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Old 01-11-2013, 05:58 AM   #1
hillcountryannie
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Care in an ICU

One of my MC's is an ICU from a self-inflicted gunshot wound to the head. I think his injury is, of course, very serious but after extensive therapy he's going to do fairly well.

I've done research on gunshot wounds to the head, so I feel I've got a handle on the long term recovery. But what I need help with is the details of care in an ICU. I want the details to be pretty accurate, but I know each patient is different. So generally speaking...

1. Would a 17-year-old with a wound like this be admitted into general ICU or pediatric ICU?

2. He's unconscious for about 2 months. I know that after about two weeks patients are moved from a breathing tube to tracheotomy. What's a realistic time for him to come off the trach after waking?

3. I know people who've had a trach removed have a hoarse voice for some time after. But would someone who's been unconscious so long be able to talk (generally speaking, not taking into account the brain injury)?

3. If he's receiving OT, when would he be able to eat?

4. Again speaking generally, how long would a patient like this be in the hospital before being moved to a rehab facility?

Thanks for helping!
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Old 01-11-2013, 06:51 AM   #2
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The easy answer for all of your questions is "it depends".

More specifically:

1. Most ICUs take young adults up to the age of 21, but it depends on the circumstances. A 17 year-old with a head wound might end up in an adult neuro ICU if he was having severe seizures, strokes or other neurologic complications. It also depends on if the PICU is equipped to handle his case.

2. Coming off of the trach is more a function of respiratory status than time because people get sent home with them all the time. Respiratory therapy will usually come in and slowly wean patients off the respirator. They have all sorts of tests they run and numbers they crunch to see if a person is ready to come off the machine. If he's otherwise healthy (which is prob a stretch after a two month coma) then as little as a couple of days after waking. But, again, it depends.

3. Likely neurologic deficits aside, he would definitely have an altered voice while the area healed. Tracheostomy tubing can be very irritating and the incision would take time to heal.

4. PT/OT is hard work. I can't imagine he'd be doing that and not eating. If they had him on a feeding tube while unconscious, he'd probably move up to a diet as tolerated relatively quickly.

5. It's hard to speak generally because this isn't really a common situation. I assume the when you say he was unconscious for two months that it was a medically-induced coma to hopefully allow his body to heal. Otherwise it's hard to imagine a real-life case of someone spending two months in the ICU in a natural coma. The cost would be mind-boggling, ~$2000 a day. If you couldn't be awakened, doctors would likely tell the family that nothing more could be done and start talking about "options". Novels can take liberties, but just be aware, you're entering into soap opera territory. After leaving the ICU, he'd probably spend some time on the Med-Surg floor before being discharged. It's difficult to say how long because, like I said, this isn't a common scenario.

Good luck!
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Old 01-11-2013, 08:26 AM   #3
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Thanks for the info. Yes, medically-induced coma, but it might end up being a shorter time.

It's funny you mention the soap opera thing, because that's what I was worried about. In my first draft he dies. But then the idea of him surviving really intrigued me, so I'm going to write it and see how it goes.
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Old 01-11-2013, 10:09 PM   #4
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I'm not sure if I can help, because I'm not sure if you're looking for details from just the medical side, or what it's like to actually be there. My experience would be as a parent of a child in the pediatric ICU for a week with pnuemonia. I can tell you from that perspective what it was like to go to pediatric ICU everyday for week, including my son having roommate with a genetic breathing disorder (whose name is escaping me) and a nextdoor neighbor having brain surgery and the comings and goings of the place from that angle.
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Old 01-12-2013, 02:00 AM   #5
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My experience comes from a closed head injury (not open a la gunshot wound) but here are my two cents...

1. What are the circumstances leading up to the injury? I was also 17 years old, and in my case, I was in a bad car accident. My id was in my pocket (and I was unconscious) so they didn't "figure out" who I was until after I was at the hospital. Based on appearance alone, they could tell I might have been young enough to go to the children's hospital or I might have been old enough for the adult hospital. The ambulance opted to take me to the adult hospital because they have more experience dealing with head injuries. (It's kind of an open secret in my town that this particular hospital is in the bad part of town, so they get all the criminal/gang-related cases. As a result, the doctors in that ER are REALLY GOOD.)

2. Can't help you because in my case, I narrowly avoided a trach. They were able to wean me off of the ventilator just a few hours before they would have had to trach me.

3. No specific comment since I didn't have a trach, but I will add that this is very specific to brain injury. I was talking (sorta) within an hour or so of waking up from the coma. On the other hand, you can look at Gabby Giffords who has been in recovery for a year or two, and still can't talk "normally".

