Tuesday, March 31st. Still at Jackson Memorial Hospital in Miami

Well, March did come in like a lion and lasted all month!  Rich was suppose to have tracheostomy today, but as the ICU Medical Director was telling me that at 11:30, I looked at his tube feeding and mentioned that he was not NPO ( nothing by mouth).  He abruptly left the room and I could tell he was mad that no one wrote the order for NPO.  Okay, so now the critical care anesthesiologist fellow tells me he and the attending anesthesiologist will be doing the trach at bedside tomorrow afternoon.  When I saw the Medical Director of ICU coming off of the elevator, I asked him about a PEG tube. (Percutaneous endoscopic gastrostomy) which is a tube placed into his abdomen for the purpose of tube feedings, liquids, and medications.  He said they would get in touch with Interventional Radiology to do this.  I asked if anesthesia and radiology could coordinate their efforts to try to do it under the same anesthetic, but we will see on that.  Meanwhile, case manager working on transportation for Rich to Pensacola.  I have told you how I am going back and forth thru the stages of grieving (denial, anger, bargaining, depression, and acceptance).  Thought I was getting into the acceptance phase, only to get angry today that Rich could leave me like this.  I miss him so much it is almost unbearable.  His blood pressure on the low side today, heart rate still being controlled by amiodorone and  Metropolol .  Eyes still wandering today.  Since he doesn't have a blink response, nurse felt his eyes open today, even with ointment were drying out.   She lightly taped his eyes. I took off the tape to talk to him.   Appeared to focus at times, but eyes really wandering today.    Oh dear Lord, help us, I am so sad.

Sunday, March 29th. Jackson Memorial Hospital

This last week has been hell on Rich and me.  The TEE (trans esophageal echocardiogram) showed debris in his ventricle by his mitral valve.  Read as blood clot, vegetative growth (bacteria), or tumor. Suspect blood clot or vegetative growth.  Normally would take patient to surgery, remove the growth, and replace the infected valve.  This would be open heart surgery, and due to Rich's bleeding problems, cannot do.  In the meantime, the heart has pumped out and pushed this debris into his spleen, kidney, brain, and intestines, killing off tissue where the emboli have hit.  The only treatment for that right now is antibiotics for this infective endocarditis. He has been bleeding from his intestines for over a week and has required several blood transfusions for this.  Meanwhile he went into multiple organ failure, and severe sepsis, he did not go into septic shock, as he did not require a vasopressor to keep his blood pressure up.  He was border line DIC (disseminated intravascular coagulation, a clotting disorder), and required several units of fresh frozen plasma.  He remained in a coma unti last Sunday when he opened his eyes, grimaced, and frowned when the nurses washed his hair and shaved him.  So the next stage after coma is called a "vegetative state", where the patient may emerge into consciousness, or progress to a permanent vegetative state, where eyes can be opened and even follow voices, but no one knows if they have any cognitive thinking going on or only reflexes.  Rich's eyes were reactive to light, had a slight gag reflex, but no response to painful stimuli, and no movement of any limbs.  On Tuesday the intern was asking about his code status, and I told her he was a full code, as I had no reason to believe otherwise.  She said the team had assumed he was a Do Not Resuscitate.  Then the nurse manager asked me if I thought about taking him off of life support.  They had a "palliative" doctor come talk to me about palliative or supportive care at a specialty hospital, but Rich would need to have his endotracheal tube removed and have a tracheostomy, which he needs to have anyway, as the ET tube has been in too long.  He was scheduled for the tracheostomy on Friday morning. Meanwhile, I asked Rich's brother to come back to Miami, and his other brother's son came too, as his one brother was busy at the Mayo Clinic with his own health issues.   On Thursday morning the Neurology team came to see Rich.  On Wednesday, he did not react to painful stimuli, but on Thursday he did to the sternal rub, and also his right foot responded to pain.  The attending neurolgist told us that Rich still had swelling around the brain, so a prognosis is really not available until the swelling goes down, and then you can evaluate the mental and functional deficits.  He told us it would take time.  Meanwhile, Rich has periods that he opens his eyes, and family swears he is trying to focus and follow the voice.  Do we really know?  No.  It could just be reflex, but we are not giving up hope, until it is truly hopeless.  Rich had been in atrial fibrillation most of the week, and once in awhile would convert to a normal sinus rhythm.  On Thursday he was in a normal sinus rhythm most of the day, when my nephew came out of his room to   tell me his heart rate was elevated.  I thought he was back in atrial fibrillation, but when I got to his room his rate was in the 160-170s.  The nurse called for the Medical Intensive Care Unit (MICU) team to come.  The Medical Director Doctor, passed us in the hall and stated they put him on Esmolol to lower his rate.  A few minutes later, the nurse manager comes out to tell us that Rich was in a full code, CPR, chest compressions, and shocking him.  Those were by far the worst 10 minutes of my life.  They got him back, and he spent Friday on cardiac drips to maintain his blood pressure and lower his heart rate.  The doctors don't really know what happened, as his EKG did not show a heart attack.  Yesterday, he was able to maintain his own pressure and was off of all drips until late afternoon when they put him on a drip to lower his heart rate.  Yesterday, Saturday, we were sure that Rich was responding to my voice as he looked like he wanted to say something, and his eyes followed my voice no matter what side of the bed I was on.  Again, we do not know what, if anything is going on.  In the vegetative state Rich goes in and out of awake/sleep cycles.  If Rich remains stable enough for the tracheostomy, he will have that done this week, with hopes of transferring him to Pensacola specialty hospital, and then we will continue to watch, wait, and pray for improvement.

