Crisis Phase - The ICU Jump Back to Crisis Phase- The ER
The Intensive Care Unit
As soon as the patient is stabilized they will likely be moved from the ER to the Intensive Care Unit (ICU). They will be monitored closely for any change in status. You can expect additional tests and procedures as the doctors gain more information about your loved one’s condition. Some procedures, even minor surgical procedures, may be done right in the room in the ICU.
Around the Clock Care
The ICU offers the highest level of care to the most critical patients. The nurses are very highly trained and have only a few patients to care for. Your loved one will receive constant attention 24 hours a day. The equipment and supplies the staff needs are readily available and should an emergency arise the response is swift and comprehensive.
Your loved one’s specific injuries will determine which doctors that are involved in their care. In our daughter’s case there was a Neurosurgeon who was managing the head injury and the Trauma Team who handled the rest of the person’s care while in the ICU. Both the Trauma Team and the Neurosurgeon will typically have coverage 24 hours a day in the major trauma centers. Other specialists will be called in as necessary.
A Frightening Sight
The sight of a seriously injured person in the ICU can be very terrifying as there may be wires and tubes everywhere. Your loved one looks so vulnerable and frail and the equipment so intimidating. Understanding what the equipment is and what it does is the best way to overcome the anxiety the appearance brings.
Below are descriptions of some of the possible treatments and equipment you may see as your family member tries to recover:
Patient Monitor / Telemetry –– Many hospitals have telemetry equipment set up to monitor the patient’s vital signs such as the pulse and oxygen saturation levels. A bundle of wires are attached to the patient and the output can be viewed on the monitor. Ask the nurse to explain the different lines and colors to you. The signals are also monitored at the nurse’s station. (photo)
Ventilator – The ventilator is a large machine that may be breathing for your loved one. Sometimes it is because the patient is not breathing well enough on their own and other times it is needed because the patient has been given drugs that suppress the breathing. You may have heard the term of a drug-induced coma. (photo)
IV’s – There may be multiple IV’s hanging by the bed providing fluids and medications. Often an IV pump is used to meter the flow. The alarm on the IV is one noise you will probably hear a lot. (photo)
NG Tube – In order to provide nutrition a Nasogastric tube, commonly called an NG tube, may be inserted through the nose. Liquid nutrition can be given through the tube. (photo)
Blood Pressure – Most hospitals will use the newer blood pressure cuffs that are left on continuously and then the machine kicks on at regular intervals to take the blood pressure automatically. The results are usually displayed on the telemetry monitor. (photo)
Urinary Catheter – The patient will typically also have a urinary catheter inserted. The tubing empties into a container hung on the bed frame. This allows the doctors to monitor the patient’s fluid output. (photo)
Secondary Insult - Brain Swelling
As if the initial brain injury was not bad enough, some of the real danger can come from the secondary insult caused by the brain swelling. A doctor explained it to us with the example of hitting your thumb with a hammer and the fact that your thumb is going to swell. He said the brain reacts the same way to its impact but the only problem is the skull severely restricts the space the brain has to swell.
The swelling, or edema, causes the internal pressure in the brain to rise. If the swelling gets bad enough it can cause the brain to herniate and push the brain stem down towards the spinal column. This can cause death by stopping the basic functions of the brainstem such as breathing and the heartbeat. The swelling can also cause additional brain damage which makes the challenge of recovery that much harder.
There are a number of studies ongoing to identify the mechanics of what actually happens in the brain at the cellular level and to find ways to stop the swelling. There is the phenomenon of brain cell death where doctors believe that some of the brain cells that were injured and die from the initial injury send off chemicals that cause a chain reaction among other brain cells causing them to die. There are some drugs if given within the first few hours after the injury that seem to help. There is also work being done to determine if hypothermia will stave off further brain damage. Consult with your doctor and explore what is right for your loved one.
Doctors have a few ways to try to manage the swelling. There is something they call a monitor Bolt that is used to measure the Intracranial pressure (ICP). The monitor Bolt has a catheter that is surgically implanted into the brain to measure the pressure levels in the ventricles of the brain. If the pressure rises the doctors will increase the drug levels to try to minimize the swelling. The Bolt may also have a valve that can be opened to drain some of the cerebro-spinal fluid from the ventricle.
There is another procedure that is employed by some doctors called a cranioectomy. This procedure is a surgical removal of a piece of the skull in order to allow the brain to expand into the opening and decrease the chance of brain herniation. After the patient passes through this critical phase the piece of the skull is reattached.
I know in our case, the swelling almost killed our daughter. At one point the doctor told us Ashleigh only had an hour, maybe two, to live. The swelling had gotten so bad that her brain was bleeding diffusely and the doctors said there was nothing they could do. This was after they thought that danger had already passed. In fact, they had already taken the Bolt out and quickly had to re-insert is as the swelling started to get worse. All of the movement my daughter had in her arms and legs in the days previous was gone. She went from moving her arms and legs and appearing on the verge of regaining full consciousness to her only movement left was the ability to blink her eyes for yes or no. We are very lucky she survived.
