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I’ve mentioned the drainage coming from Nancy’s chest.  From just after her operation until today the rate of discharge has steadily decreased and is now just half of what it was.  It still seems a lot to me but the surgeon thinks that it will soon be time to remove the tubes.

The pleural space is the space between the inner lining and the outer lining of the lung.  A drawing can be found here:

http://www.nlm.nih.gov/medlineplus/ency/imagepages/9968.htm

A tube, usually about as big around as a small finger is inserted in the pleural space. This tube is sutured into place and the skin around the tube is sutured. This tube can be hooked to suction to facilitate drainage.  The function of this set up is to help get the serum or fluid out of the body without allowing fluid, air, or organisms to enter.

You can learn a bit more about this by visiting the following site.

http://web.mac.com/kieran.mcmanus/Chest_drains/Chest_drainage_systems.html

There is a simple drawing showing three bottles and the basic set up.  Scroll down to see the 3-chamber plastic unit such as is being used for Nancy.  This is not shown in use here but continue scrolling down and there is a photo of a plastic unit (a Portex bag) showing the color of the initial fluid being drained from Nancy.  Over time this color has become more pink and transparent.

The pleural fluid allows the pleurae or membranes to slide effortlessly against each other during the breathing process.  The fluid is produced and reabsorbed continuously.  The decrease in volume and the change in color indicate the improvement taking place within Nancy’s body, especially the chest cavity.

Soon the sutures holding the tubes in place can be removed, the tubes pulled, and the holes closed – then her lymphatic system will have to take over the absorption of any excess fluid.

Everyone seems to be in agreement that as Nancy consumes better food and starts to move more (as in physical therapy) she will speed her recovery.  The doctor is pushing the food aspect and indicated he is currently keeping the chest drains in especially to prevent any pressure on her lungs.  When I arrived today the physical therapy team was completing a session with her and then later the nurse brought a padded chair and propped Nancy’s feet up to lessen the pressure in her legs.

Her heart rate, breathing, and oxygen saturation (without supplementation) were all in good range today.  All signs that the repair of her heart has worked as planned.

A few days ago the ICU was a bit quiet.  Not so last night and today.  We never know who is there or why but it is easy to tell when patients in serious need are there.

One of Nancy’s new “friends” following along suggested a tattoo on Nancy saying “No Heparin” and seems like a good idea.  The question is where to put it.  A medical bracelet was/is a good idea also.

I’ve thought of getting a sweatshirt listing all the things she has endured in the last year – something like

“2009 was a great year –

I survived

and then the list”

We’ll need a big sweatshirt or tiny print.

Yup.  That is all that is new today.  At a time when many open heart surgery patients would be home Nancy still has a chest drain and holding excess fluid, mostly in the lower body.  As her arms have been freed up and she has been able to move them and exercise her hands, these have taken on a normal look.

The surgeon requested of the ICU nurses that they record what part of her meals Nancy actually eats.  Then the nutritionists can calculate the nutrients she is ingesting.  The nurses just love to do this!  Yeah, right!  Having enough of the proper nutrients is essential to cell recovery and lessening the edema.  With her refurbished heart doing well they feel it is time to focus on this other problem.

At 2 P.M. a crew of two from the physical therapy staff showed up to work on Nancy.  I left.

Nancy seems to have had very little trouble from the open heart surgery.  Rather, her entire body has suffered from the allergic reaction to heparin – the anticoagulant.  Over the weekend she will stay in the ICU, then on Monday she will likely have the chest drain removed (or maybe not) and move to the fourth floor.  There they can be more active about getting to work on the lower body therapy which she badly needs.

While we are now counting nutrients we are not yet counting down the days to the end of the hospital stay.  It does seem that we will soon be doing that too.

After I arrived today two nurses came with a wheel chair for Nancy.  Then Nancy, a nurse, and I left the ICU, went down the elevator one floor to the main level and went to the front entrance.  We told Nancy we were going to escape!

Actually, on either side of the main entrance there are large windows and one can look off toward the hills east of downtown Yakima.  The temperature was cold outside and it wasn’t a really pretty day but it was the first view of the world outside of hospital rooms Nancy has had since Thanksgiving.  For four of those days her rooms had windows but there was nothing to see and she was not in shape to care.  The ICU room has a tall, thin window that lets in fuzzy light and looks at another section of the building.  That one is behind the bed so it isn’t useful either.  This was the first chance Nancy has had to become orientated – both where the ICU is within the building and where she is relative to the city.

