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Posted 2015-10-13T06:09:00Z

October 12, 2015 - Start of Week #12 in the J5-5 CVICU

Josh RN provided an update that Perry’s night was uneventful as he slept through most all of the night with just a few awakenings.  Dean met with Perry for an early AM PT session & transferred him into the chair at the end of his session ~915.  Perry had not noticed but as soon as I entered his room I noticed several Cleveland Indian Tribe pictures placed about his room, with "DiGiovannis Love the Tribe" & "Go Tribe" on them.  I immediately knew the culprit was "Warrior Todd" RN.  His efforts & the taped “x” sabotages on the poster with all of the Chicago teams logos made me laugh & brought a smile to Perry’s face.  He tolerated being in the chair until ~1130 due to complaint of lower back/buttock pain, so Dean & another therapist, Julio, helped him to stand up from the chair which he had not done since 8/4 & pivoted him back into bed.  Perry’s seat cushions had been placed under the lift sling, so unfortunately he was not getting the full benefits of the padding.

Dr. Robert Kotloff, this week’s Attending Pulmonologist, stated that the team met this morning & decided not to proceed with a bronchoscopy this week but instead plan to now wait until the end of the month when the next bronchoscopy would actually be due.  Since Perry has not exhibited a fever or other concerning signs/symptoms relative to the fluid collection in the L lung, they would rather not increase his risks & further complicate his recovery as it is an invasive procedure.  I asked whether Dr. Koval from Infectious Disease had been made aware of today’s plan.  The Pulmonology resident further updated Dr. Kotloff on Dr. Koval’s input for the bronchoscopy & wanting to obtain additional lung fluids for additional diagnostic testing.  Phrenic nerve stretching vs phrenic nerve damage during his transplant procedures was once again discussed relative to whether or not his diaphragms are functioning.  Phrenic nerve stretching effects lead to a temporary condition of diaphragms not being able to function whereas phrenic nerve damage effects are permanent.  At this point, it is inconclusive as to which may be the case, & time will provide the answer as he undergoes more vent weaning trials.  I further discussed with Dr. Kotloff that Perry has continued to sleep a majority of the daytime for ~3 weeks & in my opinion his sedation does not seem to be relative to his activity although he’s been undergoing more stressful PT & vent weaning trials.  I also stated it does not seem to be a result of depression/sadness as Perry’s been able to state to me his concerns & denies that he is sleeping more as an escape in order to cope with the depression & that he has been showing an interest again in watching the Cubs & Bears.  I also mentioned that it does not seem to be relative to a change in his medications as many of the dosages have been decreased & he is on many of the same medications that he was on prior to 3 weeks ago.  He also is not considering the Epstein Barr virus as contributing to Perry’s increased sedation.  I expressed concerns in regards to the increase in myoclonus during awake & now sleep states which has been a change from his baseline & that per my request Klonopin & Ditropan started being given every 8 hours for around the clock coverage instead of @ 9a, 1p, & 9p.  

Dr. Koval, Infectious Disease, came in shortly after Dr. Kotloff, so I informed her of the decision conveyed by Dr. Kotloff of not proceeding with the bronchoscopy.  She stated she would talk with Dr. Kotloff as she was not able to be present for the team meeting.  I also expressed to Dr. Koval the same information regarding my concerns of almost 3 weeks of increased sleeping during the daytime & ~1 week of increased myoclonus.

Dr. Richard Fatica, Nephrology, then rounded & also made aware of my concerns regarding Perry’s increased sleep & increased myoclonus.  I also informed him of noticing increased cloudiness in his urine intermittently yesterday & today.  During his visit, Perry also had a blood/tissue strand slough drain from his urinary catheter which he was not concerned about.  He originally planned to continue with dialysis as needed twice a week, but then came back a few minutes later with the decision to proceed with dialysis 3 times a week in the event solutes may be the source of some of Perry’s sedation.  It will be worth a try, will help to decrease lung fluid which will further help with breathing & hopefully lengthier trach capping times.

He was able to tolerate trach capping from 1000a-1027a (=27 minutes) at which time Bill RT provided trach suction & decided since Perry was starting to exhibit more abdominal movement & oxygen desaturation to 94-95% so he ended the session.  Perry had complaint of headache shortly after ending session.  He then slept until ~245p & asked to try trach capping again.  He fell back to sleep for another 40 minutes.  He then tolerated another session of trach capping from 331p-358p (=27 minutes) with same abdominal effects & starting to have 94-95% oxygen desaturations near very end so Bill ended the session.  I’ve been told by one of the intensivist that they need to “see” how Perry does during his vent weaning trials.  I have previously stated I would videotape him during his trials, but was turned down.  Since timing is everything & only 1 doctor has ever been present for ~2 minutes a few weeks ago to “see” him in the process of trach collar breathing, I proceeded with videotaping segments of this afternoon’s trach capping. He returned back to sleep & then received a shave & bath followed by range of motion exercises provided by me.  

Perry was able to stay awake throughout almost all of the Cubs vs St. Louis Cardinals playoff game & was of course very pleased with the final “W” outcome.  Shortly after the game ended, he asked me to stay with him through the night for a few stated (mouthed) reasons:  loneliness; the patient in the next room has had frequent loud distressed suffering moans for the last 3 days & nights.  Perry’s assigned RN’s have that patient as well, so they have been kept busy attempting to comfort & care for the patient; & Perry wants me here in case the doctors round early tomorrow morning so that I can show them the videos of today’s afternoon trach capping.  

 

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