Keith and a medical situation

Newer notes, from Friday March 8, are at Keith, better days in the hospital

And NEWER newer things: from March 13

Summary in advance as of 3:30 PM, Thursday, March 7

Keith/Gunwaldt is stable but critical, unconscious and well attended, in intensive care at UNMH.



Coronary fibrilation, cardiac arrest (at Montgomery Park Sunday noonish—CPR by SCA friends, then by EMTs)

Coronary angiogram (UNMH 4:00 or so)

Another cardiac arrest after that (CPR in ICU, 6:30 pm?)

Stabilized but on many machines and IV, since later that night.

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I'm gathering things I wrote as they unfolded, to put in one place and share with friends and relatives. I'll add to it as more is known. Feel free to send the URL out and about to others who might wonder and worry.

Elizabeth McLaughlin wrote: More info from the park. Everyone there helped. Albinas dialed 911 the instant we saw Keith's condition, and stayed on the ph w/ dispatch, keeping them informed of everything we were doing, so when the paramedics arrived, they jumped out with equipment in hand, and a plan to help. Jenn, Loucretzia, Rados, & Constatine stripped Keith of his armor, in seconds, helped with CPR, and they and everyone there cleared all the arms & armor, preparing the area for the emergency crew. People were in the street to flag the ambulance, and point the crew to Keith. Anyone not actively helping, stood out of the way, but close enough to help, should anything be required. No one had to tell anyone what to do. Everyone acted as a well oiled machine. Loucretzia organized gathering Keith's gear, and getting it in Marty's car. Kayda and Bela both interfaced with the paramedics, to inform them of what we knew of family coming, and Keith's health history. from Sandra: THANK YOU, one and all. I am very grateful, both for the help people offered so quickly and generously, and for the account and the credits of it.

Midday Sunday, March 3

Keith went to fighter practice to fence. During or after a bout, he said he was out of breath, stepped back, and fell backwards. Someone called out for help and Brigitta, Bela, and Kayda (Sherri) ran to do CPR. Someone called 911, and called Marty, who called me. Holly and I started over to the park and got there as he was put into the ambulance.

Bela drove Marty to the hospital, and Holly drove me. Bela's account (and action) were important for them all to hear, as various doctors came and talked to us about different aspects of what was happening.

NOTE to Paul, Jeff and Steve-&-Beau, 5:45 pm Sunday (still Day 1):

They did the coronary angiogram. It wasn’t a heart attack, but there was blockage, and they put two stents into the LAD / front wall artery.

The doctor said that at some point in the past, Keith had a heart attack, and the front wall broke, and blood leaked out into the body cavity and calcified—on the heart, and maybe also lower down, but they’ll know more later. The heart had developed collateral vessels (like a natural bypass, he said).

The left side of the heart didn’t have significant disease, but the right had not much flow to heart tissue.

What happened at the park was that he had coronary fibrilation and cardiac arrest. So not a heart attack today, but the effect of a heart attack whenever-back. Dr. Garcia described coronary fibrilation later as "an electrical storm of the heart," and I wrote the phrase down. It didn't seem to be a good time to point out that if someone said that at our house on a normal day, probably Keith or Holly or I (if not two or three at once) would have started singing it to the tune of "sudden eclipse of the heart."

When he had his shoulder surgery most recently (November?) they made him get approval of a cardiologist first. And that test showed that he had had a heart attack at some point. That seemed odd, because we couldn’t think of anything.

Today, though, I’m wondering. Beau, do you remember when or where at an Estrella (or maybe a Battlemoor) when Keith went to the toilet at night and then had pain and a hard time getting back to the tent? He thought it was because of his back. He said he eventually made it back to the tent, and barely made it into the bed, and then stayed there for hours, and could hear people in the morning saying that he had probably already gone to the field, or had left early. He could hear them, but couldn’t get up. Then he said Beau came and checked on him later, and helped him for the rest of the time.

That might have been a heart attack.

Keith and his high pain threshhold…..

The’re putting him into the ICU, and just called me (we’re in a cafe down the hall) to get permission for a unit of blood and a blood-pressure medicine that goes by IV, but needs to go into a bigger vein, so they’re putting it in his neck. I said okay, becuase I don’t know how or why I would not say okay.

That’s what we know now.

I took notes to tell you that stuff, Jeff, because I knew you would want to know. I wish I knew more.

7:00 p.m. to the same group, plus Ashlee, who was in the Presbyterian Emergency room while were at the UNMH (university hospital, a mile and a half or so from there). Ivan's mystery rash and hives had worsened.

