Pullman Regional Hospital - Sunday April 4, 2021

   These entries will be a bit odd as I (Jess) will be transcribing text messages from Dusty of the events as they happened and he had time to reach out to myself and the family. I will have him come back and edit/add more when he can. 

8:24 a.m. Dusty: Dusty arrived to PRH, Day nurse Janine on phone with X-ray.

8:25 a.m. Dusty: In Joyce's room. Breakfast just delivered. Janine off phone now. Morning meds administered to Joyce. Joyce reported to have "slept some" last night, "Little better than her first night" according to Janine. 

8:26 a.m. Dusty: Planned X-ray will be to check Joyce's lungs. 

8:27 a.m. Dusty: Janine checked Joyce's vitals (lungs and heart) with stethoscope. X-ray is because docs want to rule out pneumonia. Dusty reminded staff Joyce habitually breathes shallow. Janine confirmed they know. 

8:28 a.m. Dusty: X-ray will confirm if pneumonia or if Joyce's shallow breathing is preventing lungs alveoli from fully opening. 

8:30 a.m. Dusty: Heparin (blood thinner) increased to 1000 units/hour, 20 ml/hour. Docs think they can try switching to oral dosage later today. 

8:31 a.m. Dusty: Joyce not quite coherent. Believes Dusty is her brother Skip. 

8:34 a.m. Dusty: ICU is quiet this morning so Janine & morning team are less overwhelmed vs. yesterday with problem patient(s). As Dusty got in ahead of visiting hours, room sliding door is open so nurse's station has direct line of sight to Joyce at the moment. 

8:37 a.m. Dusty: Breakfast (toast w/butter and Jam, hashbrowns, oatmeal, yogurt). Joyce appears happy with the toast. Not very communicative so far. 

8:55 a.m. Dusty: Respiratory tech stopped by to check oxygen flow and oxygen levels - fluctuating between 92- 94% currently on 2 liter flow rate. 

8:58 a.m. Dusty: PRH cannot find documentation that Joyce has had pneumonia vaccine recently from Moscow Medical or Gritman records so they will plan to administer it today. 

9:15 a.m. Dusty: Breakfast abandoned. Only ate toast and yogurt, 1/2 of water bottle drank. Janine prepping to take Joyce to x-ray.

9:50 a.m. Dusty: X-ray completed, Joyce settled back into room. Janine checking vitals again. X-ray results should be available in next 1-1.5 hours. 

10:02 a.m. Dusty: Joyce's kyphosis (hunchback) might have caused trouble for clean x-ray readings, tbd. Janine suggests that a back brace/ posture corrector or visit to chiropractor may be topic to visit with Joyce's PCP Dr. Collins in the future if the family thinks it is an issue worth treating. Joyce accepting sensors being on her again (night shift managed to hook her back up when she was passed out). BP127/62    Temperature normal (no fever), Janine will check back on Joyce later.

10:32 a.m. Dusty: Dr. Helen Carlson just visited. Heparin drip will be stopped. After all tests, sensor readings, etc. it does not appear Joyce is having a current heart attack but that she had one sometime between last EKG taken (June 2020) and present. Current looking like Joyce has pneumonia and/or congestive heart failure. 

10:33 a.m. Dusty: Plan is to administer antibiotics and diuretic and continue monitoring with lab tests. Results should be apparent if it is pneumonia and/or congestive heart failure. More extensive tests to be done tomorrow when weekday team is available to run them. 

10:34 a.m. Dusty: After those tests are run and results generated they will determine next steps for Joyce (discharge on Monday afternoon/evening or remaining in PRH additional 1-2 days for treatment and observation if needed.)

10:36 a.m. Dusty: Dr. Carlson hoping diuretic will drain any water around Joyce's heart. Antibiotic treatment would help clear lungs. Results should be that Joyce's ongoing chest pain ceases. 

10:37 a.m. Dusty: Joyce continuing not to be communicative. Currently passing out intermittently in room recliner. 

