Category: Post Visit

I got the day right but missed the time.  Last week I had to pick a time to get the car serviced and hoped to combine activities, thereby having to make one less trip to Yakima.  So, I said to the man, “Sure, lets do it Wednesday.”  Then I estimated they would discharge Nancy right after lunch and picked a 10 A.M. appointment with the service shop.

There was a problem.  Magnesium (Mg).  This element is used by the body in many chemical reactions.  It is an important electrolyte along with sodium, calcium, potassium, and chloride.  The last is discussed here:

http://en.wikipedia.org/wiki/Chloride

Magnesium is discussed here:

http://en.wikipedia.org/wiki/Magnesium

… where it claims it to be the 11^th most abundant element by mass in the human body.  Scroll to “Biological role” more than half-way through the page.  Well, the point is that the doctor decided Nancy was a quart low and as long as she was in the shop, why not just top-er-up some.  Why not indeed?

Time is why.  Slower is better.  Look at this: “Supplementation with 1 to 4 g of MgSO4 over 1 to 4 hours is usually adequate, depending on the extent of deficiency; the administration rate should be slower for infusing increasing amounts in nonemergency situations to avoid hypotension.”

http://www.heart-disease-bypass-surgery.com/data/articles/35.htm

Hypotension simply means abnormally low blood pressure.  Sure thing we don’t want to do that to Nancy, so slow it is.  So, over lunch and into the afternoon Nancy was infused with antibiotics and then switched to a slow drip to bring her Mg level up to the “full” line.

Long-story-short:  She exited through the front door at 4:05 P.M. and we were home at five o’clock.  She is feeling good.  Sleeping.

It is 6:30 as I write.  Nancy has been resting well and improving.  The cardiologist felt she need not be on constant monitoring and so they moved her to the 4^th Floor into a big room with windows and a potty.  Except for sky there isn’t much to see out the windows unless one stands up on the sill and looks over the SW wing of the hospital.  Still, the view – any view –is much better than in the ICU.  Likewise, having the ability to use a real bathroom is, compared to a bed pan or movable stool, a major improvement.  It also brings increased movement – we want no regression on the lack of muscle tone.

She is still on a liquid diet in anticipation of procedures to rule out (or in) possible sites for blood loss.  The INR test suggests this could be done on Sunday, but not Saturday.

While I was there this afternoon a blood-draw was done for the purpose of checking on the bacterial infection.  Her color and vital signs suggest a rapid improvement since she went to the ER on Tuesday.  I want to know more about the bacteria and what they measure.

I still haven’t met the infectious disease doctor this go-round.  Last December I sat at opposite ends of the same table with her when I was being briefed by Nancy’s nurse and the doctor was reviewing files.  Later the nurse told me about the doctor but Nancy’s issues at the time did not involve bacteria.  Anyway, Nancy may have to ask for a page or two of notes as the names and spellings of the critters is beyond us and so I have no key words with which to search.

That’s it for Friday.  John

A correction to a previous assumption is in order.  Our thoughts on the ICD have focused on V-fib and that is what we assumed happened.  Upon reading the data stored by the unit we now know the thing fired-off because it sensed a too-rapid heart rate, namely, 188 beats per minute.  This is called tachycardia.  The term tachycardia comes from the Greek words tachys (rapid or accelerated) and kardia (of the heart). The gizmo on the dash of a car that gives RPMs is a tachometer and has the same Greek word origin. Tachycardia typically refers to a heart rate that exceeds the normal range for a resting heart rate – for folks over 15 years this would be any rate over about 100 bpm.

Nancy’s rate had been running a bit high (I thought) during the past few weeks, frequently 80+.  She has had frequent atrial fibrillation …

from the Mayo Clinic:

http://www.mayoclinic.com/health/atrial-fibrillation/DS00291

“During atrial fibrillation, the heart’s two upper chambers (the atria) beat chaotically and irregularly — out of coordination with the two lower chambers (the ventricles) of the heart. Atrial fibrillation is an irregular and often rapid heart rate that commonly causes poor blood flow to the body and symptoms of heart palpitations, shortness of breath and weakness.  Atrial fibrillation can also cause fatigue …”

Monday’s report explained how the “King of Hearts” monitor was rendered useless by the frequent A-fib, and the need to switch to a Holter monitor.