She will stay in the ICU over the weekend it seems.  She talked to the surgery team’s nurse about not wanting to be moved because she is so weak and because there is less constant and immediate care in the Advanced Care Unit (ACU) where she was for the two 2-day periods when she was not in the ICU.    Nancy thinks a move just before a weekend is a bad idea.  I surely don’t know, while she might.

Her refurbished heart seems to be doing fine.  She is not up and around but by the time she is, about two weeks will have gone by since the surgery.  Currently she indicates there is no pain associated with the upper chest area but neither is she coughing with a pillow held closely as we were told to expect.  Her lungs are being helped to clear without that.  I think if she were more vertical then coughing might be more normal.  Nothing is normal about this though – not only is her heart healing but damaged lungs, kidneys, and liver (and her whole body) are also along for this ride.  That is why hers is a special case and why she is still in the ICU.

Nancy was getting doses of Robitussin© today with emphasis on the expectorant potential.  It seems to be working.  She is still in the ICU.

This is post-op day 8.  A regular (if there is such a thing) open heart surgery patient would likely be out of the hospital on day 5 or 6.  Nancy’s back road’s way of getting to this stage included heart attack and cardiopulmonary collapse from heparin-induced thrombocytopenia (HIT).

http://en.wikipedia.org/wiki/Heparin-induced_thrombocytopenia

I now have a single-spaced 3 page transcription of the operation as dictated by the surgeon.  I’ll work to summarize it and post that later this week.  Given my lack of medical knowledge, such a summary would not be possible without the resources on the internet (or WEB or Cloud, or whatever it is called this week) and a relatively fast connection (DSL via phone company for us out in the county), nor would this manner of providing updates on Nancy’s progress.

Nancy is slowly being transformed into a bionic woman.  Some years ago she had intraocular lenses inserted to replace the natural lenses of her eyes.    Now she has a porcine valve in her heart and, using her own donated tissue, some new plumbing for her blood.

Today the team decided she need no longer have the external pacemaker that has been with her for some time.  It has been turned off for a couple of days and she wasn’t needing it for a time before that.  So the wires were clipped and the ends leading into her heart were given a few gentle tugs.  One came out very nicely.  The other one seemed more securely anchored and so it got to stay.  It was stretched out ever so gently, clipped off, and allowed to retreat beneath the skin.  Truly, a spare part.

Otherwise, for Nancy, this was an uneventful day.  We are again talking about (but not having) a timeline for leaving the ICU and going to a skilled care facility.  A comment was made today that “there is light at the end of the tunnel.”  True, but it has turned out to be a very long tunnel.

New today is a ‘midline catheter’.  I wonder why they don’t call it an MLC?  Almost everything is known by acronym.  It’s maddening.  And I think it should be a mid-length catheter – but I didn’t get to name it.

Catheters are short or long tubes that can be inserted into the body, in this case Nancy’s, for the injection of fluids.  Thus, she gets one poke that will do for many days rather than multiple pokes.  The down side is that you have the end sticking out and taped to your skin – often in an awkward place.

The midline catheter usually goes in on the arm near the elbow joint and runs up into the area just short of the axilla or near where the arm connects to the shoulder.  I’ll get a look tomorrow.

Nancy had a PICC line (peripherally inserted central catheter) inserted last summer.  That story began in April and you can search for endocarditis to catch up.  Nancy had four different bacteria in her blood and the protocol was for 28 days of injections of about 30 minutes.  That line went from about the same location near the elbow into the artery near her heart and so the medicine was released close to where it was needed.

Today, I was there for lunch and visits by a nutritionist and a social services case manager. The case manager gave us a large 3-ring binder with reading material designed to guide us through the recovery period, especially that time after Nancy leaves the hospital.  There is also a section on pre-operation instructions and one on how to quit smoking.  I’m thinking of buying a parakeet so I’ll have something to do with those pages.

Open heart surgery was last Tuesday, so I appoint that as day “zero” and today is day 5.  They say time rushes by when you are having fun.

Actually, about half-way through our visit today Nancy said what day is this.  We knew it was the 3^rd but not the day of the week.  Then I remembered I had picked up the Sunday morning paper – from Yakima – that we just started (Sundays only) a few weeks before she went to the hospital.

When one is working or has another regular schedule the days are easily kept track of.  Not now, with us.  Nancy has a TV but isn’t interested – nothing new there.  At home we have a TV set but no reception.  Last summer I almost did something about that, namely run a line to an aerial in the middle of the pasture 300 feet out.  We bought a converter box also, but it seems a lot of work for such little reward.

