Keeping track

Over the past few days certain tests were showing minor improvement even while Nancy did not seem better.  She was not eating much, her speech was more labored and difficult, and she continued to require a smallish amount of supplemental oxygen.  Eating grapes, yogurt, water, and a few bits and sips of other things isn’t much nourishment regardless of the good stuff the kitchen sends to the room.

The team of doctors contributed in various ways to a meeting this morning to examine evidence and plan a corrective course of action.  They reflected on the Friday morning (11/27) heart attack and the following cardiopulmonary collapse on Saturday.  The reason for this has not been known but they now think it was part of the heparin allergic reaction (I’ve previously discussed).  This collapse landed Nancy in intensive care fully sedated and on life support for eight days.

When the ventilator and the rest were removed this was a sign that things were improved and likely to continue.  But, she was never able to function without some small amount of supplemental oxygen.  Studying this situation the team collectively believes Nancy’s system took a big  ‘insult’  from the heparin-induced thrombocytopenia (HIT) (low platelet counts) leading to the condition she is in and the inability of her body to heal and strengthen.

So, they are going to try to help things along by inserting an intra-aortic balloon pump. This device consists of a cylindrical balloon threaded through an artery and into the aorta – the main artery that brings oxygenated blood to all parts of the body.  The connected apparatus inflates/deflates this small balloon in a timing sequence with the beating heart such that there is a greater supply of oxygenated blood being generated and sent to the body with less of a demand on the heart.  This should effectively mimic a more healthy heart not unlike repairing leaky valves.

Thus, they are going to try to cause improvement in her cardiopulmonary functions and, simultaneously, get a clue as to improvement expected from valve replacement and/or repair.  They will also supplement her food intake, especially with the protein necessary for better kidney function.

The pacemaker is of no relevance in all of the above as her heart has not needed it – so any change there is on hold.

While the intra-aortic balloon pump is in place Nancy will have to be fully reclined (flat on her back).   [ WHY?  I didn’t ask. ]

I left at about 2:30 when a 3-member-team from the catheterization lab swept in to take her to their home roost.

I’ll see her again at 7 PM.  A later post tonight is unlikely.

Here’s to a great Christmas Eve!                                                                                                              (it’s 4:57 here)

Really, today was just like yesterday.

I’ve got some things I need to do today and early this evening and so won’t add anything else.

Tomorrow may be just like today.

Well, it will be Christmas Eve.  That will be different.

Not a lot to report today.  Her general condition is changing slowly now so just ‘when’ I visit may mask anything else.  Maybe she has just had a short nap or maybe she has been awake and just had several pricks, prods, or questioning staff of one sort or another.

Yesterday afternoon was the ‘handoff’ of the day shift from doctor to doctor.   So Dr. X was around to hear from Dr. Y about the patients – Dr. Y having been involved for 4 or 5 days.  Thus, this morning Nancy essentially was being seen by an unfamiliar doctor and attended to by an unfamiliar nurse.  When this happened ten days ago the newly arriving doctor told me he had just spent 1 ½ hours reviewing Nancy’s file and he, in fact, already knew her and her background.  I have no doubt that these folks know what they are dealing with.  The nurses are smart, well trained, and experienced also – they wouldn’t be in an intensive care unit otherwise.

Still, this morning, Nancy felt a little miffed at the new team.  I figure if you are feeling well enough to notice the difference you might be recovering.  Just a thought.

The implantation of the pacemaker is tentatively scheduled for Wednesday morning.  Again, this is dependent on the clotting time to fall to a safe number.   The modern measure is standardized so that regardless of the particulars of the testing a number is reported that can be compared to other test results.  This is called the INR or International Normalized Ratio.

The appropriate range for a non-ill person is an INR between 0.8 to 1.2.  Nancy’s number has been much higher in recent days and was still at 2.7  on the latest test.  They are hoping for about 1.5 tomorrow morning.  From yesterday in a chat with the doctor I got the impression they would wait for it to adjust on its own rather than add platelets filtered from donated whole blood.  Note the word ‘impression’ in that line.  I could have misunderstood and/or they may change their minds.