A brain injury leaves a person open to a number of complications. Some are as a result of the person being immobile while others are due to the fact that the brain’s control of the bodily functions has been compromised. Some of the complications may include:
DVT’s / Blood Clots – The lack of movement leaves the brain injured patient susceptible for Deep Vein Thrombosis (DVT’s) commonly called blood clots. The major concern is that these clots will travel in the body and cause a pulmonary embolism which can be fatal. You will find it pretty common for the hospital to use prophylactic measures such as intermittent pneumatic compression boots or compression stockings to try to prevent their formation. If the patient develops DVT’s the doctors will likely start the person on blood thinning agents to break up the clots and then continue the drugs to prevent them from forming. There is also a mechanical device such as the Greenfield Vena Cava Filter that can be surgically inserted into the vein to catch the clots before they travel to the lungs.
Anti-Seizure Medications - Seizures are a somewhat common occurrence after a brain injury. The seizures can occur soon after the injury or sometimes months later. Seizure medication is often given prophylactically. The downside of these medications is that one of the side effects is they can have a sedative effect. Not exactly what you are looking for when you want your loved one to become more active and alert. However, you certainly don’t need seizures right now either. (When you get into rehab remember to speak with the doctor then about reducing or changing the medication if alertness is still a factor.)
Pneumonia – Many brain injured patients on ventilators end up with pneumonia. The staff almost seems to be expecting it as they look out for the symptoms and treat it fairly quickly. It can however be a serious complication.
Ulcers or Sores - Another complication caused by the lack of movement are Decubitus Ulcers also known as "bed sores" or "pressure sores”. These sores can take forever to heal and are best avoided rather than cured. Our daughter was placed on a pressure relief air mattress overlay from KCI while she was in the ICU. We still use the air mattress and four years later we have had no problems with decubitus ulcers.
Drop Foot – In layman’s terms, drop foot is a complication where the toes point severely downward and the tendons can shorten. It is difficult to reverse and makes walking difficult or in severe cases, impossible. It can be controlled fairly easily if caught early with the use of splints. The key is early detection so make sure you ask the therapists to watch for it and stay aggressive.
Autonomic Functions – Damage to areas of the brain such as the hypothalamus can disrupt the body’s ability to manage its autonomic functions. For example, you may see very high temperatures not related to an infection. If your loved one is unlucky the staff may break out their medieval torture machine, the cooling blanket. This device is placed under the patient and then cold water is pumped through it. To make it worse they may also place ice bags under their arms and on the legs. It is painful to watch your loved one lying, shivering on this blanket in an attempt to bring their temperature down.
Metabolic Functions – The insult to the brain can affect many of the metabolic levels in the body. The doctors will request blood work to determine the levels and make adjustments as necessary. Levels out of the normal range can cause serious if not life threatening complications.
Other Procedures / Treatments
G-Tube – If the doctors decide that your loved one will need to use a feeding tube for an extended period of time they may ask you to let them place a G-tube (astrostomy or PEG tube) instead of the NG-tube. The G-tube is placed through an incision made in the stomach. It is supposed to be a lot more comfortable for the patient. It does require a general anesthetic but seems to be a fairly simple operation. The G-tube does require replacements from time to time. It also requires daily maintenance to keep the site clean and free from infection.
VP Shunt – After a brain injury, the person may develop hydrocephalus due to an increase in cerebrospinal fluid (CSF) raising the intracranial pressure. The neurosurgeon may want to place a ventriculoperitoneal shunt (VP shunt) to relieve the pressure. The shunt has a catheter that is surgically placed into the ventricles in the brain. A small pump then pumps out the excess fluid into a tube that empties into the peritoneal cavity. The newer versions are programmable so that the doctor can adjust the flow rates without another surgical procedure. Obviously, this is a major operation and does carry risks. The shunt does require an adjustment period while the neurosurgeon finds the right balance. The shunt can also malfunction which can have life-threatening effects. Make sure you learn all of the warning signs.
Other Injuries – If your loved one has suffered other injuries the staff will continue to treat those injuries. As your patient continues to stabilize in the ICU the doctors may now approach you regarding surgeries or further treatments for those injuries.
What To Expect
Coma - It's Not Like the Movies...
The word is so scary to families that some doctors do not even use it. The most important thing to know about a coma is that unlike the movies, a person is not going to just wake up from the coma and jump out of bed one day back to normal.