[Small world story: Friends (Brittany related) write:

“Hi. Just read your latest comments and thought I’d share a bit of trivia with you guys. Dr. Holter was born and raised in Helena, MT. In fact, his home was 2 houses south of ours. . . he was a native son, the local history museum had a special display with his old stuff, photos, etc….”]

Now back to the main story:

When (on Tuesday) the ICD sensed the tachycardia it pulsed twice and converted the abnormal rhythm to a regular sinus rhythm.  Nancy was on the kitchen floor and shifted about until she was leaning against the oven.  She thought I was outside and sat there awhile thinking I would come back.  That plan didn’t work because I was down the hall sleeping.  From where she normally spends her time (a recliner overlooking the back forty**) she gets me awake or from the computer by activating the ringer on the house phone.  There on the kitchen floor she didn’t have that capability, so, after about 45 minutes of rest and frustration she yelled for me hoping I was near enough (outside) to hear her.  Had I been outside that likely would not have worked but being only a room away, it did.

**————skip, if you know “back 40”———————–

“back forty” is a reference to plots of land of 40 acres established by the USA’s Public Land Survey System (PLSS) –good explanation here:

http://www.nationalatlas.gov/articles/boundaries/a_plss.html

The settlers house would be located close to the public road that went by the ‘front’ of the property and frequently near the better farmland.  Some claim that if a salesman or other intruder visited the house and the spouse felt there was no need to bother her husband, she would tell the person that the entire crew was out on “the back forty” – far from the house and could not likely be found. (no cell phones then)

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Now it is Thursday afternoon — several phone calls later.  The INR is coming down but the colonoscopy won’t be done until Saturday.  At 1.7 INR the doctor can remove any suspicious polyps.  So we wait on that.  She has had antibiotics, blood infusions, and other liquids pumped into her.  Her fever is gone and her heart rate lower and steady in the high 60s.  She called after having the TEE (see Wed. posting) that did confirm something (filaments of bacteria or ‘vegetation’)

http://en.wikipedia.org/wiki/Endocarditis

on the mitral valve (donated by a pig) .

Here’s an assumption:  When bacteria in the blood inflames the heart it is called endocarditis.  Nancy’s medical problems flared last spring when this happened and she went to the ER in Ellensburg. If you look at the list of symptoms on this site

http://www.mayoclinic.com/health/endocarditis/DS00409/DSECTION=symptoms

there are several that she has been experiencing (again), namely, fatigue, fever, weakness, and weight loss, blood in urine (microscopic).  To me, this appears to be a slow-motion version of sepsis and septic shock.

http://www.mayoclinic.com/health/sepsis/DS01004

http://hopkins.portfolio.crushlovely.com/reference/article/septic-shock

The cocktail of antibiotics has been upped to four (to cover all possibilities I assume).  She is feeling much better except for a bit of raw throat from the TEE.  That and a liquid diet in anticipation of the colonoscopy.  She isn’t happy with the lumpy Jell-O just served and she questioned me on how one screws up making Jell-O.  I don’t know.  Too little stirring or the water is not hot enough, I guess.

It is almost 6 P.M. here so I have to send this to the cloud.

Bye.

John

There should be a sign above Nancy’s door.

While in the Ellensburg ER a test revealed an anemic condition so a unit of blood was started before they transported her to Yakima Regional.  She also had a high white cell count.

The latter is likely caused by a bladder infection – now being treated.  The cause of the low red-cell count is thought to be internal bleeding.  Why is not known.  An upper gastrointestinal (GI) exam is planned, as is a colonoscopy.  With all that is going on with her body the INR (blood clotting test) reading is high so that has to be brought down before any invasive procedure. That is being worked on.  When that reading is where they want it, then those tests can be done.

