Intensive Care (ICU) - procedural issues, hope for the future

Intensive hospital care over the years has become an increasingly important specialty in the medical profession. It is staffed by folks who are under significant stress and who typically aim to make the patient comfortable while administering procedures to improve and stabilize body functions to a state of self sufficiency. While under the care of these special people, a person will be constantly monitored and there will be a rapid response to discomfort and any threatening change of condition. However, I have an experience to tell, as many of you probably do as well, where there are serious issues with the processes and procedures.

In my case, a fairly healthy somewhat weak elderly person incurs a fall, perhaps due to a mild heart attack. She is unable to rise but crawls to an emergency call button in the middle of the night and attempts to get help but passes out just before she gets to the button. Her distress is not discovered for more than a day.

When discovered, she is transported to the hospital and treated in the emergency room where her condition is stabilized. Then she is taken to the ICU unit to be treated and monitored until she can be moved to a regular room. In the ICU, the family is solaced to see her being cared for intensively. She is connected to a heart monitor and a breathing monitor; she is apparently comfortable. Now her family sees and hears that her vital signs indicate that she is OK. One day later, this person is conscious and able to discern what is happening around her. Things are looking up!

In two days, she looks better and is moved to a regular room. She smiles and is happy to be around her family. The heart starts to beat at a high pace, so she is moved back to the ICU. Now after two days, new problems surface. Her skin is damaged by laying on the floor. She is beginning to suffer more from the weakness of being bed ridden along with the trauma of the fall and laying on the floor.

In a day or so, due to her skin condition, a special mattress for burn patients is ordered. That would seem to help and it probably did. Yet the burden of weight on those same damaged tissues presents a serious threat to her health, sustaining the wounds, even though she is turned every two hours. She is on some serious pain killers for her skin. Nurses keep saying that they are trying to make her as comfortable as possible. That is their goal. Then I am approached by the doctor. Levels of care are explained to me by the attending internist. He says she is in serious trouble and that we need to know the levels of care the hospital offers: (1) All emergency care needed to sustain her life, (2) All care to improve her health but without certain life saving procedures such as heart electrical stimuli should her heart fail, (3)Discontinue life saving techniques altogether and give her everything to make her comfortable until she passes, (4) Take her to a facility for the terminally ill, away from treatment facilities.

We chose the first level. This lady (my mom) had elected to live to the age of 90 or beyond. She was mentally competent and was able to live independently. She had events coming up that she did not want to miss. She wanted to live! So we gave her our full support.

Over the next three weeks in ICU, her health bounced around with good days and bad days. At one juncture, the internist wanted to talk to her and see if she still maintained her posture of recovery irregardless of the pain and difficulties involved. He took her off of sedatives with our consent. He told her to our surprise, that her condition was grave and she had less than a 5% chance of living through this. She could not have surgery because of her weak condition, and it appeared that she would need the surgery if her colon did not start to function very soon. He felt that her colon would never restart. In tears, my mom agreed to go to level two support. I intervened telling the doctor to at least tell her she had a fighting chance! Now I could tell that she was beginning to give in to the illness. She would never recover from this declaration by the doctor. No superman saving techniques would be allowed now.

The next day, dramatically her colon starts to function. She is recovering and able to eat now. Off with the intravenous liquid feeding. This afternoon, the doctor changes his prognosis to a 60% chance of survival, but is unable to tell her so under the same conditions as before. He does say the words, but in my estimation, she does not understand what he says. She does not respond. We remain at level two support.

A few days later, her lungs can no longer sustain her. She has liquid in her lungs and even though she is not running a temperature, the doctors say she needs breathing assistance. She has been on oxygen for a couple of days. So as an emergency procedure, her family decides to put her on a respirator. This is not considered a level one procedure but must be administered as such, because we waited until the last minute to allow it. Now she is on a respirator, a liquid food diet administered by tube, a kidney dialysis machine, and bi-daily skin care.

Her health gradually deteriorates.

Finally, after one month of intensive care, we honor her written request to be taken off of life support systems. She passes away hours thereafter.