We’re still all waiting to go in and see him. Kirby and Destiny will go first, when they let us in to the ICU room; their kids are with a friend. Then Bela and Marty, then me and Holly. Bela will take Marty and Holly back to the park to get Marty’s jeep and Keith’s truck. I’ll stay here a while, probably.
Or if they say Keith will be fully unconscious, maybe we’ll use my van to get people to cars.

Transport ended up being different, but all vehicles were retrieved before long.

Later note, for the record. Holly didn't see Keith that night. She left with Kirby to retrieve Keith's truck from the park. Bela would have taken Marty over to where Ashlee, Ivan and Treva were, at Pres, but they were being discharged already, so Bela took Marty to his jeep, at the park.

There was a time, earlier today, when they said he would be sedated for at least two more days. Since they’re not needing to do a surgery, though, that plan might be cancelled.

We might or might not know more after we see him.

They let me sit with him a bit before the angiogram. He was cold, but Bela figures cold is a good thing.

People here are cheery and telling fun stories, now that we’re less afraid. Marty’s anxious to get back to Ivan, so I hope they let us in soon.

While we were waiting, Keith had another cardiac arrest, after they moved him from the Cardio Cath Lab to the ICU.

11:30 PM they hooked him up to the big catheter. It goes in at his neck, and has blood pressure medicine and a cold water unit so that cold water circulates though a closed loop to cool his blood.

They're trying to keep his temp at 36C, which is not very much colder than regular, but cooling the blood can help prevent continuing brain damage.

He's breathing by machine, but his lung has re-inflated (it was punctured by a broken rib during CPR).
His heart beats on its own with the help of epinephren in the IV, and blood pressure meds in the newer, larger line.

2:15 AM 3/4/19

When they were changing the pads and the bedding, he moved, grimaced, opened his eyes a bit a couple of times (but didn't focus). Opened his mouth wider (discomfort of tubes maybe), but he wasn't really awake. It was in reaction to them rolling him on one side and then the other, I think.

I held his hand through most of it, but he didn't squeeze back. Still, it felt good, and I saw his eyes, even though I don't think he saw me.

4:52 AM 3/4/19
took him for CT scan. There was an earlier request for another look at the heart, but it's hard to move him with all his stuff, so the nighttime doctors were going to stall until he was more stable, or until there was more need.
They woke me up to say they were taking him for the scan so the cardiologists could look at his heart later, but now they wanted to see his abdomen to see if he was bleeding somewhere, because his blood levels were dropping.

5:30 AM 3/4/19
5:30 they came back, and it took 20 minutes to get all the hoses reconnected from the travelling units to the big solid one.
There's no news or report of it, though. Unless it's going to require a new procedure, the doctor won't come and talk to me about it.
More blood has not been ordered, but it might be.
Even if they see where he might be bleeding inside, they might be able to affect it without surgery, says this nurse I like.

6:00:
The nurse says Keith is one of the sickest here, so there will be a lot of activity in here around 7:00 and I might not be able to sleep. Also he says when the residents do rounds, they do it outside and not right in the room, usually, and if I were to go home I could get a report from one of the doctors later.
I'm going to try to sleep for an hour or two anyway, since I have two blankets and a bed now.
I'll go home and shower and eat after I sleep some, I think.

10:15 AM:
I'm back at the hospital. Today's nurse called and asked me to come. There was another CT Scan this morning, and they found aspiration pneumonia. They're putting him on antibiotics right now.

Sometime during the CPR at the park, stomach acid (contents?) came up, and he breathed some, and now they're "treating him for aspiration pneumonia." Whether it is already pneumonia is kind of a grey area, though, but the official phrase is that above.

The other new concern is kidney problems from insufficient blood flow to organs, because although his heart is working, it's not working as strongly as it should. They have maxed out the doses of the three heart-pressure medicines, and the 4th doesn't make sense for his particular case, so they won't use the 4th one.

This morning between 7:30 when I left for home and 10:00 when I got back, Keith woke up some, and flailed a bit, arms and legs. The nurse (Annika) says he was trying to get tubes out, so she quickly increased the sedative, but that it was a good sign that he could wake up and move, and that he moved both sides, and not just one.

Noon, 3/4/19
I noticed even the chaplain came in in a gown with gloves. Thinking back, it's been since I got here.

There's a sign on the door, too. Keith tested positive for Methicillin-resistant Staphylococcus aureus (MRSA), so visitors need to wash hands before and after, and employees need to use gloves and gowns so they don't pass his staph infection to other patients.