An  echocardiogram or ‘echo’ revealed something on her heart valve, possibly a bacterial growth (she had this last year).  A blood culture revealed two strains of bacteria in her blood so they started a 3-drug cocktail that may be adjusted when the exact strains of the little devils are known.  However, to get a better look at the valve and its hitchhikers they scheduled a transesophageal echocardiogram or TEE, where the echo transducer (sound producer) is placed in the esophagus or food pipe that connects the mouth to the stomach.  This gives a much clearer “picture” of the inner heart as the waves do not have to travel into the body from the surface. See:

http://www.heartsite.com/html/tee.html

So with all that has been done and all that will be done on Thursday there is a steady stream of nurses, doctors and more doctors, blood takers, blood infusionist, menu bringers, cleaners, and others lining up at the door to get in and question, prod, poke, stick, listen, and so on.  They get in each other’s way.  She needs that sign.

Take a number.

Today I’ll continue with the “life happens while you are making plans” theme.

Nancy woke up long enough to take two pills and is now sleeping again.  It is cold and windy outside and I need to feed horses and uncover my garden – that is, 4 tomato plants.  I’ve about given up growing veggies and things here but figured I could handle 4 plants.

We had below freezing temperatures Friday and Saturday nights.  The first week of the month it was so cold that all the main buds died on the walnut trees (both black and Carpathian).  The black walnut trees are about 18 years old and the others about 10 years and all were producing.  Just this week they were starting to push out new leaves from secondary buds.  As neither are native to this area and frosts are common here at 2,200 feet elevation, I have to keep this in perspective.  If they do not recover I can try something else or just photograph the naked trees and call it my contribution to folk art.

Nancy’s sore throat and sniffles are fading so won’t threaten the implantation scheduled for June 1^st, a week from Tuesday. Meanwhile she has gone through several boxes and sorted out a few keepers but most of the stuff will be recycled or go to the “covered” transfer station – the place we take our garbage.  Times change.  Years ago the place where one took garbage was called a dump, was outside, and was home to rats and mice.  My father (when young) and a friend would each get a nickel and buy a box of 22 ammo for a dime, go to the dump and practice shooting.  After tiring of hitting cans and bottles and a few rats they would hold sticks out with their hands or with their teeth and try to hit what the other was holding.  About the time I got big enough to try such things they closed the dump and Father and older brothers monitored shooting activities more closely.

Two months ago, when I thought I was monitoring our dogs closely by closing our “in-season” female into a bedroom – I goofed.  She was in a different room.  When I let the male in from the yard he ran down the hall and found her and we had a mating before I had the sliding-glass door closed.  Oops!  So as fast as Nancy could clear away a stack of boxes I replaced it with a new set as I made space for whelping quarters for our expectant mother (that would be “b—h” in dog language).  Luckily the mother-to-be has gotten too wide to crawl under the bed so I have a chance to get her to accept the whelping pen (this has inside panels so she can’t crush a puppy against the inner wall) as the preferred birthing place.  She may attempt to carry them under the bed afterward (when she is thinner) but I’ve seen that trick before and will be firm in refusing her intentions.

There are lots of other things going on this week so we do not need and did not want this puppy-thing.  At least the births will happen a week before Nancy’s ICD is implanted.  That’s good.  I will have to contend with week-old puppies and their new mother while Nancy spends two days in the hospital in Yakima, 50 miles away.  I’m having a hard time finding the good in that.*  It must be there so I’ll keep searching.

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*To read “The Pony in the Dung Heap” visit the link below and scroll down to the “Michele W—- on December 30, 2009 at 3:48 pm” entry.

http://goodvibeblog.com/2009/12/qa-how-to-deal-with-multiple-difficulties/

A visiting doctor thought Nancy might be experience gastroparesis.  This translates to stomach paralysis.  Test will be on Thursday.