In retrospect, I can see very significant opportunities for improvement in the processes and procedures I saw during this long time in the ICU. For one, I feel she needed to be floated, suspended in a water type bed where the medium would be about the same density of the human body. She needed to be removed from the consequences of the gravity of this earth. Medicine apparently does not offer such support systems. I ask the question, why not? Isn't such an invention available? It is an obvious solution to the problem. When we are in water, there is great relief by flotation. Then we look at the other obvious and related part to this. Should not there be some way for a person to get exercise in this environment? Is the ICU patient supposed to abandon all exercise? Is the patient capable of some form of exercise? Isn't exercise supposed to be part of maintaining the human body?

I had this general topic on my list of things to write about, but until today, I had not seen anything supporting this thought process. Today I just read one in the New York Times (see link below). This is a good start towards improving the ICU. I plan to respond, supporting this study on exercise for those in an ICU, especially for those with extended stays (more than 2 days).

It is my sincere belief that my mom died before her time, even though she was 87 years old, because of ineffective procedures and archaic thinking in the ICU. Her age and the related ICU strategies is another subject that I will write about some another time.

New York Times article - A Tactic to Cut I.C.U. Trauma: Get Patients Up

Preparing for Hurricanes - Woodlands edition

Having lived in The Woodlands for 12 years does not make me an expert on hurricanes here; neither does living on the coast for my entire life, but after experiencing a few of them as a victim and as a spectator, I am ready to share what I know and what I do to prepare for them.

First, a hurricane is just a routine summer event around here. It's like being at a shooting range and being the target. You think one of the shooters might hit you, so you dodge your head or jump to the side. Or you see someone with a shotgun - then you just get the heck out of Dodge! We expect hurricanes. We plan for hurricanes. We rarely get the heck out of Dodge, because we live in this place, and we want to be with our possessions when the high winds come.

Sure, we live far away from the coast. But I tell you what. I can drive down there in a little over a couple of hours! We are not that far away from the worse of a storm. Although out of harm's way for tidal surges, we are in a prime wind threat area, including tornadoes and flooding. People say, I have never seen it flood here. Then one or two who have lived here their whole lives step up to say, "remember the flood of 1994?". Personally, I have not lived here long enough to vouch for the few floods in this particular area, but in the general area I live, Southwest Texas, I can testify for flood conditions many times, whether it be a tropical storm or just a tropical thunderstorm. The flood of 1994 was caused by a torrential rain from a tropical storm - 30 inches of rain in Magnolia Texas flooding the nearby watersheds and affecting Spring Creek flooding.

In any summer, we basically live in the tropics where water comes from the sky in torrents like Noah's flood. We live next to a creek that sends the runoff water to Lake Houston. That exit is limited. The creek turns into a huge running lake, dammed up by excess water. It has no where to go except up and then it spreads spatially to the lowest places it can find, like any flooding river or spring. I have reviewed the local area for flood vulnerability. Water will collect in low spots and along the main exit arteries such as Spring Creek. I live on ground 165 feet above sea level. Much of Grogan's Mill is 20 feet lower; my home is 20 feet lower than the intersection of 2978 and Woodlands Parkway. In case of Noah's flood, I think I will take my tent and canoe up there.

Let's talk about wind. What if Freeport and Southwest Houston was hit directly by a major hurricane? I lived in Southwest Houston when a cat 3 hurricane (Alicia) did that very thing. At landfall, the storm packed 130 MPH winds. The eye passed right over our home. Just a small storm, mind you. By the time it reached us, the winds had subsided to about 80MPH, a Cat 1. Trees fell and power went out. My automobile was trapped inside tree rubble, and I could not leave the house until it was cleared. Further to the east and north (the dirty side of any storm), in the Spring area, homes were without power for two weeks for some people. Trees fell in many places. That damage was only from tropical storm winds in this area! We had about 90 MPH winds in Southwest Houston and here about 70 MPH with higher gusts. People living in Spring at that time remember it well. Just ask them. There is a discussion on the topic at Weather.com by Dr Stephen Lyons.

Let's take a cat 5 storm with winds of 180 MPH striking the coast at the same place. Houston would be a disaster zone. The tidal wave would reach all the way to Loop 610. So water would not exit the rivers and streams very easily as long as the effect of the tidal surge was so high. Assume for the moment that the storm is moving fairly fast, say 12 MPH. That would give us about 8 inches of rain. If it was moving at 5 MPH, we would have about 20 inches of rain, all within about one day. Now that would have some noticeable effect! Flooding would be terrible.