Two things they may or may not recommend we consider, depending how everything else goes:

• swan catheter (to measure pressure in the chambers of the heart)
  
• impella (a pump that goes inside the heart temporarily)

9:55 PM: Kidneys are slightly improved. Kidney injury is resolving. Still chilled; the coronary proposals are off the table for now, nothing of note, sleeping, moved some.

Tuesday morning They were having a hard time getting him to 36C, so at 3:00 am (I think) they had set the machine to 35, to try to get him to 36. Shivering was warming him up, and they don't want him to be moving, either, so they added something to the cooling (something in the bed? I slept through it) and when I left, they had set it back to 36. Then there's a sort of bubble-wrap-looking layer above him, with a blanket on top of that. They blow warm air through channels in the plastic "blanket," to keep him from shivering while his blood is cooled. He looked comfortable. I've come home for a few hours, and Holly went to the hospital about 9:30.

Noonish Tuesday, 3/5 Dr. Ling called. They want to replace the chest tube that was taking out blood and air, initially, from the chest cavity outside his left lung, and replace it with a smaller tube that goes into the space near the top of the lung, through his chest. The other, bigger tube was having problems with flow, and they don't want air to put pressure on his heart in there. The new one will only be pulling air. (This is what I understand from a phone call. I asked some questions, there was a witness, and they took verbal approval over the phone.)

2:30 PM and a bit after Holly says that procedure was done at 2:30, and when needed her to leave so they could X-ray to make sure it was in the best spot, she decided to go find food. I'll leave to go back in just a bit. They have started very gradually warming him back up to normal temperature which should be completed at 3:00 Thursday morning. I think it's then that they plan to assess brain function. Somewhere around there.

9:00 PM, still gradually warming. He moved around some, and when that happens they make him comfortable and give him an extra bit of the regularly-ongoing sedative (Fentanyl). The new chest tube is working and the older one stayed in also, and is working better too, for an unexplained reason. (I will ask for an explanation, and maybe it won't be unexplained anymore. :-) )

11:50 PM I asked. The nurses know the story, but they don't know why either. When the new one was put in, the older, larger one started flowing. So they left them both. "Mystery tube," one said. Okay then.

They started a nutrition... packet, bag today. It goes through a tube to the stomach. It's flowing VERY slowly. "Tube feeding with a kangaroo bag." This is why I didn't know. It's secret lingo. :-)

1:40 AM Wednesday, March 6—Hiccups. I saw Keith moving and went to see if he was shivering. It was hiccups, the nurse said. She was right. Hiccups have always been painful, to Keith. Mine are minor, but his are deep and strong. He started to grimace with each hiccup. Amanda gave him a sedative boost, because it was looking uncomfortable. She turned the heat up on the cover, too.

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Wednesday, March 6 they continued to gradually bring his temperature down, kept him sedated, monitored the pumps and substances—all the machines and IVs (each bag has a beepy thing which might beep if the supply is low, or not flowing, and might beep if the battery is low).

Wednesday was a brain rest day.

Beau and Laurie came to visit in the morning, bringing recorders with extras for me. We played music he would recognize. There wasn't any for-sure response, but he didn't grimace, either. :-)

Off and on, hiccups. No sound, just the spasms.

Later in the day the cardiology department considered a swan catheter to monitor heart pressure (Jason, the nurse, had explained it well enough that I agreed for them to use one). Given progress and the various substances and number of "insertions" already in play, they decided it wasn't needed right now. These are my words, after hearing from Sadie, who was here during the decision. They might reassess later.

7:20 AM Thursday, March 7 He has a slight fever and they gave him Tylenol. Maybe it's the inhalation pneumonia, or not.

When they get to the assessment (described above) they might restrain him.

9:08 AM Thursday, March 7, the fever (slight as it was, probably 99 or so) broke. That's good. He's at his own natural temperature, after days of cooling and heating.

11:20 AM Thursday, March 7, one of the blood pressure medicines was weaned down earlier, so he's only on one, for the purposes of the tests: SAT (Spontaneous Awakening Trial) and SBT (Spontaneous Breathing Trial).

The sedative has been turned down, too.

Spontaneous Awakening might go well, in which case they will assess, a bit, his reactions to verbal requests, and his responses to stimuli. If that goes well, they can set the respirator so that Keith is the primary breather and the machine is back-up, to see how well he can breath.