Today Nancy showed me how to find an e-mail address book on her laptop within Mozilla’s Thunderbird mail application.  I’ll start going through that list and sending news of this site out to folks – so, if you found your way here via someone else, you may get an e-mail from me soon.  I’ll put a Christmas/New Year’s greeting on the top and you can ignore the rest.

Today was a no-go on the pacemaker implantation.  Instead they substituted a CT brain scan.  Both decisions were based on caution.  A TEE was also done.

Nancy’s blood’s coagulation characteristic did not reach the level appropriate for the small incision and threading of the lead to the heart.  The anticoagulant mentioned yesterday is cleared quickly by the body so the problem seems to have been that the blood platelet decline had not resolved from the previously used harapin.

There is the fact that she could be losing blood somewhere, and there was none in the urine or otherwise noted, so the possibility of bleeding in the brain triggered the CT scan.  That was negative.

She was more mentally playful today than yesterday – this, I think, because the adjustments in meds to prepare for the pacemaker allowed her blood pressure to come up some and so she felt better.  They started fussing about her at 4 AM so by 2 PM she needed a nap.  Interestingly, because she is getting supplemental oxygen her blood is oxygen-saturated and short of carbon dioxide.  Sleeping in this case allows her to relax and because it is the carbon dioxide in one’s system that triggers the breathing mechanism she will stop breathing for many seconds.  It sounds scary but we are told not to worry.  Easy for them to say!

Above I mentioned the TEE or Trans-Esophageal Echocardiogram done today.  For this exam an ultrasound transducer (sound source) is guided down the patient’s throat into the stomach and rests just below the heart.

The TEE provides a close look at the heart’s valves and chambers without interference from the body, ribs, or lungs.  Prior “echo” exams for Nancy where all done in a conventional way – the transducer was outside the body.  Today’s pictures were sharp enough that the doctor believes the bacteria infection last May/June was established on her tricuspid valve.  We’ve know since August that both the mitral and tricuspid valves are damaged.  This is one of the tests –because of its sharpness—that the surgeon wants to see before planning on what will be done during an operation.  [That is not currently scheduled so I look for this TEE exam to be done again – when the time comes.]

And speaking of time, today was the winter solstice in the northern hemisphere at 9:47 AM in the Pacific Time Zone.  Here’s to longer days and a brighter future.

I found out that the tech-staff in the hospital begins work early so that their results will be available when the day doctors and nurses come on duty at 7 A.M.  Thus, they may wake you up at 5:30 to take an x-ray or a blood sample.  This happened to Nancy today as they make plans to implant a permanent pacemaker on Monday morning.

They had given some meds to lower blood pressure and control her heart rate, among other things.  When I got there about 11:45 she was worn out, sleepy, and not in her usual upbeat attitude.  I helped with lunch and ate part of it.  She was ready for a nap and was nodding off, so I woke her up to say goodbye.

Today they were trying Argatroban (ar GA troh ban) as an anticoagulant.  As these things go it is relatively new and people seem not to develop the allergy to it as they do with heparin that leads to low platelet counts – if so inclined, look on the web for heparin-induced thrombocytopenia (HIT).  For any of these things there is a lot of info on the web but a nurse said to me “Remember they tell you way too much.”   Indeed, they do.

The pacemaker implant procedure is scheduled for late morning on Monday.  Apparently, Nancy will receive drugs so as to not feel or remember any of this, unlike when doing the temporary one.  There will be nothing to eat from midnight until she is reawakened.  Bummer!

When learning of Nancy’s hospital stay, one of her e-mail correspondents sent a version of the alphabet such as has been used to help children remember.  Such as, A is for apple, and B is for boat.  This one is for seniors and begins – A is for arthritis; B for bad back.

Find it here:    http://wwwwj.net/joke02/j063.html

At the end are two extra lines:

I’ve survived all the symptoms, my body’s deployed,

And I’m keeping twenty-six doctors fully employed !

I thought of this today when Nancy and I were visiting with the cardiologist in the ICU for the day.  He mentioned that later today Nancy would be visited by a hematologist.  Someone could put together a list of all the specialties and post it beside Nancy’s bed for the doctors to place a check on when they visit.  With the rotation of folks through the last two weeks she has been seen by many doctors, but most have been cardio-types.

