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SUNDAY — Drip. Drip!

Nancy’s follow-up to a week of intensive care . . .

Hello folks, I’m back. We stayed till 9:30 at the potluck and jam session. Each day at 3 P.M. I get infusions. Rocephin. Drip. Drip. Gentamycin. Drip. Drip.

Saturday and Sunday the procedure differs because out-patient services are not open on the weekend. So I go to the regular Medical Surgical nurse station (MedSurg in hospital-speak) and check in. They treated me like a million dollars too… and all went well. John brings a book and I sleep.

I’m a thousand percent better, if that is possible mathematically, from last Tuesday a week ago when I entered ER in Ellensburg. They still did not really find a source of internal bleeding, so I’m blaming it on the bacteria and hopeful the antibiotics will vanquish them forever and the blood loss. (Maybe it could be suppressed production and not a loss? Just a thought. Either way, maybe it will vanish. JFH) Only 5 ½ weeks to go. Drip. Drip. The Gentamycin was added because of my pig valve in my heart. Previously, June/July ‘09, I was on straight Rocephin.

I think the one day I had the CT Scan, Endoscopy, Colonoscopy, and a ton of Barium X-rays of the whole track, upper and lower intestines, from 2:45 till 10:00 P.M., and about 5 blood draws, that I deserved the an award for the most procedures one patient was subjected to in one day. I might have had the TEE that morning too. That also included a rude awakening early morning by the nurse who had seen a succession of atrial fibrillations and thought there was a V-tac going on. It was not. She was obviously upset and wanted to know if I had any chest pain; well no, only the continuing pain from the two clots in my spleen. I also said I was having a night mare (probably caused by the antibiotics, she said). So I was ready to go back to sleep and await the morning blood draw at 5:15 a.m.

Rest in the hospital has to come in pieces. One morning (night?) they woke me at 3:30 to weigh me. Hello! I’m supposed to rest. I got pretty good at it. The last few days there I was moved to a MUCH quieter room on the 4th floor in ACU (Acute Care Unit). That is one step down from ICU (intensive care) but honestly in my case I was still on telemetry and oxygen and still very monitored.

We’ll return to Sunday postings now. I trust the next reports will continue with my feeling better and improving. Don’t quite have the stamina back yet after a week of bed rest, but I’m getting there.

~ ~ ~ ~It seems when Nancy has issues the house colludes with her. Our water system – well, house, barn, yard – seems to be leaking. We have a 30 gallon pressurized tank. The pump is supposed to keep water in it and another gizmo inflates an internal bubble and presto we have water when and where we want it. Currently the pump and gizmo do their stuff and then the water drains back out via some unknown leak. Then the pump – pumps again, and it drains out again. Drip. Drip.

Nice folks came this morning and carried away the penultimate puppy – I turned the pump on and got enough warm water so we could send her off without the dirt. We still have the male but need to wait a few more weeks until he develops immunity to parvovirus because of the known incidence of it somewhere visited by the family that got the little guy that died (and the virus is now in their own house and yard). We stopped and got him an extra vial of prevention today. So he gets a shot tonight. Ouch! — but hopefully no drip, drip.

We have a report back on the little puppy who left today. She slept the entire 3.5 hour trip home. They have introduced her to their securely fenced backyard, and their older dogs in the house. She has explored the house. She also found out about a water sprinkler and enjoyed getting her head wet, staying a happy puppy. We are grateful for yet another fantastic home.

THURSDAY — Double Dang!

I think Nancy feels better today than she has in a couple of months. A lingering question about the blood loss remains. If not caused by the bacterial infection, then what? The heart issues will be treated continually, so, while she is examined, tested, and treated appropriately for her finicky heart over the next few weeks, the anemic aspect will be watched. Multiple exams ruled out many things, so with respect to this, we are in a period of watchful waiting.

She went to the local hospital for antibiotic infusion via the PICC line today. The pharmacy folks indicated they were okay with both of the compounds going in at the same time. That cut the procedure down to about an hour. They fixed up a nice comfy bed for the duration and when I returned she was ready to go.

I hadn’t stayed. That’s the “double dang” part. One of my jobs yesterday was to clear out the hospital room. Things such as un-opened fruit juice and the plastic pans for holding tape or other incidental items – these things all get sent home with the patient or tossed out. I cleaned up all these things into a couple of small boxes and a plastic bag. A nurse brought a wheelchair, I went ahead and brought the car to the front door, and minutes later we were on I-82 heading toward home.

