Tuesday, July 07, 2009

ICU Day 18 and 19

Monday and Tuesday are very similar days to a degree.

They started weaning Andre off the sedatives and he responded with differing degrees of agitation. The biggest battle is always when he's waking up from sedation and sleep in the mornings. He would shake his entire body, breathe rapidly, increase his blood pressure and heart rate, have V-tachs and SVTs, and pull off everything that's attached to him--the electrical leads, the feeding tube, and the breathing tube attached to his tracheotomy tube. He managed to remove the breathing tube on Monday morning so the nurse had to put him on restraints which was very difficult to witness. I hope Andre doesn't hate me for allowing that since it was done with the best intentions.

Tuesday was worse than Monday in terms of his agitation. To make matters worse, Andre has a new pulmonary & critical care fellow in-charge of his care. During Andre's most agitated state which occured at about 12:30 PM, she ordered a couple of tests that I didn't agree with--an arterial blood gas and a chest X-ray. The nurse also questioned the orders but only to me. I had a problem with the arterial blood gas because it's a more painful process than a simple venipuncture (they have to go deeper with the needle to reach an artery) which can increase Andre's discomfort. They also haven't done arterial blood gas measurements on him for at least two weeks since they took out his art-line, and his venous gas level has been a good enough estimate of how well his gas exchange is doing. In fact, they've been doing only venous gas level measurements on him everyday for the last two weeks through his central line--a process that is painless and non-invasive. The fellow's defense of the going the arterial route is that she wants to look at his O2 level even though she admitted that she is more interested in the blood CO2 and pH, two numbers that can accurately be derived from the venous blood. I pointed out to her that Andre never had any problems with his O2 level and that the O2 sensor attached to him 24/7 had never indicated any issue with his O2 saturation. My problem with the chest X-ray is that they've just X-rayed Andre in the morning (in fact, he gets this every morning) and doesn't need the extra radiation exposure since the "respiratory event" that she's so worried about is clearly agitation induced and nothing out of the extraordinary. She would have found this out if she had talked to me, listened to the nurse, or have read his charts. They did do the second X-ray of the day and as I expected, it came back with clean results. She also would not listen to the nurse when told that Andre required some bolus of sedatives throughout the day to maintain his calmness.

It took calling the attending doctor to finally let the nurse give Andre more sedation to rest him for tomorrow. They've taken off several sedatives/pain meds for the rest of the day so they can "re-boot" on how they're balancing Andre's pain and agitation with his wakefulness.

The good thing about these last couple of days is that when Andre is calm and semi-awake, he manages to communicate with me and the staff. He kisses me when I ask for them (although at one point, he withheld his kiss when I apparently pissed him off for not understanding the words that he was mouthing and I kept shouting at him to calm down and control his breathing). He's able to tell us if he's in pain and if he wants to be turned. He also understood the news about Ben Spies, Sarah Palin, and Michael Jackson (I don't know though if he'll remember them). The funniest thing that Andre did was when he gave a sarcastic smile to his nurse who gave him high praises for being able to dangle his feet off his bed during physical therapy. It was classic Andre.

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