Where Are We Now?

Well, it’s the end of another day and Dr. Rick just came in to check on Rudy one last time before the day shift ends.  It was a full day in the unit…LOTS going on in the hallway outside Rudy’s door with the trademark “quiet bustle” that starts to stir when things get busy.   Of course, busy usually means serious needs and that weighs heavy on my heart…always.  It must have been weighing heavy on Rudy too because he struggled some this morning finding a comfortable breath and heart rate.  He received a couple of doses of meds and by 2pm this afternoon, he fell asleep and soundly slept all afternoon. 

We come, now, to the end of another week and my question as I prepare to head back to Santa Barbara tomorrow is “where are we now?”.  Last week there was hope we would attempt to extubate early this week.  That didn’t happen and there hasn’t been any talk of how long it’ll get pushed back.  Two weeks ago the order to stop feeds to his gut was given until he is extubated.  Is that still the plan or does the delay in extubation change that?  What are the big risks now?  Last week there seemed to be light at the end of the vent-tunnel…and this week it feels like Rudy is marooned on vent island.  In my check-in with Dr. Rick, I’d say he is guarded but continues to feel Rudy is on a slow upswing…that’s encouraging coming from Dr. Rick.  I appreciate his perspective.

Although we didn’t talk specifically about extubation today, my guess is that it won’t happen anytime soon.  In talking with Dr. Robert last week, I believe at this point the key to extubating Rudy is sprinting.  We need to get Rudy back to sprinting 3-4 hours three times a day.  Rudy stopped sprinting last week because he wasn’t tolerating it well and was easily agitated.  We have reason to be encouraged by his vent settings of 14bpm and pressure support of 12 but we have stalled a bit.

This brings us to the issue of feeds…how much longer will they put a hold on feeding Rudy?  He had a metabolic test today and the test results should come back tomorrow.  The information gathered from the test will help the team determine the best nutritional/caloric combination for Rudy at this point.  The decision to stop the feeds until Rudy was extubated was, in part, to give the lymphatic system time to heal.  The problem with waiting too long is that TPN (the nutrition he gets through his IV) is hard on the liver over time.  So far the liver looks good and we certainly don’t want to compromise the liver’s health with too much TPN.  Dr. Rick wants to consider all this information carefully and come up with a plan to start feeding possibly with a feeding tube that goes through his stomach and directly to the top of his intestines.  Rudy was weighed today (see picture) and weighed in at 11lbs and .07 ounces!  He’s definitely growing!!!

So, damage to the liver is a potential risk but I think infection still remains the greatest risk.  Thankfully, Rudy only has three “foreign” lines right now…the ET tube down his throat into his lungs, the feeding tube down to his stomach through his nose and the IV in his left arm.  These are all potential sources of infection but thankfully his cultures this week have come back negative!

Lastly, Drs. Brian and Rick have ordered a CT scan of Rudy’s chest tomorrow (Fri.) morning.  They want to take a closer look at pockets of fluid that have accumulated on Rudy’s right side.  This mornings xray was about the same as the past couple of days but not as good as it has been.  Dr. Rick said that if tomorrow’s early morning xray shows a decrease in the fluid then he will cancel the order for the scan.  I’ll wait to return to SB once Rudy is safely settled back in his room if the CT scan does happen.  We’ll have to wait and see…that seems to be the case with everything I’ve listed here tonight so we’ll keep you posted as things continue to unfold.  Please pray that things will, indeed, unfold!!!