Here is a link and the first paragraph there from:

http://www.gi.org/patients/gihealth/gastroparesis.asp

>>Gastroparesis literally translated means “stomach paralysis”. Gastroparesis is a digestive disorder in which the motility of the stomach is either abnormal or absent. In health, when the stomach is functioning normally, contractions of the stomach help to crush ingested food and then propel the pulverized food into the small intestine where further digestion and absorption of nutrients occurs. When the condition of gastroparesis is present the stomach is unable to contract normally, and therefore cannot crush food nor propel food into the small intestine properly. Normal digestion may not occur.<<

Today’s events:  All was progressing well today until after lunch.  I had been talking to the nurse about having Nancy do more than just be in the bed.  Could she walk around some?  Was there a 4-wheeled walker around or could I bring one in?  That sort of thing.

There was a CWU EMT student there for the day so the nurse agreed to more exercise after she and the young man checked Nancy’s vital signs as she moved about – sitting, standing, in and out of a chair.  That all went well.  So after a little exercise she got back into bed and I started to leave.  At that point she expressed some stomach discomfort – like she had to burp.  I urged her to sit up straight and do so.  It was more than a burp.  It was all the liquid she had consumed at lunch.  She has learned to keep a pan handy and so all the mess was contained.

Shortly thereafter the visiting “hospitalist” came in and talked to Nancy and the others that had witnessed the event.  She was less than surprised and based on Nancy’s long stay in bed before and after surgery expressed her opinion that this would not be uncommon.

She wanted Nancy to eat (mostly liquid and soft food tonight) and then nothing until they start the examination tomorrow.  They will give her food with ingredients that will show on an X-ray and then over several hours and several pictures determine if the food stays in the stomach overly long.

We will learn more tomorrow.

Pneumonia was not confirmed.  No fever and no sign of the right germs or whatever it takes in one’s coughed-up material, which there was almost none of anyway.

A couple of weeks ago with Nancy seemingly stable the diuretic was eliminated from the drug arsenal.  But as she was not eating the right stuff, combined with the less than robust heart function, she began to retain fluid again.  To Nancy, currently, the ideal food is Lipton or Campbell noodle soup with a fake chicken aroma and lots of salt.  Sometimes she even eats the noodles.

I can’t hardly buy anything she will eat that isn’t loaded with salt.  I guess the next thing is to buy a grinder and get pieces of things small enough that she will swallow them.  The local hospital calls this a soft mechanical diet.  Think of a chicken salad sandwich without the bread.  Such pureed foods are sold, I think, in the grocery store under the heading of baby food.  That probably won’t do.

Before they kick her out of the hospital tomorrow I will have to have a plan in place.

The past week and weekend were busy and the night’s not very restful.  By Sunday evening late Nancy’s heart rate and pressure were going up and her breathing a bit ragged.  This morning Nancy called the doctor’s clinic and talked to a nurse that knows her.  The nurse, based on the sound of Nancy’s voice and the above mentioned symptoms, suggested bypassing the clinic and going to the ER.  Off we went.

Sure enough, after listening to chest sounds and looking at the chest X-ray we were well on the way to being admitted to the ICU – again.  That occurred right after a massive IV of the combo-antibiotic Zosyn®.  The ER nurse was new to Nancy but the ICU nurse called her by name – not having seen her since last June.  She was the nurse on duty the night Nancy had a big fluid build-up and was sensing an on-coming heart attack.  She initiated the move from the normal hospital bed to the ICU.  Today was just her fourth day of being an ICU nurse.

I spent the initial ER time with Nancy and then ran out to get food.  I was beginning to think they would have to admit me too.  I got back just as the initial Zosyn-IV finished dripping into her arm.  Then I helped with (or got in the way of) the move between ER and ICU.

The expectation is that Nancy will be there two days.  Assuming an improvement the norm will be for discharge (Wednesday?) with oral antibiotics and related follow-up.

I came home about 4 P.M. and missed a lengthily visit by an ICU doctor. I’ll add more information here as soon as I can.  It is now 5:30.  I’ve got dogs and horses to feed and then I’ll head back into town.  I likely won’t get home before 8 or 9.

Pneumonia is covered here:

http://www.medicinenet.com/pneumonia/article.htm