At the hospital with Dad - March 16, 2015

My father was diagnosed with a possible damaged aorta valve.  He was admitted to the hospital on March 5th for an exploratory procedure to verify the status of the valve and to see if the arteries to the heart were restricted.  The procedure verified that the valve was damaged and had to be replaced.  The hospital immediately started a series of tests and surgical preparations and the open heart surgery was scheduled for the 10th of March.  The surgery was successful except for some bleeding that was corrected.  During his recovery he faced a couple of other minor, but painful, complications from some previous treatments he had to his prostrate.  I was on a business trip during the operation and came back a few days before.  I agreed to take my turn as a patient "advocate" and stay my father at the hospital during the day on Monday March 16th.

I arrived at his room at about 9:15 a.m. after dropping my son off in school.  Harvey, my brother-in-law had just arrived about 20 minutes earlier.  His first comment was that there was no flow into the urine discharge bag from the catheter.  His father had just gone through a similar procedure a little over a year ago and had a similar situation where the attending nursing staff was not paying close attention to the patient's needs.  He also noticed that the drip from his saline solution bag was not flowing, the solution tube was up to the top and there was no flow.  Moreover, the solution bag was totally empty.  This was my first time in the hospital room since my father was admitted for heart valve replacement surgery.

 We looked for the attending nurse, who had six other patients to care for, and he immediately came and started to clear off his catheter discharge tube that he thought must have been plugged.  Whatever process he was using, he managed to remove at least three blood clots about one quarter inch in circumference.  I was sitting next to the bed and could see the blood clots move down the tube into the discharge bag.  The nurse also changed the saline solution bag and began the flow of fluids again - one of the bags had gone totally empty.  A little over four years ago my father had some sort of laser/radiation therapy to destroy cancer growth in his prostrate.  Apparently, this same radiation treatment also destroyed some cells in his bladder or urinary tract and the resulting "scar" tissue has not been able to properly heal.  The catheter he had installed irritated the wall tissue in his urinary tract and bladder and was the most likely source of his bleeding.  The Urologist had order a constant "flush" of his bladder in the hope that the source of the bleeding would heal.

At about 10:30 a.m. two other nurses and what seemed to be a Nurse Practitioner, came in to initiate a blood transfusion.  His hemoglobin count was at 6.9 and it should have been at 10.  However, there was reluctance to initiate the transfusion because his blood pressure was 203 / 88.  The rule was that they could not give a transfusion when the blood pressure was high.  They asked him to try to relax to see of his pressure would go down.  They took his pressure several times and the lowest that it reached was 178 /80.  My father must have had a premonition of what was to come because he kept indicating the nurse that the "blood was no good."  The nurse kept reassuring him that the blood was good and it was his type.  I did not hear the final decision but the attending nurse and another (what seemed to be a more senior nurse) initiated the transfusion.  The plan was to give him two units of blood that day.

At about 11:20 a.m. both Harvey and I noticed that the flow into his discharge bag had stopped again.  We looked for the nurse but could not find him - the shift nurse that day was Ben and he was very efficient, but had five other patients to handle.  We paged him through the call button on dad's bed and he came by about three to four minutes later.  He tried the same procedure to unplug the flow at the outlet part of the catheter but it did not work.  My father was complaining of pain in his lower left abdomen, probably due to the accumulation of fluids in his bladder.  The nurse called the Urologist and the Urologist came and initiated a manual flushing procedure of his bladder.  Using a large syringe, he pushed fluid into his bladder and extracting it again.  Each time he emptied the extracted fluids from the syringe into an empty one-liter bottle.  The procedure was very painful and dad screamed in pain every time he pushed and extracted fluids.  It took about twenty or thirty "flushes" until the urologist was satisfied that it was clear enough.  The fluid extracted was red (blood red dissolved in water), however the bottom part of the two liquid filled bottles, about 100 ml in each, were nothing but blood clots that he had extracted and were the likely "culprits" blocking the flow of fluids.  The urologist indicated to the nurse that he should maintain a rapid flush for the rest of the day and that he would come and check him at midnight, at that time he would decide if they needed to go in and surgically seal the sources of blood.  The rapid flush corresponded to about 3000 ml (about three quarts) every forty minutes.  The urologist finished the procedure about noon and dad felt much more comfortable.  The nurse had to empty the discharge bag every 40 minutes.