We talked with the nurse some today and she claims many people do not remember these days after open heart surgery.  Nancy and I are having very normal conversations and the medical staff will converse with us about many different things.  It will be interesting to see what Nancy remembers of all this.  I do need to take a calendar to her – at least we would know what day it is.

They did bring Nancy a breakfast she would eat – an omelette of some sort.  I should have thought of that.  Yesterday I promised to bring a real ice cream chocolate shake.  About a mile before the hospital I stopped and bought one, she ate it, and then they brought lunch.  Bad timing.  Well, the lunch was green beans, white rice, and meat balls.  Good luck with those.  On a really hungry day she might eat the meat, the green beans never, and the white rice – probably not, or not much.

But progress is progress.  Day five becomes known as the day she ‘started’ eating real food.  The doctor claims this is necessary for her to flush (my word) the edema from her body and recover the look of a healthy person.

Day 6 or day 7 may be the day she sheds the chest drain.  We spoke with the surgeon about it today but he wouldn’t commit.  It even seems reasonable now to think of her leaving the ICU and going back to the fourth floor Advanced Care Unit (ACU).  Then what?

I arrived today to find Nancy in a chair.  It is not an easy task just yet for that to happen.  She is still connected to a couple of drip lines, an oxygen line, and the chest cavity drain.  She also has a suction line such as the one dental assistants use to clear your mouth.  This is a great advance over having to cough and spit into tissue.

Some body chemistry is still marginal.   Fluids are an issue partly because she is drinking a lot and not eating much solid food.  Getting rid of the fluids takes out some of the desirable chemicals, such as calcium.  While these things are easily correctable they do require monitoring, injections, and pills.  They are also (and have been for awhile) giving her low doses of insulin, as in being diabetic.  We think this may just be because of all the things that have happened and that it will not remain a long term issue.

Nancy is right handed and moves the right arm and hand more than the left.  This shows in the degree of puffy-versus-normal in the appearance of her left hand. [The puffy or swollen aspect is referred to medically as edema, caused when fluid is retained in the spaces between body cells.]

Her lower legs are likewise swollen.  This is her 37^th day of being in bed, many with almost no movement.  With the open heart surgery behind her it is a sign of progress that edema is the concern of the day.

Today, there was also the issue of the bed.  I guess she has used it so much it needed to be replaced.  So, before moving her from the chair with the Robin’s egg-blue “float” (a canvas like sling), the broken bed was moved out and a new one in.  These things may not roast the Christmas turkey or fly you to your Hawaiian vacation but they are marvels of engineering and construction.  They also cost about 50 grand.

Nancy continues to do well.  We’d like her to eat more real food but at the moment she is not much inclined to do that.

She got a big red heart-shaped pillow for her new year.  I didn’t know about these things until last night.  The gentleman homeowner who hosted the potluck last night asked if Nancy had gotten her pillow?  He had multiple by-pass surgery in the same hospital a few years back.  When I said I had no idea what he meant, his wife brought out a large red pillow in the shape of a heart.  This had an image of a heart on it and over that someone had drawn each of the by-passes that had been done inside his chest.  Also, about a dozen people had signed it – doctors, nurses, and family.

I got home to find an e-mail asking the same question?  “Did Nancy get her special pillow?”  I’m I the only one that didn’t know of these?

Well it seems that when your chest is split open and then closed again that in the weeks to follow you have an urge to cough frequently.  So as to keep it from opening again when you cough, you are told to hold a pillow tightly against your chest.  A stuffed teddy bear is sometimes given but any pillow would do.  It seems the red heart-shaped ones are the “special” ones – it could be considered a badge of courage and a statement that one survived.

Much of the very high-tech equipment was gone from Nancy’s room today.  There remained a gizmo on the floor at the foot of her bed making the sounds of a little stream tumbling over rocks.  This is part of a ‘chest drain’ and its purpose is to allow any fluid, blood, or pus to exit the ‘pleural’ cavity by way of a long tube.  Translated into English this means ‘from the hole in your body where they were working.’   Seems to me the original meaning (now said to be side or rib) has gotten lost somewhere along the path from Greek to Latin to Middle English to the World Wide Web.  A wine maker would recognize this as a “water sealed fermentation lock” with a vacuum assist through the water causing the bubbling sound.

Each of the two doctors on the floor visited briefly today and listened to her heart and lungs and pronounced her in good shape – for the shape she is in.  Many times a heart patient in the ICU will only encounter one or two doctors during a stay of a few days.  Today was Nancy’s 36^th day there and she is on their (the doctor’s) third or fourth rotation.  Somewhat uncommon we were informed.