4. In my case, I was eating within a day or two after I woke up. I still had a feeding tube through my nose for several days (part of the weaning) but was on solid food pretty quick. To add to what the other people have said: The one thing I remember most vividly about PT/OT is being tired almost all the time. To say it was hard work is an understatement. Between my body working to recover and all the physical stuff I had to do - I pretty much did nothing my therapy, eat, sleep, the whole time.

5. I echo what was said above about it being hard to speak in generalizations. Part of your problem is that every patient and every brain injury is different. In my case, I was in a coma for 11 days, in the ICU for about two weeks, and on the med-surg floor for another week. Thanks to a good therapist in the hospital, they allowed me to go to rehab on an outpatient basis (instead of inpatient rehab). I've known people who were in a coma for less time with worse injuries, and people who were in a coma for a longer time with less injury. Feel free to PM me and I would be glad to help out however I can.
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Old 01-12-2013, 11:39 PM   #6
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Thanks for all the help. I know that each injury is so different and specific, but I wanted it to at least realistic.

Melinda, his wound is self-inflicted. I'll PM you if I have any other questions. I've done some more reading that helps fill in the holes.

I have friends with very, very serious head injuries. One was in a parachuting accident, and we didn't think she was going to make it. The first year or two she had really bad short term memory, but now after 6 years she's back in school to be an RN. She had a trach but her scar is not so noticeable and she talks just like she did before. My other friend (didn't know her before the accident) has a scar from the trach and her voice sounds, not hoarse, but sort of labored. Like she had to re-learn to speak. Strangely, she was a speech therapist. She went back to work and is doing well.

I know how much hard work PT is. I was going for something minor and even with that I was so sore and exhausted when I came home.

Last edited by hillcountryannie; 01-12-2013 at 11:49 PM.
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Old 01-13-2013, 01:04 AM   #7
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So much of this depends on where and how extensively the bullet injured the brain. (I'm a rehab medicine physician who works with brain injured patients) A two month long coma is VERY long, whether medically induced or a result of the brain injury. The longer someone remains in a coma as a result of the brain injury, the poorer the neurologic outcome, generally speaking. Similarly, medically induced comas are usually a protective measure to help keep brain swelling down, etc. in the earlier days following injury, and if this is necessary for a long time, then the medical situation is more dire to begin with.

As far as eating, the swallow mechanism can be affected and put the patient at risk of aspirating/choking when eating, so this is a main reason why some patients cannot take food by mouth right away. Or the patient can simply be too weak initially to eat and swallow safely. Someone in a two month coma would have a gastrostomy tube (stomach tube) for nutrition, and this can be used after they wake up until they are ready to eat. This can be right away or weeks to months later, depending.

Patients can go to rehab when they are medically ready to be discharged from the medical unit AND are able to participate/cooperate/tolerate/benefit from therapy services including physical therapy (strength/mobility/coordination/balance, etc), occupational therapy (upper extremity function/self-care/vision) and speech therapy (cognitive/speech/language/swallowing). Major rehab units called acute inpatient rehab units are the most intensive and require the patient to tolerate 3 to 5 hours of therapy per day minimum. That's a lot of therapy, especially for a brain injured patient who may have problems with attention/overstimulation/agitation/concentration. But again, it depends. Frequently, brain injury patients start in sub-acute rehab units where the therapy required is not as intense, but patients have to be more medically stable in sub-acute units because the nursing and physician acuity is lower.
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Old 01-13-2013, 06:04 AM   #8
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Quote:
Originally Posted by c.e.lawson View Post
So much of this depends on where and how extensively the bullet injured the brain. (I'm a rehab medicine physician who works with brain injured patients)
Thanks for taking the time to provide all of that info. Very helpful.

I figured two months was too long. What other setbacks would require more surgery (besides replacing the skull)? Could additional swelling require more surgery? Basically, I need there to be uncertainty about his survival past those first couple of weeks.
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Old 01-13-2013, 08:49 AM   #9
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You're very welcome.

Well, unfortunately, there are all sorts of medical complications that can occur, if you want him to have uncertain prognosis for survival. The most common complications after a serious injury like that include various infections (at the injury site, or a pneumonia, or a bladder infection from the catheter, or a tracheobronchitis, or even the stomach tube site etc.) which you can make as serious as you need for your story. These patients can also develop a thrombosis in the deep veins of the leg (DVT), parts of which can break free and move to the lungs (pulmonary embolism) which is extremely serious or even fatal. Stomach ulcers can occur and be severe enough to cause dangerous bleeding. If you want another neurosurgical procedure to be necessary, then your patient can have acute hydrocephalus, which is a blockage of the flow of CSF which then builds up and causes a dangerous pressure increase. Treatment is placement of a catheter to drain the fluid, usually to another place in the body such as the peritoneal cavity where it can be absorbed.

