Sunday, March 15, 2015

Came into work again today which is Sunday. The day has turned into a very bright sunny day with a brisk wind. Again, I went to the SCSU and Rick Davey and I went in together to take care of . Some lab parameters are better and some are worse. The most worrisome of all is his respiratory situation. We have corrected what we believe is over hydration by cutting down on his fluids and giving him a diuretic. However his temperature is still 39 and he is still breathing at 35 to 40 breaths per minute. Of particular concern is the fact that on 2 L/min of nasal oxygen, his oxygen saturation is still only about 88%. Also, on call is Bob Danner from the ICU. Bob increased the nasal oxygen to 4 L/min and we had a discussion about the possibility that we might need to intubate the patient since he will likely soon get soon very tired from breathing at 35 to 40 breaths per minute. Cliff Lane was on a phone conversation with the people from Emory and Nebraska and they mentioned that even when they thought that they had very good control of intake and output of fluids, around day 8 to 10 of illness, patients often had unexplained accelerated respiratory difficulty requiring prolonged intubation. I hope that it does not come to that with however, it is entirely conceivable that it will. I will go over to the SCSU again tonight for a conference with all of the team to make these decisions. Drama tonight in the SCSU. Some change in status. All metabolic numbers, BP and cardiovascular, kidneys etc. were fine and even improving. However, he continued to be tachypneic at 35-38 resp/min. During the day, his OxSats were in the low nineties and he responded first to increasing nasal O2 from 2 to 4L/min. However, as we got into the evening, his OxSats dropped into the high 80s. His resp. rate was 38- 40. We considered elective intubation at that point, but watched him for another hour to see if he would stabilize. Instead, his OXSats dropped to 78-80 despite increasing the nasal O2. His resp. rate went to 40+. At that point we did an elective intubation performed by Bob Danner of the Clinical Center ICU. It was uneventful and now he is paralyzed with deep sedation and on the respirator. His OxSat is now 99-100% and the machine is set at 15; he is breathing on his own at 20/min. We spoke to our colleagues at Emory and Nebraska who had taken care of Ebola patients in an intensive care setting. They said that this was exactly what they had seen, i.e. a patient seems to be doing well with good numbers and then goes into an ARDS picture. They intubated them and after a variable period of time, the patients (2 in number) recovered. Hopefully, that is what we will see with He went through the night without incident.