Dad
Wednesday, March 5, 11:30pm
Mom called at 11:30 last night and said "good news!" Dr. Lee had come in to check on Dad and said "oh...you're in normal heart rhythm!" so I guess the shock worked after all. I don't know why it didn't work immediately...or maybe he regained it on his own.
So now the plan is that they started him on the drugs last night to protect his kidneys, and that needs 2 days, so now we're back to Friday morning for the cath. I'm sure we're all relieved that it won't happen until after Cheryl gets there.
Mom said Dad was sitting up, was relaxed, and did not remember the procedure. He was hungry, though, and dinner arrived at that point, so Mom hung up to go help him.
Wedesday, March 5, 4:45pm
Barry Wed. 1645- Just spoke to both M&D. He is sitting in a chair and they washed his hair and gave him a sponge bath. He sounded great and Mom said things are "looking much much better today". His blood pressure and heart rate were all good and he is off of oxygen completely. Oxy saturation has been 90 to 95 which is good. Dr. Weston told me to look for 94% or above while he was still on the oxygen so maintaining this without any ox is great news. The cath is still being planned for Friday and Mom is very happy that you are on the way Cheryl. Mom said they had visitors today and in fact were there when I called so she has not told Dad about your trip yet. Dad spoke to the lab on the speaker phone today and told them he would be back to pester them soon. She also said he has been laughing and making some jokes today so his spirits are obviously up.
Creatinine levels dropped to 1.4 and again this is another positive sign.
The next concern is mom flight. Can one of you work on that? Might be possible Dad is released and cleared mid week.
Tuesday, March 4, 9:30pm
Spoke to Mom and Dad a few minutes ago. Things sound much better tonight as Mom is more comfortable and Dad is improving. The results of the EKG today were the same as Friday so there has not been anymore damage over the last several days. They are planning on performing the cath on Friday and may want to keep him for as much as a week afterward. The cardiac enzymes are all normal and he is developing an appetite and kidney output is good. He sounded good and asked about the family, his car, and such and they had just finished watching a movie so he is obviously more comfortable and "with it"(my words). Dana called and was able to speak to them today as well and the ICU Dr. has been in several times today just to check on him and is pleased. I still think we need to discuss someone going out there and I certainly volunteer. If they really want him there another 7 to 9 days then I think a new face would be welcome by both Mom and Dad even if his health improves every day. Let me know what you guys think.
Tuesday, March 4 6pm
they've cut back on the O2 urine output looks good Lee is conferring with dr. hale - the intensive care physician lee is pleased with progress since last night cardiac enzymes - back to normal level
bck enzyme are at normal level
nose is dry - he's on a small face mask - no small tubes in nose
Contents |
more J - info
--Cheryl 16:32, 4 March 2008 (EST)
More information from Jennene:
I read through the website stuff. It looks like you guys got most of the answers for now.
FYI, the stroke risk that you have most likely read about with atrial flutter or atrib fibrillation is mostly a LONG TERM thing -- not necessarily relative to your dad's situation. If this is a short term problem, the risk is actually quite low, particularly because he is likely on blood thinners at present. Just to further explain it, it is all just a mechanical issue -- because the atria are not pumping and emptying fully, the blood tends to pool just a little bit in there. As we all are aware, pooled blood has a tendency to clot. This may be prevented by restoring normal rhythm or by giving blood thinners. The reason that you can "cardiovert" or defibrillate in the first 24 hours is because it generally hasn't been long enough for clots to form (which could travel elsewhere when normal rhythm is re-established), however if he is on blood thinners, this extends the time period during which it is safe to "shock" it back indefinately.
Many patients convert back to regular rhythm on their own, after the shock of the heart attack resolves (some of which is helped by some of the drugs that he is already on, like the digoxin, etc.). If this doesn't happen, the doctors will determine if he is "stable" in this rhythm (mostly related to heart rate and ability to maintain blood pressure) or not. If he isn't tolerating the rhythm, they will try more aggressively to convert him back. If they are unable to get him back to a normal rhythm before discharge, they will address this issue and likely send him home on blood thinners to prevent clots and therefore stroke (or other clot-related complications).
If the EF was truly 45% since his heart attack, this is indeed good news. And like Dr Weston said, this will likely improve over the next several weeks, as he heals and the medications help get his cardiac status stabilized. Also, 30 minutes of pain is not too bad in the whole scheme of things. He is a very lucky guy to have gotten good medical care so fast. Considering the complications he has had from just 30 minutes, I would imagine this could have been much worse had he not sought care immediately or if he had been "out in the boonies" somewhere. He must have good karma.
The best thing he has going for him is your caring and involved family. Good for you guys for being right on top of it. Family support makes all the difference in cases like this. Truly.