10:45 a.m. Dusty: Joyce's heart does not appear to be damaged from heart attack (whenever it happened post June 2020)

12:06 p.m. Dusty: PRH Physical therapist arrived just ahead of lunch delivery. Dusty provided update on previous Physical therapy work done September 2020 to December 2020.

12:07 p.m. Dusty:  Reviewed home care plan and how family care providers log care, how Joyce functions and activity levels. 

12:09 p.m. Dusty: Home care equipment reviewed (shower, toilet riser, powered recliner, etc.) PT work underway with Joyce, taking her on walk to check balance, mobility, etc. 

12:21 p.,. Dusty: Jenny (PT) happy with Joyce's mobility and flexibility. Saw not in Joyce's file about kyphosis someone put in (unknown) to see if it is related to possible Parkinson's. Dusty informed Jenny that was the first he heard about it. Jenny will follow up about the kyphosis/Parkinson's note on Joyce's file and see if it was idle speculation/ concern or a request for test to be done. Joyce eating lunch (mashed potatoes and salmon)

1:34 p.m. Dusty: Janine arrived to check Joyce's vitals. Joyce's blood sugar levels have been on the high 200s for 24 hours so insulin will be administered with dinner this evening. Joyce may have to resume insulin use for a few days upon returning home, dependent upon if her blood sugar levels stabilize and return to normal. 

1:36 p.m. Dusty: Blood thinner "bridge" medication administered to help restore Joyce to pre-heparin levels (counterpart the heparin) and bring her back to normal non-thinned blood level. 

2:06 p.m. Dusty: Technician arrived to draw blood. 

2:41 p.m. Dusty: Joyce begins negotiating for clothes and plan to escape hospital. 

3:07 p.m. Dusty: Lunch finished, all food eaten. Janine stopped by to change Joyce's diaper and gown but Joyce still chewing last of her meal. Joyce attempted to negotiate escape and bargain for her clothes with Janine. 

3:35 p.m. Dusty to Jess: Janine told me (Dusty) that I should do a career change, I've been a huge help to her today with watching Joyce. 

5:05 p.m. Dusty: Janine arrived to check Joyce's blood sugar level @ 186. 2 units of units administered to Joyce. 

5:11 p.m. Dusty: BP 167/66

6:11 p.m. Dusty: Joyce confused, thinking Craig and Carol and their little girls are waiting for her outside in their car. Joyce does not believe Dusty when he tells her she is in the hospital when she asks where she is. 

7:11 p.m. Dusty: Sam (night shift nurse) arrived to check on Joyce, collect vitals. 

7:12 p.m. Dusty: Joyce not responding to verbal interrogatives well nor speaking. 

7:17 p.m. Dusty: BP 181/55, Oxygen level @ 88%, oxygen level increased to 4 liters temporarily. Sam summoned assistant to adjust Joyce's position in the recliner to promote deeper breathing. Sam stepped out to get blood sugar testing kit. 

7:18 p.m. Dusty: Dusty confirmed with Sam the Joyce hasn't been very communicative throughout the day compared to yesterday. 

7:19 p.m. Dusty: Sam doesn't think blood sugar levels or insulin a factor in Joyce's lethargy. Blood Glucose @150 (good) currently.

7:21 p.m. Dusty: Sam asks Joyce to squeeze her hands or smile but Joyce does not respond. Joyce resumes sleeping. 

7:30 p.m. Dusty: Sam returned to check on Joyce and let Dusty know the doc will come ad check Joyce over. 

7:31 p.m. Dusty: Sam checked Joyce for signs of a stroke. 

7:32 p.m. Dusty: Joyce not able to remain conscious enough to provide responses needed for cursory test for stroke.

8:12 p.m. Dusty: Diana Collins ( night hospitalist) arrived to check on Joyce. Sam and Diana had difficulty rousing Joyce. Unable to get good neurological assessments. Currently continuing to try with Dusty's help. Sam confirmed her experiences with Joyce previous 2 nights with Diana, using that as a "normal baseline for responsiveness"

8:15 p.m. Dusty: Joyce woke randomly as Diana and Sam were leaving the room, Dusty recalled them. Joyce unable to respond to interrogatives and verbal stroke tests. Diana contacting doc to see if they should move Joyce onto escalating testing for stroke. Joyce resumed sleeping. 