Big mistake. Someone (me?) forgot to unplug two power supplies – one for her cell phone and one for the laptop. Bummer. Ensconced in a fluffy bed, Nancy recharged while I boomeranged from Ebrg-to-Yak and back. Wind gusts today were nearly 50 mph and the passenger side of the car sometimes makes an odd woodwind sound when air begins passing over us at about 100 mph. I got that a lot today along with the turbulence. I did see a large column of dust coming from the lower valley south of Yakama and streaming into the area above the clouds over my route. That was very interesting. On the ground these dust steams make for nasty driving, accidents and closed roads.

Now that Nancy has her computer back I will expect her to write on Saturday.

There is a potluck by and for the Kittitas Valley Fiddlers and Friends tomorrow evening, so, Friday will be an off-day for our communications.

WEDNESDAY — Dang!

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.

TUESDAY — Oops!

One of my favorite sites on the Web is called the “oops” list:

http://micom.net/oops/

The Oops list has many photos and a few video clips – funny and odd things, many of airplanes in various states of not flying. Give it a look.

So, my “oops” is that yesterday I wrote that Nancy’s PICC line had been inserted. I called that one too soon – sort of a “Dewey Defeats Truman” thing:

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

I was out-maneuvered by the medical folks. In searching for internal blood loss their tests were coming up with a lot of nothing. Thus, the PICC inserter was pushed away from the insertee and folks showed up (mid-afternoon) with a yummy barium sulphate drink. X-rays have an unfortunate propensity to pass through empty intestines but not through barium. By ingesting and thereby coating the walls of the gastro-intestinal tract (in Nancy’s case now, the small intestines) with barium the snaky little thing shows up clearly on the X-ray pictures.

Barium in its elemental state is not found naturally as it combines easily with lots of other things thereby producing a variety of compounds, one being Barium Sulfate (BaSO₄). In most mineral collections you can find Barium-“Desert Roses” and these are a concentric pattern of increasingly larger crystals stained red with iron. Picture here:

http://new.minerals.net/mineral-variety/Mineral/Desert_Rose.aspx

That is about as familiar as one gets with Barium unless you are lucky enough to be handed a glass of Barium Sulfate liquid mix. This is not anyone’s favorite drink.

So you drink the stuff, gag, spit, and wait. After sufficient time the small intestines are ready for their time before the “camera” and then you wait some more and they are back for second and third exposures. This exam is sometimes called a “Barium follow through” and in Nancy’s case yesterday the follow-through ended at 10:30 P.M. She had gone a couple of days without real food and her digestive tract – well cleaned out – was not prepared for crispy chicken and biscuits. We have one very unhappy Southern belle.

The day ended with no PICC line so that procedure was today but delayed because the PICC-inserter had a full schedule and did get to Nancy until about 3:15 P.M. They finished with an X-ray to check for proper placement of the end of the catheter. She called me about 5 P.M. to confirm all is well. Except for the known issues with her health they have found nothing new.

I have a car-service appointment (a mile from the hospital) at 10 A.M. tomorrow so we are hoping she might get walking papers by noonish.

We’ll see. John

MONDAY — Anticipation

Yesterday nothing showed up on the CT scan of the pancreas but the spleen had two spots indicating, I think, blood clots. These so called “splenic infracts” are blockages of the veins or arteries for the blood supply to the spleen. Atrial fibrillation and bacterial endocarditis are known contributors to splenic infractions. These are expected to be reabsorbed after awhile. Nancy’s current case of endocarditis has been halted. We also hope something can be done to reduce the incidents of A-fib. In any case, now the infractions are known about and fit into the general situation and are not a big worry. It is also a relief to know that the pancreas is without problems.

Splenic infarction can occur without symptoms (asymptomatic), which was the case with Nancy until this week. This week the typical symptom — severe pain in the left upper quadrant of the abdomen showed up. Sometimes the pain radiates to the left shoulder but that wasn’t the tell-tale sign. Fever and chills develop in some cases and she did have these, but, again, with the other things happening (including the bladder infection) they were not the symptoms that led to the CT scan.

So, onward. This morning the nurse told Nancy that her colonoscopy was scheduled for one o’clock. The nurse didn’t seem aware that an upper GI endoscopy had been talked about and so went off to check. Sometime later she came back to report that both were to be done – and so they were. So they looked into her from both ends and found nothing. Good news.