One last thing, as I mentioned to Cheryl, he will likely need cardiac rehab when he returns home. This is basically a monitored exercise/fitness program that is designed for people who have suffered cardiac damage. If you can get him referred to one, it can be of great assistance in increasing his long-term mobility and survival. He won't feel like doing it at first and many patients resist it, but those that stick to it gain benefits such as better overall cardiac function, better stamina (in the case of future events -- related to forcing the heart to grow new arteries -- yup it will actually do that under the right circumstances) and will improve cholesterol and overall health. As his family members, you can likely be helpful with the paperwork/insurance stuff required to get him set up for that and also encourage him to continue to attend. Good luck and safe travels if you go! -Jennene
atrial flutter
I was on the phone with Jennene right before I had to hang up and run out to pick Brandon up from his shadow day at Lovett. Anyway, she was saying the Atrial flutter was not out of the ordinary for his condition. She explained the "atrial kick" that Mark Weston described to Barry. She explained it as the atrium gives one last quick squeeze right before the heart pumps out it's load to "top off the tank". With Atrial flutter, it's just that it's not doing that every time. She said they talk about a 2-1 flutter, or a 3-1 flutter. She said the fact that it's "flutter" and not full fibrillation is a good thing.
She said that the two main methods they use to try to get back to a normal rhythm are medicines (like last night) or a mild controlled defibrillation, performed under mild anesthesia, to "shock" the heart back into a normal rhythm. If they are going to use defib, they do it within the first 24 hours. Again, since it's a flutter, it will probably work itself out.
Cardiac Enzymes
Jennene said an important number to ask about is the Cardiac Enzymes. These are enzymes that are released when heart cells are damaged. She said this number will give an indication of just how much tissue damage he suffered. Key cardiac enzymes are Troponin and Creatine Phosphokinase (CPK).
Cardiac enzymes and what they do
blood test for rapid detection of heart attack
Answers from Mark
--Cheryl 14:34, 4 March 2008 (EST) (from Bary's email)
- Does yesterday push back timeframe?
No, looking at the end of the week for the cath.
- Are they waiting for a particular creatinine level before they do another procedure? Actually his level is fairly good at a 1.5 and we just do not want this number to go up. Most likely they will start him on a drug (vacamist)sp? the day before which will help his kidneys handle it. He believes Dad was at 1.8 or 1.9 when he arrived so this has improved.
- What caused sudden change? Allergic reaction to ACE? No, this is part of the heart attack. The flutter is not uncommon after the heart attack and it changes amount of blood flow as the camber cannot fill that quickly and therefore the heart is less efficient. It changes the "atrial kick" and timing of the heart and this is what they were dealing with last night. He jumped to 100-150bpm and they had to slow the heart rate down. He is on dopamine. His rate as of an hour ago was good and his systolic was 100mm, so he sounded pleased with both of those numbers.
- What are some key target numbers to look for?
Oxygen saturation- we want 94% of higher...of course depending on how much he is on. Right now 5L per minute.
Kidney output- Net diarisis(sp?) is 1 liter of fluid so he is pleased with this as well. Keeping the BPM and pressures stable
- Is pacemaker a possibility? No, I do not believe this is an issue.
- How would you categorize the progress since Friday night? On course
- What is the plan for the next 3-5 days? Perform cath, balloon if needed and keep a normal rhythm. Reasonable to expect being discharged a couple of days following the procedure.
Misc. statements and notes:
He had approx. 30 minutes of chest pain on Friday and the clot buster no doubt stopped the heart attack. The first 24 hours are the most critical and we are far past that. He was encouraged that the clot buster worked so quickly and the time of chest pain was only 30 minutes. We need to wait on the "dust to settle" on the E.F. number as it takes the muscles and cells that were effected a week to a month in some cases to respond. He believed Dad's number was 45, so not normal, but that is to be expected. The sonograms and EKG's performed immediately therefore can change during the first few weeks.
I got so carried away with my notes and sheets I forgot 2 questions that Cheryl had given me...sorry did the best I could. Cardiac enzymes and what part of the heart. We can hit him next time with these.
Dr. Weston was very happy to answer the questions and stated to call him anytime, so I suggest we review and digest this and Mom's input today and maybe call him again tonight with the above 2 questions and anything else we come up with.
Make sure whoever speaks with Mom next shares this info with her.
Questions for Mark
Belinda's:
- Does yesterday's incident push back the timeframe for doing the next cath procedure?
- Strictly for planning purposes, can he give us any indication on what we're looking at for Dad being out there? A week? A month? Will they need to wait until they do a cath to make that determination? I fully understand if the answer is 'we don't know yet'
- Jennene covered a lot of good info about the flight back. What else will Dad need to have, and what symptoms do we watch for. This is probably a question best left for later.