If Spontaneous Awakening doesn't go smoothly, they will restore the sedative, let him relax and recover, and probably not try again until tomorrow. Partly, if I understand it well, that's because the breathing trial (if it goes well) can lead to extubation (taking the respirator tube out). That should only be done in the morning of a day shift, because there are fewer people at night to put in a new tube if something goes wrong. So because A can lead to B can lead to C, and C is safest in the morning, they don't want to initiate A at other times. I think.

11:55 AM Thursday, March 7, he's waking up, a bit. He did do "thumbs up" when the nurse asked him if he could, and he opened his eyes, sort of. :-)

They're going to do the breathing trial right now.

12:28 PM, Thursday, March 7, Keith was calm at first but got a little agitated. They set the machine to the mode where Keith is the primary "breather" and the machine is backup. He was breathing, but the tube's position was a bit bad and he was breathing around the tube, which creates a danger of aspiration. Also he coughed up some stuff that needed not to go back down. So they put the sedation back on, and will try again tomorrow.

They just repositioned the tube with the help of an x-ray, and will try all that again tomorrow.

The blood pressure medicine needed to be turned back up, which will keep them from trying again this afternoon. Blood pressure might have gone down because of the sedative. The sedative was turned back on because during the breathing trial, Keith was getting more agitated.

But he can wake up, he can follow directions (not counting be calm, yet), he *can* breathe on his own, and it should go better the next time, which should be Friday morning.

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I want to mine this for things to keep, but it's past all this now, so I'm setting it apart a bit. Sorry for the construction mess, those trying to read.

PLANS / PREDICTIONS:

Thursday, March 7 At 3:00 a.m. Keith's temperature should reach normal. (It did that Wednesday afternoon; they took the cooling machine off right at 3:00, though.) Later in the day there will be tests of neurological function. Already they know some things, though. He has responded to some stimuli, and reached to pull tubes out. He has bitten on tubes, too. He has bitten down hard enough to make alarms go off. When these things happen, he is given more sedative, not just to keep tubes in but so he can be still and not shiver while he's being kept chilled. Keith has had a scrape on his leg for over a week, and had a Bandaid on it. A nurse took that off mid-Monday, and cleaned the wound and put Betadine on it. As though in his sleep, Keith pulled his knee up (to the side, in the bed, and then stretched it out again. Then he pulled it up again, and stretched back down again, as thothough trying to get away from the Betadine. :-) That (I have been told) is called "withdrawing," and it's a good sign. One thing they do if someone doesn't respond to verbal commands (I'm reporting what was explained to me) is to pinch a fingernail, and see if the person pulls away to avoid that pain. The Betadine on the wound was not intended to be a test at all, but it still was informational.

Bringing him to consciousness is (I think) gradual and tentative. One nurse said he could wake up like a banshee. :-) I think if that happens he would be sedated some. If he comes to consciousness in agitation (biting or jerking anything around) they sedate some more. They're after calm and responsive. "Responsive" is going to involve some things like "Can you squeeze my hand? Can you give me a thumbs up? Can you stick your tongue out?" Those are things people can do with tubes in them.

If he reaches a calm and responsive phase, they will turn down the ventilator, to see how well he can breathe on his own. The display already shows if he takes a breath, and sometimes he does, when he's not so deeply sedated, or if they're changing he bed or rearranging him and it rouses him a bit and he moves. When he inhales, the monitor shows an "A" for "assisted breath" instead of a "C" for "controlled breath." When the machine does the whole thing, it shows a C. If Keith breathes in, the machine is still going to pull air out, so that's "assisted." I think (not positive) that they turn it down gradually to see how much "A" activity comes, and if he's breathing on his own after a bit, for reals, they take the tube out. For people who are not very responsive, they might keep the ventilator going because of the danger of them not knowing they need to cough or spit.

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So the summary of the preview is:

• Don't expect anything at all new on Wednesday, unless something happens.
  
• Something will happen Thursday—maybe neurological function assessment (or discovering it's too soon to do that, if he's an agitated banshee of any sort) and maybe trying to take him off the ventilator.

Newer notes, from Friday March 8, are at Keith, better days in the hospital

Disclaimer:

This is my understanding from asking questions or overhearing things or having something explained to me which I might or might not be clear about. If there are mistakes it's because I'm trying to understand things while I'm exhausted, afraid (trying not to be afraid), and moving between bafflement and glimmers.

Some vaguely related photos

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I came back at the end of March to build a trail for Keith (or others who want to read the full saga later). Both links are above, but this one was added too, and will be of interest to Keith: Visuals, and notes—where he was, where I was to get to him. That has a link to the next-newer medical progress report, too.