They refer to the upper GI exam as an “EGD” – and for good reason. Who wants to say “esophagogastroduodenoscopy” more than once? Rather than me explaining that you can read about it here:

http://www.gicare.com/endoscopy-center/upper-gi-endoscopy.aspx

A follow-on regarding the duodenum (the first section of the small intestine) is here:

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

This test ruled out any bleeding within the three structures, and that’s good.

The last procedure for the day is the instillation of a “peripherally inserted central catheter” (PICC or PIC line) for which, in previous reporting, I used the acronym PICC. You can read about it here:

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

I will add a bit more on this tomorrow. We then may have some indication of a release-from-hospital date because there are no more procedures scheduled and the PICC line can be used at the Ebrg hospital to infuse the antibiotic therapy as was done last July.

So while no plans are yet made, we are anticipating escape release soonish.

Cheers, John

SUNDAY — A trip to the CT lab

Being Sunday, this is the one day of the week that we have been writing. If you are returning for the first time since last Sunday you will want to go back and start on Monday (a catch-up day) or on Tuesday when an early morning event sent Nancy back to Yakima Regional’s ICU.

~ ~ ~ ~ ~ ~ ~ ~

The only news for today is that late this afternoon Nancy had a CT scan of her spleen and pancreas. This site:

http://pedsurg.ucsf.edu/conditions–treatments/splenectomy.aspx

shows the location of these. The spleen has important roles in regard to red blood cells and the immune system. The pancreas is a gland that produces many different substances to both aid digestive functions and regulate other processes. If you look at the image on the suggested web site you can see that these organs are within a three dimensional jig-saw puzzle with other soft tissue parts, namely, the stomach, liver, and gallbladder. Projecting X-rays through the body to the far side and onto an imaging surface or film will give a muddled picture.

Think of taking two thin clear wine glasses of different shapes, say one is more cylindrical and tall and the second is more of an onion bulb shape.

Set one in front of the other and look along the line that goes through the center of both. This might make for a confusing image, at least, more so than if you slid the one out to the side from behind the first.

When trying to “see” internal body parts with X-rays we can’t just move the parts around as with the glasses. But, by moving an X-ray source and the film to many different positions the technician can get individual thin sections, pick only ones imagining, say the spleen, and then stitch those sections back together again and reassemble a picture; or you can just look at the individual slices.

There is an explanation and color image here:

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

The word “tomography” is explained there.

Nancy had to drink a bottle of Gastrografin, which contains a molecule with Iodine and aids in producing ‘contrast’ so the image picks up the target tissues, that is, the intended part or parts.

Nancy left her room at about 5 P.M. and was back by 5:30. She said they took about 400 images. This information will be sent out to an experienced person who will interpret and consult with the doctors in charge of Nancy’s care. So at this point we do not have any results.

Meanwhile, she stays on a liquid diet in preparation of the upper-GI and colonoscopy, now planned for tomorrow.

She has given up on the Jell-O and is very tired of the special juice drinks provided for sustenance. Who can blame her?

FRIDAY — Better and waiting

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

THURSDAY — Progress, I think.

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)

————————————————————————

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

WEDNESDAY — Take a number.

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.

TUESDAY — Yikes!

We’re back in the ICU at Yakima Regional. Nancy has something going on and not being sure what, the consensus of the medical profession was that Yak-Reg ICU is the best place for her for a few days.

I’ll make this short (for now): We woke early this morning, I think about 5:30. I let the puppies out, asked Nancy if she was okay. She was, then she wanted something to spit into. I got that for her and went down the hall and went to bed. At some time later she got up and went into the kitchen and was dumping here tiny waste bucket into the sink. At that point she apparently had a ventricular fibrillation episode and sank to the floor. Her ICD responded with a double whammy and converted the beat back to normal.

Her legs and arms are weak (and maybe more so from the incident) and she rested a time on the floor but did not get up. She thought I had gone outside and expected my return. After about an hour she yelled for me and, being just down the hall, I appeared after the first yelp.

We then went to the Ellensburg ER where they soon determined the main thing wrong, as far as they could tell, was from a blood sample. She was quite anemic and the doctor thought that might have triggered the V-fib and set off the ICD. Test of the kidney function did not suit them either. They cannot download the data from the ICD here and so, with a unit of blood hanging beside her – off to Yakima she went.

I talked with her a few minutes before 5 P.M. and she sounded fine but had little real news. I’m posting this at about 5:25 and will head on down.

More Wednesday.

John