My basic fear in this area is the wind. We could see winds of some 120 MPH in such a storm. Pines are like twigs in such a wind. The problem is not the velocity itself, because a pine can withstand that wind force. The problem is the shifting directions of the wind causing an entire tree to snap in two, just like whipping a brittle stick. I have seen that result here in routine thunderstorms. One thunderstorm caused a downdraft that brought a large pine crashing down on a neighbor's home and it sliced the home into two sections. Have you ever researched what a tree weighs? If you have ever cut one down, you realize that they weigh tons, literally. See this USDA article on a study of weight vs height. OK then, tons of falling timber on your roof, your car and no telling on what else, would certainly not be safe. I believe everyone would agree on that. That would be a safe bet! And people wonder why some folks evacuated from here to escape from hurricane Rita.

The solution is not to cut down the trees. Our trees are very valuable. If you have ever assessed the monetary value of a tree, you know that insurance does not pay much for them but they may take 50 years to get the size that we have them here. That is a lifetime. In reality, our trees are priceless. They are highly prized in this community. Your tree is mine and mine is yours. They are abstractly communal property.

No, the solution is to get the heck out of dodge when you are in harm's way. A shootout at OK corral is not the smart thing to do with your family. They are much more important than anything you have in your home or anything in it. That is why people evacuate.

My advice? Take super hurricanes very seriously and do not risk the health of your family for macho reasons nor for material things. Board your windows. One thunderstorm came through and a tree limb was blown out of a nearby tree through one of our windows. Shattered glass was everywhere in the room where we normally watch TV. If my children had been in there watching TV, they could have been killed by that shrapnel. As it was, they were upstairs at the time and we were busy doing chores in the house. I thank God that he taught me that lesson without harming my family. Now, the blinds and curtains are drawn for thunderstorms. For hurricanes, tape the windows. The amount of damage that a sliver of glass can cause is proportional to the velocity of the wind that blasts it through the air. Make sure everything outside is picked up. The winds can take plastic chairs and easily hurl them a hundred feet. Your neighbor could be the victim. A bird feeder could be hurled through a window. Make sure the trees are trimmed away from the house. You don't want tree limbs crashing against your home. They may just take the siding off the home.

These are other precautionary measures one should consider. If you go on vacation in August or September, assume your home will be hit by a hurricane. Don't leave it as it was. Leave it as you want to find it when you return. My advice is to expand this beyond hurricane season because Fall and Spring cold fronts often bring similar threats to your home.

OK then, you did not evacuate and decided to face the storm. I hope you have candles, water, batteries, flashlights, canned goods (you might also consider a manual can opener which does not require electricity), butane or propane gas and a generator. Always fill up one car with gasoline if not all of your automobiles. That gasoline can come in handy of you need to leave or you need it simply for storage of extra gasoline to use in the generator. A gas BBQ would be great under such an emergency, especially if you depend on electricity for cooking. You should have first aid kits(s). I have plywood ready to nail to the house should I need it. Remember, an ambulance may not be available to you. A firetruck may not be available to you. Plan for the worse and hope for the best. The stores tend to run out of it quickly. It is miserable to have a long power outage. Mosquitoes, humidity, continuing rains after the storm all contribute to a raw ugly living standard for days. If water cannot be delivered, that makes it even a worse situation. Communications may be lost. Have a book or two available, you may need some reading material. Most of all, keep track of all the little ones and the pets. Wandering off in a disaster cannot be tolerated. Have an way to get emergency news. A battery operated radio could be quite useful.

I listened to the news via short wave in Corpus Christi when we decided to weather out Hurricane Carla. In retrospect, my dad played the odds and was macho in his approach to that storm. Had it turned into Corpus Christi, the storm surge would have put our home 15-20 feet under water. I am glad I did not know that then. It was a fun adventure for our family but could have been the end of us.

One useful reference to understand the frequency of storms just to our south may be this link, looking at Freeport Texas.

Local emergency preparation information can be found at the Community Associations site.

Play it cool. The chances of being hit my such a major storm is small. Know that you are ready and not be panicky when threatened. Decide when you will leave and follow your plan.