is much better equipped and much better skilled to wean somebody off the ventilator than a long-term acute care facility, right? So but, let’s take one step at a time, and number one, make sure they can wean him off the ventilator and the breathing tube if they can. And again, if that fails, fair enough. If they’ve given it a good go, fair enough. Let’s look at the tracheostomy. But for now, it sounds to me like they haven’t even tried to get him off the ventilator and the breathing tube in the first place, it sounds. Is that how you feel?
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Caroline: Yes, they haven’t. Yes, I do, I have a question for you.
Caroline: If they say, “Okay, we’ll try to wean him off,” and things of that nature, I’m going to make sure I’m there to witness it, if I’m not, I’m going to get Charly in there. So the question would be, let’s say they wean him off completely, and an hour goes by, and he breathes, and then the second hour comes and he can’t do it, what would the option be at that point for them to do? Would it be the tracheostomy at that point?
Patrik: Yes, so if that happens, right, he would end up with the breathing tube again, and then he would have a tracheostomy. So there is no way that they could do a tracheostomy without the breathing tube in place, right? So if, for whatever reason, he fails extubation, extubation is the term for having the breathing tube removed, let’s just say-
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Caroline: Get removed, yes.
Patrik: He fails extubation, yes, they would put the breathing tube back in, and then he would have a tracheostomy. However, I do strongly believe that if that happens, they’ve tried, and then you know that the tracheostomy is the right decision.
Caroline: Now, would that be a problem for him to get re-intubated, to then get a tracheostomy? Would that put too much pressure on the body?
Patrik: No, probably not. Probably not.
Patrik: I’m a strong believer that’s what’s called a trial extubation is important, to not rush into a tracheostomy.
Caroline: Yes, okay.
Caroline: Alright, I guess, yes, it seems …
Patrik: You know what, if you can send me a picture of the ventilator, that would be very, very helpful, because then I can tell you how far away he is from being extubated.
Caroline: Oh, okay. Alright, well, all I know-
Patrik: That would be very helpful.
Caroline: He is consistently at 20. That’s all I … And he’s done more than that. The most he’s done is 34.
Patrik: Okay, do you know-
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