Friday, February 7, 2020

There is something going on with Bill and everyone involved in his care the last few days seems to think he needs to have another broncoscopy, except for Stephanie from the lung group. She was off the first part of the week and when she came back yesterday the only thing she was really concerned about was that he had refused to do something, or let something be done. He does try to refuse therapy if I'm not there, but if I am there, even if he refuses, I make him do it. He did refuse to let a night nurse draw labs the other night, but let the day nurse do it. I don't know what went on with that. It could be the nurse just woke him up, which he doesn't like, or couldn't get a good stick, it's hard to tell. His veins are so small and fragile and there aren't many places on his arms left to stick. 

Anyway, he's still very junky and coughing up ugly stuff and having to be suctioned very frequently. His heart rate was up and his sats were down because he was laboring to breathe around all of the junk. And his sats did what they had done before, he was at 93% when I got there at 7:30 and a few minutes they were in the 70s. They weren't going down slowly, but would just plummet. That tells me there is a mucus plug in there that he can't move, which has happened before. But, even though his x-ray didn't show any worsening, the secretions have to come from somewhere.

Stephanie's choice of treatment was to put him back on the vent in the SIMV mode, which is the one between full vent and CPAP to let him rest. The good news is that he had been on trach collar for 24 hours and that usually means he was successfully weaned from the vent! But, of course Bill can't do anything the normal way. At first he fought the vent, and I think he was given some Ativan. I left the room for a few minutes and when I came back he was asleep, but he was very fidgety with his hands, it was like he was putting something together. 

The nurse brought the physical therapist in to look at his numbers before trying to do any physical therapy and since his heart rate was still above 110, they decided not to wake him and try any therapy. Speech did come in and he was awake and did some ice chips and swallowing exercises, but she could tell he was having a difficult time, whether it was from the secretions or from the medication.

When Cam from cardiology came in he said he was going to get with the lung group, and of course he would report to Dr. Edwards. Since he rounds so late, he may have given an order to have him bronched, even if he's not a lung dr. 

He needed cleaned up in the afternoon and when Tralena took his blood pressure, it was in an acceptable range for her to give him something to help him rest. I don't know what they decided on. I do know that in the ICU they gave him Presedex to calm him, but she said they couldn't use that because it had to be tritated. I don't know what that means, but she wasn't able to do that. Almost as soon as she gave it to him, he was out, and he barely opened his eyes when I told him I was leaving to beat the weather coming in. It wasn't much earlier than I usually leave. His sats had finally evened out, but his heart rate was still hovering right around 100-110. But, he was finally resting.

So, that's the medical side of things. Unfortunately, he was in better shape when he left ICU than he is now, not that he's not getting good care, but he was off the vent completely, and was standing with a walker. Now he's been in restorative care for 3 1/2 weeks, with most of it on the vent, and very little therapy as yet. 

I talked to Stephanie from Mayo yesterday morning. She was just checking in. She wrote down Dr. Yaranov's name and said she would update the team on his condition, and tell Dr. Patel the he was being seen by Dr. Yaranov. She also said to give Bill a hug from her.

So, that's another discouraging day. I told Emily last night that if they decided to do a bronch in the night, they would have to call me for authorization, because Bill was in no mental condition to legally sign consent. And since I didn't get any calls, I don't think anything was done. I think the Drs. round on Friday's so maybe a decision will be made. It was last Friday that the Dr. overrode Stephanie's weaning process and got him on trach collar the next day, so we'll see what happens today.

We got a little skiff of snow last night and it was heavier farther south, so the drive should be fun. They said the major problems would be bridges and overpasses. So, I'd better get a move on now and get going. I'm hoping to walk into his room and see him awake and smiling with good numbers!

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