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.
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