Wednesday, March 18, 20015 Jackson Memorial Hospital

Arrived Jackson Memorial Hospital in Miami via Lear Jet with flight physician, flight nurse, and paramedic on Wednesday March 11th about 9:00 p.m. Admitted to the medical ICU.  Thursday attending physician showed me his chest x-Ray which was almost entirely white with pneumonia.  He also showed me the MRI from Nassau which showed brain bleeds in all 4 quadrants of his brain.  On Friday, March 13th, his chest x-Ray was greatly improved, and the doctors were amazed by that.  However, now the sepsis was attacking his kidneys, and he was put on dialysis on Saturday. He has been in atrial fibrillation before and since our arrival.  They did cardiovert (shock the heart) to get him back into a normal rhythm, but that was short lived.  Meanwhile, he is now having issues with his clotting factors, and bleeding around the dialysis and other catheters, so they had to give him 2 units of blood.  They also gave him 6 units of fresh frozen plasma.  He definitely is septic with a staph aureus infection.  On Monday his liver enzymes were greatly elevated, so we are now getting into multiple organ failure.  On Monday they did a CT scan of his chest, abdomen, and pelvis.  It showed infarcts (dead tissue caused by obstruction of the blood vessel), in his kidney and spleen, most likely caused by the heart pushing blood clots or debris. The Infectious Disease doctors were consulted and they are starting to think infective endocarditis (infection of the valves and/or lining of the heart).  Tuesday they did a TEE, trans esophageal echocardiogram, in which they put a large tube down the esophagus with a camera to look at the heart and valves.  Today, Wednesday, March 18th, still awaiting complete report, but am told he has a growth in his ventricle of his heart, which may be the vegetative growth of the bacteria.  Right now he is "stable, but critical", and the hospital team has not sugar coated anything.  I ask only for your prayers for Rich.  If you are wondering about CJ, Bitts, and Rikava, God has taken care of all of them.  So happens that on Saturday, March 7th, 2 of Rich's friends were driving to Miami to pick up Dave's new boat.  Rick, a good friend from the marina grabbed his passport and came with them.  Dave had a friend in Miami with a float plane who flew Rick to Staniel Cay, where Rick met up with our old friends on Trumpeter who were taking care of CJ, Bitts, and the boat.  Rick got the boat to Miami and I got to see the dogs.  My best friend Jan flew down from Ft Walton Beach, then rented a car to bring the dogs back with her and dog sit while I attend to things here.  Rikava is buddy boating with Dave, and they left Miami today.  I will probably do a weekly synopsis of what is going on to keep you informed.  Thank you for reading our blog, CJ enjoyed writing it.  What was at one time a short while ago "Livin the dream, is now Livin the nightmare"!

March 10, 2015 Sudden End of Our Trip

This is Kathy taking over from CJ.  We have got a serious situation going on right now.  It is a long story, but right now Rich is in Doctors Hospital in Nassau, fighting for his life.  I will try to make this as succinct as possible.  Last Monday, March 2, Rich pulled something in his back in Staniel Cay.  We were anchored off of Big Majors Spot.  Got him back on boat, and he took motrin and flexeril, and cold to back.  By Tuesday morning he was literally crying from the pain.  He took a Lortab and that seemed to help with the pain.  Wednesday he was actually looking and feeling better.  Thursday he woke up and seemed a little lethargic and really sleepy.  I told him he might be oversensitive to the Lortab and flexeril, and that we should stop that and only use the motrin.  He agreed.  I also started him on some deep breathing since he had been lying in bed for 2.5 days and I did not want him to get lung issues.  He sat up and ate lunch, and had chicken enchiladas for dinner.  Then wanted to go to sleep.  On Friday morning he was very lethargic and we took him to the nurse run clinic in Staniel.  He was dehydrated and in atrial fibrillation.  Got 2 liters of Lactated Ringers, and once the EKG confirmed the atrial fibrillation, the Dr in Georgetown stated he should go to the ER in Nassau.  We chartered a private plane to get us there.  Went to the ER, where Rich was getting confused, but still alert, though sleepy.  After a slew of tests, he was admitted to the intermediate intensive care unit.  Early Saturday morning he was placed in ICU for better monitoring.  When I got there he was not responsive mentally.  He was found to be in sepsis from a gram positive infection, staph aureus, origin unknown.  Kidney tests out of whack, and an MRI and EEG done.  His MRI of brain showed some capillary bleeds in multiple locations.  When I arrived this morning, he had his eyes open, and was lifting arms and moving legs, due to pain.  His blood oxygen saturation had dropped and he was getting a breathing treatment  An Echo ultrasound was ordered to make sure he did not have endocarditis.  Meanwhile, his oxygen saturation drops, and they had to intubate him, put in a central venous line and an arterial line to monitor him.  We were suppose to be airlifted back to Ft Walton yesterday, but the hospital did not have an available ICU bed.  Today all bets are off on moving due to his deterioration.  Obviously I am distraught, but my younger sister who is a critical care nurse told me to
start thinking like a nurse.  It is better that he is intubated and on a ventilator, and being monitored
closely.  The ICU doctor and the nephrologist both thought the best place to medevac him would be

to Jackson Memorial Hospital in Miami, so arrangements were made to get him there by Lear Jet.