So why the hematologist?  Apparently the chemical of choice to prevent clotting during open-heart surgery is heparin.  Nancy has developed an allergic reaction to this resulting in the degradation of blood platelets – which corrects itself when the drug is withdrawn.  There are substitutes for heparin including one derived from the saliva of leeches.  Synthetic versions have been developed insofar as leech saliva is not abundant.  I had to leave before the doctor arrived and I don’t think she was going to do much today but believe this will lead to analysis of Nancy’s blood chemistry to advise the growing team planning her surgery.

A is for anticoagulant;

B is for blood

C is for ………………

Oh, Nancy slept well last night and felt better today.  Her voice is returning.

Nancy was doing fine today and from Noon to about 2 o’clock we visited and looked at Christmas cards and she wrote short notes on the bottom of letters I’ll mail to family and friends for whom I haven’t found e-mail addresses.  One procedure, done before I arrived, was the withdrawal of 800 ml of fluid from her lungs via a needle through the back.  Ouch!  The issue is they want her lungs to get better as fast as possible so the valve replacement operation can be done.  Taking out the fluid is the fastest way of helping that problem along.  Her heart seems to be strong enough – as a muscle – but the leaking parts need fixed real soon.

I am in awe of modern medicine.

I am less respectful (rant alert) of some of the ‘stuff’ that happens.

Nancy has had “procedures” in the Catheterization Lab twice.  One and one-half days after the first she was on life-support and fully sedated in the ICU within the same building (I think the former is one floor above the later).  Within two days she received (at home) a letter and survey form wanting her to confirm their high regard for their services.  I sent it back suggesting – to the Director – that their protocol include finding out the whereabouts and health status of the intended recipient.  Her second visit to the Cath-Lab was the night time attachment of the external pacemaker and she is back in the ICU again.  The letter and questionnaire almost beat me home from the hospital.

But wait, there’s more.  The dear patient (or Nancy as we call her) gets a second letter.  This one advises her that she is pre-scheduled (what’s the purpose of the “pre” here) for a ‘pacemaker check’ at 2 PM on January 6^th 2010 and failure to appear could cost her $100.  Okay, they provide a number to call to alter this.  Hello, hospital!  She is in the ICU.  She is going to get a permanent pacemaker on Monday.  The one this letter is about – we’ll send it back in a plastic bag for you to check.  (Rant off.)

Finally – if you are still with me – the ICU discourages visitors.  In Nancy’s case she is quite able to have visitors but people in nearby rooms are very seriously ill.  If it were not for potential problems with the heart valve they would likely move her out and if they need the room, they will.  So, no visits, please, as requested by the ICU nurses.

There was heavy fog today.  They closed I-82 for a time but I apparently passed the exit they were to set up at before the police got there.  When I came down off the last ridge into our valley I could see the flashing police car lights blocking the south-bound lanes.  There was only one short stretch where the cars and trucks slowed to about 60 mph, and keeping a respectable distance between us, we sailed on through without a glitch.

The timing of the beating of one’s heart is an important and complicated process involving chemical and electrical signals and best left to someone else to explain.  Nancy’s heart has been irregular and a bit fast at times and so she gets a pill to slow it down.  As that chemical waxes and wanes so might her own internal controls and if the two combine just so – sometimes her heart rate slows.  It did that last night.

The doctor in charge of the evening crew thought Nancy’s heart was being less than true and sent her downstairs to have a temporary pacemaker attached.  For closer monitoring purposes they than moved her back into the ICU rather than into the room on the 4^th floor where she had been.  I talked with her and the nurse at about 1 AM, then went down in mid-morning.

In the ‘temp’ setup the power source is outside the body with a lead to the heart and then initiates the impulse for contraction of the heart muscle.  [Look up the ‘sino-atrial node’ if you really want to know more.]  The plan was to insert the lead up through a vein in the crotch area.  Those veins either had a problem because of having been used earlier for the balloon angioplasty, or perhaps has some blood clots from weeks of inactivity.  In any case, those trying this entry point had no luck and after some considerable period of time decided on a new route through the side of the neck.  That was quickly done.  Nancy compared their antics to The Three Stooges.  I don’t know if she told them so but she did tell some of us at mid-morning.  I don’t think the decision has been made to implant a permanent pacemaker although that is a possibility.  Meanwhile the pulse is steady now.

