Regular readers of the blog will recall a recent discourse on the concept of the hospital time warp, that phenomenon wherby single days seem to take forever, yesterday seems to have been a week ago, and yet nothing has been done by the time the day is done. “Good evening, friends, you are now entering The Hospital Zone.”
Well, today was one of those days. We hardly left Tami’s room today – a lunch visit with a friend from home and another who lives nearby here, and a dinner excursion for Alexander and me – so we should have a long, complete story for tonight. Yet it’s after 10 p.m. and I wonder where the day went. I’m sure I’ll reconstruct the most of it, but it’s a weird feeling sitting here, nonetheless, the day gone, doctors and nurses and others having passed through multiple times, yet there is not a big story to tell today. In fact, somewhere in the hospital time vortex is a Facebook post that I began about 11 this morning that never seemed to materialize…
Anyway, we began the day being told (Tami alone, first, before the rest of us got there) that her “numbers didn’t look good” and that things seemed to have taken a downturn or had a mild setback overnight. They had increased again by then the epinephrine (I’m going to go all jargon and start calling it “epi”…) that had been reduced so successfully on Monday night and started another med to help increase the pumping efficiency of the heart. The whole plan for today had been to let Tami rest and let the heart recover some more and just work slowly on reducing some of the ICU-only heart meds. Several people have asked about whether Tami has been able to get up yet or walk any – the short answer is no, that’s down the line still, after removing the epi completely and after removing a catheter in her neck that is measuring pressures in and near the heart. So the plan was changing.
The first group of doctors who came by (actually the second since it was the doctors who had told Tami earlier that her numbers didn’t look good…) said that they were “generally pleased” with her progress, but that the trajectory of recovery, which had been going up and up seemed to have turned down last night for some reason. First, this is not unusual, and, second, this is not a major concern yet. It happens often that the recovery from a transplant surgery goes forward a couple of steps and then back one to regroup only to go forward again. Furthermore, this is a long process, so one day or one set of numbers doesn’t mean everything is wrong, it’s just part of the process. In fact, just to demonstrate the puzzle which is the transplant recovery, they said at one point today that either Tami had excess fluid and needed some diuretics or that she was dehydrated and might need to be given fluid and that the only way to know was to try one and see if it helped.
So the concerns were these – the right side of the heart didn’t seem to be pumping as efficiently as it should be; there was too much pressure in the main vein in the neck vein leading into the heart (maybe related to the first concern); her blood was too acidic; and she seems to be retaining fluid (likely related to the first two concerns. So what to do? The only one that we can work on is the blood acid level, which is most likely caused by not breathing deeply enough and leaving too much carbon dioxide in the lungs. So Tami practiced many times today inhaling deeply, using a little device to tell how much she was inhaling and working on inhaling longer, deeper breaths. It’s a crazy balancing act that ties in with everything else, but, long story short, she was doing much better with that by this evening and the blood gas lab results were showing an improvement there. As for the other stuff, the doctor said that we did remove a lot of mechanical and medical support from the heart and lungs yesterday and that that can be contributing to the downturn also. The heart seemed to be doing great with support, but with the supports gone, the heart is now having to catch up and that may require adding back support or just being patient.
The second group of doctors, including the surgeon (who I hadn’t seen since 12:30 a.m. Sunday night/Monday morning after the surgery), a couple of transplant cardiologists that we know, and some others, came in to say that they like the way Tami’s recovery was going – though they definitely liked it better on Tuesday. Her pulse is good, heart rate steady, heart output good, just a couple of things – one in particular – that seem troubling. And it all seems to go back to this “central venous pressure” (CVP) that is high. There’s a reason they don’t take your blood pressure in your neck (ok, besides the obviously awkward squeezing of a cuff around your neck…) – in a normal blood pressure, say 120/80, the average of the two – called the mean arterial pressure – is obviously 100. In the vein from your neck into your chest into your heart, the average pressure (that’s the CVP) is less than 10 – so obviously really hard to measure – but the blood is just flowing back at that point, with no real pressure. Ok, so Tami’s has been that, but it went through the teens into the 20s today. Why? Well, apparently the heart isn’t pumping like it should so there is a backlog – think traffic jam – getting back to the heart, so creating pressure. They can tweak some meds, etc., we’ll watch that all day, see where we are, as it improves we’ll get back to the original plan maybe, etc., etc.
The best thing, though, would be to get a picture of the heart working – an echocardiogram – yep, they have done a couple already, they are pretty easy to do (just an ultrasound image), great. And it showed that the heart is structurally sound, mechanically strong, and has no signs of anything wrong at all. That, my friends, is really great news. So the transplant cardiologist (that we have started liking quite a bit) comes back in the room and says, “If it wasn’t for this number here” (and he points at the monitor and covers the CVP) “no one in this room would be worried about anything at all.” But the CVP and the echo are conflicting. Hmmm. So here’s a specific prayer request: for clarity for the doctors about how to proceed and how to resolve the conflict between good, but conflicting and confusing, information.
The other possible source (likely, in fact) of the excess fluid, which leads to too much blood backing up in the veins, which leads to high CVP and apparently low RH output, is that Tami’s kidneys aren’t happy and aren’t playing well with the rest of her body so far. So they put her on several IV and oral diuretics today and tonight to try to help the kidneys out. Now in defense of Tami’s kidneys, we know that her previous, poorly functioning heart had caused chronic kidney disease, so it is possible that there is still some residual effect and that the kidneys simply are still recovering, too, like the rest of Tami’s body to years of being poorly supplied with blood. Well, we saw a nephrologist tonight (that’s a kidney doctor) who was going to take some samples and see if there was anything else that could be done on that end to help the fluid, etc. issue. The good news was that he said he could rule out any obvious bad things and the heart meds, diuretics, etc. seemed to be appropriate for now to keep Tami stable and moving forward. So here’s the other specific prayer request: that Tami’s kidneys work like crazy and get rid of lots of excess fluid and start and continue to work well on their own.
As the cardiologist reminded Tami, “I’m talking to you and you are awake and your heart is working and, by the way, you did just have a heart transplant less than 72 hours ago, so you are doing really good!”
Ok, I’m sure I’ve left out something important. Maybe when I’m less tired tomorrow I can avoid the hospital time warp and remember it and get it posted. In the meantime, good night, pray specifically for Tami for improvement tomorrow, and thank you all for your continuous prayers and support.