8:18 p.m. Dusty: Sam informed Diana that she had overseen Joyce last night and that Joyce woke easily and responded to verbal commands when diaper changes were needed, even while exhausted from lack of sleep previous days and night of admission. 

8:42 p.m. Dusty: Sam arrived to administer additional unit of insulin to Joyce. Dr. Carlson on phone with other doc at the moment. Sam thinks we should know a plan shortly. 

8:59 p.m. Dusty: Dr. Carlson suspecting Joyce has CO2 narcosis. Respiratory tech has been summoned and a blood draw done to check for it. If CO2 narcosis, due to COPD, Joyce will be setup with a BiPAP for the night. 

9:00 p.m. Dusty: Dusty asked about COPD diagnosis as that hasn't been noted on Joyce's record before as far as he knows. Sam says it was on Joyce's record from Gritman, not sure who added it. 

9:02 p.m. Dusty: Joyce still not responsive. Blood sample collected and sent off to check O2 level, bicarbonate level CO2 level saturation, etc.

9:06 p.m. Dusty: Same arrived to check on Joyce's pupil dilation. Sam thinks they are not dilating evenly. Confirmed next step is to wait for blood test results to come back, should happen fairly quickly. 

9:16 p.m. Dusty: Joyce being transferred to bed by Sam and a nurse's assistant so she can be wheeled down for a CT scan. 

9:45 p.m. Dusty: Joyce wheeled back into room from CT scan. 

9:46 p.m. Dusty: Awaiting feedback on scan results.

10:03 p.m. Dusty: Sam returned after speaking with Dr. Carlson. Ct scan results showed no signs of stroke. There are signs of aneurysms (bulging of blood vessels) so blood pressure is now to be monitored more closely. 

10:05 p.m. Dusty: Carlson thinks Joyce has CO2 narcosis at this point. Joyce is being prepped for BiPAP use right now. Sam says current directive is to monitor JOyce while BiPAP is being used, BiPAP will be removed if Joyce perks up and regains enough responsiveness to want BiPAP removed. 

10:16 p.m. Dusty: Joyce hooked back up to room sensor systems by Sam, BP 153/57, O2 level @ 93%. Sam applied water to Joyce's mouth using swab as part of BiPAP use. Joyce responded dis-favorably to this which Sam took as a good sign. 

10:17 p.m. Dusty: Current plan is to run BiPAP for an hour on Joyce to start with, but Respiratory tech will remove it if Joyce becomes alert and responsive before the hour is up. 

10:20 p.m. Dusty: Joyce's Oxygen levels dropped to 86% while BiPAP being prepped. 

10:24 p.m. Dusty: 88% and lower are danger levels/seek medical aid. Currently at 82% as BiPAP activated and placed on Joyce. 

10:25 p.m. Dusty: BiPAP running, oxygen levels at 94% and rising. 

10:33 p.m. Dusty: Sam checked in with Dusty, she is leaving due to unexpected ICU staffing shortage and she has to cover morning shift, so she will be back tomorrow morning. Kelsey taking over as primary night shift nurse. 

10:34 p.m. Dusty: Confirmed plan is to keep Joyce on BiPAP until Joyce becomes responsive enough to find it uncomfortable. Joyce's blood pressure is closely monitored and medication to control it administered. 

10:35 p.m. Dusty: Joyce continuing to breath shallow and rapid per her usual pattern. Sam made sure Kelsey and respiratory tech know that is baseline normal for Joyce. 

10:58 p.m. Dusty: Kelsey arrived to talk with Dusty. Confirmed BiPAP appears to be working. CO2 levels dropping, blood pressure dropping back to safe levels, heart rate normalizing. ICU team will continue to monitor Joyce through the night. Current estimate is to expect Joyce to find BiPAP uncomfortable in 1-2 hours and be responsive. 

10:59 p.m. Dusty: Dusty Departing and will return to PRH tomorrow to keep continuity of updates.