When I arrived this morning a crew was doing an exam of veins to check for the aforementioned problems suspected when the ‘stooges’ [I’m sure they are skilled and nice people.  They just irritated Nancy.] could not get the heart lead inserted. I think the machine is the same as used for an echocardiogram but used differently or with additional chemical tracers and software (I missed all but the last minute – poor timing.) and falls under the category of ‘vascular ultrsonography’ – I think that’s what they said.

They wheeled the machine out.  Nancy, the doctor, the nurse, and I visited off and on for an hour and the machine was brought back in – with a different operator (but one we knew) and he started to set up for an echocardiogram to be followed by lunch and then, who knows?

I went to fill the car with gas and came home.  I’ll call later but don’t plan on going down again today.  We have patches of dense fog and as darkness comes driving is difficult.  Besides, I haven’t been to the grocery store in more than a week.  It is now 3:30 – I’ll post this and go.

It was a good day for Nancy and the snow/rain/ice forecast by the local office of the weather service never showed up.  I talked to Nancy in the early morning – they wake her about 5:30 – and told her I might not come down.  But as the morning progressed I could find nothing on the internet suggesting the storm was about to arrive.  So I went.

I was there for a visit from a lung specialist – he didn’t do much but the cardiologists asked for him to stop by and report for their meeting tomorrow.  Another chest x-ray was taken later in the afternoon and some other test too but I didn’t catch exactly what Nancy said and didn’t have her repeat it.  With the collected information from the last few days the doctors will consider having her move to a skilled care facility.

I stopped by one of the possible places for her to go to and came away with a packet of material to show her, and I learned of some of the things available there and some of the rules.  I also bought a $1 chance on a large Christmas-goodies basket.  I forgot to ask where my dollar will go!

I came home to find our long driveway cleared of the 10 inches of snow accumulated over the last three days.  That unexpected gift is from a neighbor with a farm tractor with a wide blade.

That’s all for now.

. . . the time frame for holiday music as there are just 10 days to go.   Yakima’s First Presbyterian Church is a block from the hospital and their Carillon Bell Tower (or a loudspeaker with recorded sound) provides a nice touch for a minute as I arrive or leave.  Nancy would enjoy this but the only outside sound to enter her room is from the helipad on the top of the next building.  Anyway, it was a snowy-wet day in Yakima but warm enough that I could pause and listen for a few moments.  Nice touch.

At about 2 A.M., Nancy woke from a dream (or not quite woke) and decided she had the wrong clothes on for whatever it was she thought she was doing.  She claims to have just about gotten out of bed and was removing the sensor-sending units stuck to her body which triggered the arrival of the night crew.  When I arrived at Noon those folks were long gone and I don’t know what, if anything, got recorded regarding the incident.  Maybe there wasn’t an incident.  Nancy says so, and had on a new clean open backed hospital gown provided after the sensors units were restored.  Her story and she’s sticking to it.

The team of doctors is scheduled to meet on Thursday of this week to decide if she is ready to transition to a skilled care facility. One of the team visited with her mid-afternoon. If this means a few tests on Wednesday they haven’t informed her as of 6 PM.  They may be getting what they need from the on-body sensors.  This is yet another mystery to the uninitiated.  In her two day stay in this unit Fri/Sat after Thanksgiving they wheeled equipment into the room and did a chest X-ray and an echocardiogram; maybe more.  So, I think such may be done now either in-room or elsewhere.

I got a list of the local skilled care facilities from the Social Services person.  I used Google Earth to locate them and in addition to “where they are” I could get a sense of the neighborhood.  One is directly across the street from Yakima’s largest high school.  Another is just off a main street in a neighborhood one would not consider idyllic or serene.  They all come highly recommended (tight regulation and control here in WA State) so location and ambiance can be considered.  We are wondering if such places have high-speed internet connections.  A question for tomorrow.