The medical experts can not even agree on a definition of a coma. Depending on the severity, the arousal process can be very slow. Waking up from a coma can be a long, slow process that can start with a twitch of a finger or a squeeze of a hand. If you are lucky, some of the steps will blend together in a matter of days. If you are not so lucky, the steps to arousal may take a long time, or not happen at all. (phases of recovery)
It's Just a Reflex
This is one phrase that you may learn to hate. When our daughter was in ICU we felt a squeeze of a hand or some other movement. Invariably, the response when we reported such movement was "It's just a reflex". That drove us nuts. We were with our daughter 24 hours a day and yet this resident, who was only with her a few minutes a day, was telling us what we felt strongly was volitional movement was just a reflex.
We were not satisfied, so we found a way to convince the doctors. We made sure to let the nurses see what we saw and then we had them document it in the chart. When the doctors saw that others with more objective viewpoints saw it, and not just the family grasping for straws, they spent a little more time and were perhaps more open.
No one can ever prepare for the emotional turmoil a life-threatening injury can bring. The panic, the grief, the fear. It is truly overwhelming. But, you can help ease the tension. First, no what-ifs. You can drive yourself crazy playing the what-if game when frankly it can do no good. In fact, it can only prove to be destructive.
Secondly, now is not the time to let the little things that drive you crazy come to the surface. I know your brother-in-law is a jerk and he drives you nuts, but just smile and let his unwanted advice roll off. All people want to do right now is to help you and your loved one and some are better at expressing it than others. You need every prayer and every good thought you can get, so now is the time to rise above the pettiness and just let it go.
Tips From One Family To Another
Easy to say, harder to do... Look, this is a terrible tragedy. Stop, break down, yell, cry, whatever. But, do it outside the room. And keep in mind that as tough as you think things are for you, your loved one is the one fighting for their life. So, suck it up. Your positive attitude, love, and compassion are the best medicine they can get right now.
Another reason to stay positive is we are convinced that the patients can hear you, even while in a coma. We have heard too many stories and even had some firsthand experience with people who heard something while they were unresponsive only to relay it later after they regained consciousness. The last thing that person needs to hear is people speaking negatively about their prognosis.
Finally, as bad as you think your loved one has it, there are many others who have it much worse. At least your loved one is still alive.
Set Ground Rules
Early on we set rules for the staff and the family. Only positives could be discussed in our daughter's room. We would stop a doctor in mid-sentence if we needed to and take the conversation to the hallway. Seeing someone with all the tubes and wires is crushing but the family and friends got the same message. Anyone that starts crying in the room, step in the hall until you get it under control. What we found that helped, especially with our daughter's teen-aged friends, was for them to look in at her through the window while we explained what the tubes and wires were for and that seemed to calm them before we went in the room.
Make sure everyone, staff and visitors, wash their hands when entering the room. If any visitors even think they are getting sick, ask the nurse and they can get them a mask to wear.
Know Every Med, Every Procedure, and Why
You need to be an active participant in your patient's plan of care. To do so you need know every medicine, every procedure, and most importantly, why. Write it down. Ask what alternatives are available, what are the side effects, are they being as aggressive as possible. Challenge the doctors and ask them to walk you through the alternatives. Finally, with all of the staffing problems and shortages, keeping track of the medicines and schedules may allow you to catch a problem before it happens.
The Doctors Are Rushed, Make A List
Make sure you quickly find out your doctor's schedule for rounds. Both the trauma team and the neurosurgeon. Be there and be as forward as you need to be to make sure the doctor talks to you every day. This sounds like a dumb thing to have to mention but believe me it is not. Some people who we became friends with in the hospital went days before talking with their neurosurgeon while their daughter was in the ICU.
At the same time, you need to understand that these doctors work very hard and you need to respect their time. It was not unusual for the neurosurgeons to have surgery starting at 7 AM and see them later that day still at the hospital at 9 PM. So, every day make a list of the questions you would like to ask.
Have It Explained As Many Times As You Need
The doctors and staff have been trained that when they relay information to the families that because of the trauma and the emotions they may need to repeat that information multiple times. So, don't feel bad, make your list of questions and ask again if you need to.
You Are The Boss, Don't Accept Things Blindly
If you are like me, you were brought up to listen to whatever the doctor said and accept it. After all, he or she is the expert. Well, our experience with months of hospitals and doctors confirms to me that my wife has a better approach. Her approach is that doctors are just people and she challenges every decision to make sure she understands it and that the doctor has considered all of the possibilities. Also, you know your loved one best. Remember, you have the final say.
Second Opinions Are Okay
Along the same lines, don't hesitate to call for a second opinion. Doctors generally do not take offense when you call in a second opinion and if they are offended, then that is not a doctor you want to keep anyway.
Develop relationships with nurses, doctors, and other families. Do this for many reasons. One, it will allow you to learn as much as you can about your loved one’s injuries. Secondly, the nurses will help train you to take care of your loved one and they know a lot of little tricks to make things easier. Finally, it will help your sanity in these trying times to develop relationships with the medical staff caring for your loved one and the families around you suffering through the same challenges.
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