- Are they waiting for a particular creatinine level before they do another cath procedure? or just overall waiting for both kidney function and BP levels to be stable?
Barry's:
- What caused the sudden change last night? Is this an allergic reaction to the ACE inhibitor or other drug, or was this a real possibility that could reasonably be expected?
- What are some key target numbers we are looking for? This would help when Mom calls.
Heart rate, B.P., oxygen levels, kidney output, E.F.
- What is the plan and expectation over the next 24 hours, 3 days, a week. What are the biggest concerns and obstacles during this same period? This will really help us with planning. What indicators, milestones, goals, whatever should we be cognizant of so we can evaluate his improvement or decline.
- What information did the sonogram provide on the condition of the heart and kidneys? Level of short term or long term damage.
- Is a pacemaker a possibility?
- How would you categorize the progress since Friday night?
- His opinion on one of us joining mom...he could help us plan based on response.
--Cheryl 11:11, 4 March 2008 (EST)
I just got off the phone with Dad's nighttime nurse, Terry. He said that Dad was awake and feeling a little better and that he had gotten some sleep last night. He is still having an irregular heart beat, but his blood pressure is doing better. He said they have Dad scheduled for an echocardiogram today.
Terry said Dad's EF number is 45. According to Jennene, 55% or higher is normal, at 30% his prognosis is better because he can regain 10-15%. At 10-20% you're looking at definite long term symptoms.
Terry said Dad is on Digoxin (slang, "didg") to help his heart contract. Jennene's email mentioned Digoxin.
Thanks, Barry, for the link for info about Atrial Flutter: Atrial Flutter
Bad news - if you read through that info, it says that having Atrial flutter adds a greater risk of stroke.
We should know a lot more after talking to Dr. Mark Weston and getting the results of the echocardiogram "echo".
As I said in email I'm going to start looking into flying out there. --Cheryl 11:11, 4 March 2008 (EST)
Jennene's email about Congestive heart Failure
HI. Yes, it does sound like he is having congestive heart failure (CHF) right now. That can be something that is temporary, secondary to the shock of the initial insult to his heart muscle. I am sure they are treating it (the treatment protocols are fairly standard). It sounds as if he may have suffered a significant heart attack. Some of this function may come back, particularly if treated aggressively. Long term, he'll need to have an echocardiogram (like a sonogram for the heart) to determine how well his remaining heart muscle is squeezing. In medicial terms, we refer to this as "EF = ejection fraction". Normal is 55 % or greater. Anything less than that is a sign of CHF. They may have already measured this and know his current number, but remember, it may improve over time. The current number may be helpful in determining his prognosis in the following terms: if the current number is in the 10-20% range -- he most definately is going to have long term symptoms and has a poorer long term prognosis. If the current number is closer to 30%, his prognosis is better, because he may gain back 10 - 15% of that, getting him to close to normal function.
He is probably on digoxin, but is likely on some other drugs (like dobutamine) via his IV, if his blood pressure is low. His body is likely trying bery hard to divert what good blood flow it has to places like brain, kidneys, major organs, etc. (His gut is one of the last, so it makes sense that he has no appetite.) He is probably also on some blood thinners and hopefully on a beta-blocker, which is important in the short term (although if his blood pressure is very low, they are limited on how much of this they can give). Anyway, they try to approach it from several directions and it sounds like he is at a decent place with standard protocols. The important thing is that he is improving.
In terms of going out there -- that's a judgement call more related to whether you think he and your Mom can understand what is being said and will follow through. It sounds like he is relatively stable and has a good chance of getting back to Tampa soon. When they do travel, he should do that with several precautions -- a wheelchair for the airport, nitroglycerin tablets in his pocket (with instructions about how/when to use) and an extra supply of all his drugs in case of delays. He needs to carry a copy of his medical record back with him for his doctor in Tampa. If he has had an echocardiogram, a copy of the study (in the form of CD or videotape is better than a paper report) should be made available to him -- to much of a pain to get it sent from Hawaii later. If he is short of breath at all, they might consider portable oxygen for the plane (or at the very least, let the airlines know when he arrives that he has just been hospitalized and to please check that oxygen is available on board if he feels poorly).
Mortality rates are very dependent upon the "EF" number. Once you know that, I can give you a better idea. In regards to the short term, he has made it out of the initial 48 hours and is improving, therefore, he has a decent short term rate -- provided nothing else happens. The kidney stuff should resolve -- you can live on less than one kidney, so they are probably just watching that. And they are already being careful about not assaulting his kidneys more by doing an angiogram, introducing contrast material that they kidneys have to filter out. The only real reason to push for an angiogram (catheterization) now is if they feel that he has more heart muscle at risk and they could balloon it and prevent more damage. They can tell that from EKG's and the echocardiogram. Anyway -- that's a lot of information. Call me if anything is confusing
