Perry had a rather uneventful night except for the same reasons which typically awaken him. He appreciated & was reassured having me here to comfort him & meet some of his immediate needs in addition to Erica RN. He seemed be able to fall back to sleep with more ease.
Rachael RN, from another ICU, was his day shift RN. He has been anxious when he is not familiar with the oncoming RN. Rachael was very sweet & attentive as much as she could be with several interruptions to care for her other patient. As a nurse, your heart is wanting to do what needs to be done for all of your patients but you just cannot be in the 8-10 places you might need to be at the same time. She hopes to be able to take care of him tomorrow & then again when she is on night shift later this week. During PT, Dean completed hip stretches & assisted Perry to stand with Julio’s help but only able to do so for a few seconds. Perry gets worn out quickly relative to coughs & suctioning which typically increase due to position changes. Dean had hoped to be able to stand him at least a total of 3 times & then transfer him into the recliner, but an urgency to use the bedpan occurred, so plan B was to conserve energy & return him back into bed.
During rounds, Dr. Kotloff, Pulmonologist, explained that the order for the diaphragm ultrasound he discussed yesterday was done by way of speaking directly with the specialist who will be completing the procedure. He plans to be in some time today to complete the ultrasound at bedside. Dr. Kotloff stated that he spoke with Dr. McCurry, Cardiothoracic Surgeon, & it was decided to continue to wait until later this month to proceed with the bronchoscopy. He further discussed the collection of fluid outside his L lung (pleural effusion) may be impairing the progress of being weaned off of the vent by increasing the pressure on the lung. Fluid over time can become gelatinous which he’s hoping is not the case. Dr. Aaron Douglas, Cardiothoracic Anesthesiology, new to Perry’s case today, did not feel that an ultrasound of the diaphragms would be all that beneficial. A L lung ultrasound was completed at bedside to determine if the fluid collection is more liquid or gelatinous. Dr. Dale Marsh, Cardiothoracic Anesthesiology, also became involved with the L lung ultrasound & recommended that a bronchoscopy be done. Dr. Kotloff, Dr. Douglas, & Dr. McCurry agree to have Perry undergo the insertion of a pigtail catheter, a smaller chest tube, into the pleural effusion in attempts to drain the collection of fluid rather than have him undergo invasive surgery to remove it. He was added to the schedule for the pigtail catheter insertion for later today in the Interventional Radiology Department as it is done under guided radiology.
Some physicians have superior bedside manner & others have pathetic & sometimes absolutely no bedside manner with lots of arrogance. Had my mother & I not had the same observation last week with Dr. Marsh I would perhaps not be quite so offended with his demeanor & his very sarcastic comment when I said to him that he needed to read & familiarize himself with the answers to the questions he was asking me regarding dates etc that would be listed on the computer. "Oh so I am glad that you have an interest in his care as much as we do" was just not what I needed to hear.
Perry was only able to tolerate 26 minutes of trach capping @ 1159a-1225p before tiring & in need of a nap. He then was capped from 332p-344p for the diaphragm ultrasound. Dr. Ajit Moghekar, the same physician who completed the diaphragm ultrasound requested by Dr. Akindepe on 8/4 completed the ultrasound today. Perry's R diaphragm has atrophied & is thinner than it was on 8/4 & is no longer functioning. He stated there is not much of anything that will be able to be done for the R diaphragm. His L diaphragm is a little thicker than his R at current & he is uncertain of its functioning. It may or may not be able to support him from being totally weaned off of the vent. The diaphragms work like pistons to help the lungs inspire & expire air. Time will be needed to see if the phrenic nerve which activates his L diaphragm has been stretched or is truly damaged/severed. It can take as long as 6-8 months or longer for a nerve to heal; however, nerves do not regenerate if damaged/severed. In essence time will tell.... if Perry will be vent dependent, partially vent dependent, or able to be completely weaned from the vent. Dr. Eduardo Mireles-Cabodevila was the physician recommended to be involved in Perry’s care as he deals with neuromuscular diseases affecting the respiratory system & prolonged mechanical ventilation.
The day & evening progressed without having the pigtail catheter inserted. The remainder of the evening was essentially uneventful. Katie RN was his assigned nurse for the night. She too is from a different ICU. He once again asked that I spend the night with him so of course I did.