Sounds like your guy is in for a rough ride. Good luck with this.

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Old 01-13-2013, 09:12 AM   #10
hillcountryannie
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Wow, so much information. I will be doing more research.

I have learned more about gunshot wounds to the head than I ever probably wanted to know. I've even been reading academic articles. But this information has been by far the most helpful and specific.

Thanks, again!
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Old 01-14-2013, 06:09 AM   #11
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Quote:
Originally Posted by hillcountryannie View Post
Melinda, his wound is self-inflicted. I'll PM you if I have any other questions. I've done some more reading that helps fill in the holes.
As far as the adult vs. pediatric ICU... I think it's basically a flip of the coin. Which hospital is better for traumatic brain injuries? What is his body size - very small or very large for his age? Perhaps one hospital happens to have a neurosurgeon who is already on-site, but the other hospital's neurosurgeon is on call. What about other injuries - does he only have the head injury, or does he also have several broken bones, maybe internal injuries from where his torso slammed into something as he fell?

Quote:
Originally Posted by c.e.lawson View Post
As far as eating, the swallow mechanism can be affected and put the patient at risk of aspirating/choking when eating, so this is a main reason why some patients cannot take food by mouth right away. Or the patient can simply be too weak initially to eat and swallow safely. Someone in a two month coma would have a gastrostomy tube (stomach tube) for nutrition, and this can be used after they wake up until they are ready to eat. This can be right away or weeks to months later, depending.
Random tidbit: yes, obviously I had a feeding tube, but that wasn't put in until almost 24 hours after the accident. I guess the feeding tube wasn't of the highest/most urgent priority. (As opposed to the respirator, IVs, bladder catheter, etc.)

Quote:
Originally Posted by c.e.lawson View Post
Patients can go to rehab when they are medically ready to be discharged from the medical unit AND are able to participate/cooperate/tolerate/benefit from therapy services including physical therapy (strength/mobility/coordination/balance, etc), occupational therapy (upper extremity function/self-care/vision) and speech therapy (cognitive/speech/language/swallowing). Major rehab units called acute inpatient rehab units are the most intensive and require the patient to tolerate 3 to 5 hours of therapy per day minimum. That's a lot of therapy, especially for a brain injured patient who may have problems with attention/overstimulation/agitation/concentration. But again, it depends. Frequently, brain injury patients start in sub-acute rehab units where the therapy required is not as intense, but patients have to be more medically stable in sub-acute units because the nursing and physician acuity is lower.
This probably won't matter for your story, but I (well, my parents) had a horrific time with the insurance. Due to those insurance problems, my rehab varied from three to eight hours a day. It was literally "how much does the insurance feel like paying today".

Quote:
Originally Posted by c.e.lawson View Post
You're very welcome.
Well, unfortunately, there are all sorts of medical complications that can occur, if you want him to have uncertain prognosis for survival. The most common complications after a serious injury like that include various infections (at the injury site, or a pneumonia, or a bladder infection from the catheter, or a tracheobronchitis, or even the stomach tube site etc.) which you can make as serious as you need for your story. These patients can also develop a thrombosis in the deep veins of the leg (DVT), parts of which can break free and move to the lungs (pulmonary embolism) which is extremely serious or even fatal. Stomach ulcers can occur and be severe enough to cause dangerous bleeding. If you want another neurosurgical procedure to be necessary, then your patient can have acute hydrocephalus, which is a blockage of the flow of CSF which then builds up and causes a dangerous pressure increase. Treatment is placement of a catheter to drain the fluid, usually to another place in the body such as the peritoneal cavity where it can be absorbed.
c.e.
I had pneumonia. My parents were told by a respiratory tech that this is a not-uncommon side effect of being on a respirator. Thankfully I didn't need surgery (neurological or otherwise), though IMO that was a miracle.

Another thought- I had a LOT of x-rays and radiation. CT scans due to the brain injury, x-rays of my various broken bones, daily x-rays of my chest after I was diagnosed with pneumonia. Sometimes I'll joke that I glow in the dark from all the radiation. :-)
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Old 01-16-2013, 07:23 AM   #12
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Thanks!

I think I'm going with the big trauma hospital in the nearest city. It happens to also be a hospital I'm familiar with, so I can write in those little details.
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