At about 1:45 p.m. dad felt comfortable enough to attempt eating, although complaining he had not slept all the previous night and all this morning.  I later found out that the previous night he had had a similar manual "flushing" that was very painful and kept awake.  He had a few sips of soup and half a hamburger that Esperanza had brought him during lunch, a glass of orange juice and one strip of bacon from his BLT.  Harvey had to leave to go to work about 2:45.  Shortly after he left, dad wanted some coffee to have with the "Campechana" pastry I had brought him.  I prepared him a cup of coffee like he likes it - hot with cream and two spoons of sugar.  

He was about to start eating his "campechana" when all of the sudden his arms began to shake and he began to complain that he was extremely cold.  I covered him with the blanket and tried to warm his arm by rubbing it but it was clear that he was not just cold; something else was going on.  I walked out in the hall to find the nurse but he was nowhere to be seen, I came back and rang the nurse call button.  Some minutes later he came in and I told him what was happening.  He immediately went to his station, just outside the room and made a quick phone call.  I could not hear what he said since I was trying to steady dad from his shivering.  A few minutes later a whole team of doctors, nurses and nurse practitioners came in and began to "work" on him  Dr. Gordon was trying to assess his vitals and was giving orders to the nurses.  Another doctor was making assessments and giving instructions to the nurse practitioner and another nurse.  One of the nurses began to install another IV in his right arm while a fourth nurse was trying to drawing blood from his left arm.  A fifth nurse was telling the attending nurse to get the medication being ordered and a nurse practitioner was monitoring vitals and calling off numbers to the doctors.

Dad was till shivering and was now was having a hard time breathing one of the doctors ordered 40 mg of Laxis (sp?) and 50 mg of Benadryl.  One of the nurse practitioners suggested giving him some morphine but the doctor did not comment.  The nurse putting in the new IV was having a difficult time and kept telling dad that it was going to hurt, but the pain of the IV was the last thing in dad's mind, he was still shivering severely and having a very difficult time breathing.  The nurse on his left side was having a difficult time holding his arm steady to draw blood and it took her what seems to be at least fifteen minutes to find the right place to draw the blood.  The pulmonary doctor (Dr. Ela) came in shortly after the IV was put in and the other nurse had started to draw the blood.  She immediately took control of the situation, it was obviously a pulmonary issue and not a heart issue.  She started giving orders to get certain vitals and began to review with the other doctors the status of the situation. 

The attending nurse prepared the syringes with the medication suggested and the a third nurse injected the medication into the new IV she had installed.  The pulmonary doctor asked for a number of tests to be run on his blood and the nurse tried to start the blood testing machine by inserting a card that the machine would not accept.  Finally, after many ties the card went in and she inserted the sample of blood into the tester.   Meantime the pulmonary doctor was querying the nurses and given orders to obtain certain vitals.  The nurses responded with the information as soon as they had them and the other nurse practitioner again asked about giving him morphine.  The pulmonary doctor ignored her and proceeded to urge the nurse with the blood tests to speed up the process - something they all knew could not be done.  Something went wrong with the blood testing machine and the nurse indicated she had to start over again.  Meantime they had placed an oxygen mask on him and he seemed to be breathing a little better but was still having trouble.  The nurse completed the blood test after the second try and reported the results to the pulmonary doctor.  The doctor was satisfied after the results and ordered a new breathing machine that was brought and placed on him.  The new machine came with a larger mask that covered just about his whole face and he started breathing a lot smoother and seemed to relax.  The nurse practitioner again asked about the morphine and the doctor agreed.  Once the morphine was administered dad seemed to relax and breath more deeply.

During this whole time the attending nurse kept changing the discharge bag from his bladder flush and an assistant later came to help him.  During the process I tried to stay out of the way but managed to ask Dr. Gordon what had caused this episode.  He indicated that it was most likely the blood transfusion and they would hold off on the second unit.  He said that he had received several units of blood during surgery and after the surgery, and although it was his blood type, he reacted to it.  I asked the same question to the pulmonary doctor before she left and she also indicated that it was a reaction to the transfusion but also added that maybe because his blood pressure was elevated, that might have caused a back pressure in his lungs that resulted in the accumulation of fluids in his lungs, and that would cause the reaction he had.  In either case when my sister Maria had come in for her "evening shift" as a personal advocate (at about 5:00 p.m.), dad was resting comfortably and breathing smoothly with the aid of the breathing machine.  It was a close call for dad and I'm glad Harvey and I were there to ensure that the nurse monitored the flow of fluids, and I'm glad I was there to notice the initial symptoms to the reaction to the blood transfusion and was able to get the nurse to act.  The nurses do not have time to check patients regularly and most likely he would not have caught his initial symptoms.  Given his scheduled rounds, he may not have gotten to him for some time, maybe even as long as half an hour to an hour after the symptoms began.  I don't think they would have been able to stabilize him if they waited that long.