Friday, September 25, 2009

Sept 25, 2009

Thanks everyone for your love, support, and prayers that have been pouring in everyday. Know that every single wish, thought, prayer, text message, and email has helped our mom and us so greatly.

After a courageous struggle, Dad passed away peacefully today at 2:37pm with all of us at his side. We take comfort knowing that Dad had accomplished so much of what he set out to do, and touched so many lives.

We enjoyed so many of the stories that were shared with us - which we also shared with Dad. We're sure he is smiling down on us now playing his harmonica with his father.

We are tentatively planning a celebration of his life the weekend of October 11th in Michigan.

Love, Caroline and Kelly Huang

connecting

Dad's eyes were brighter today. We told him about all the well wishes we've received via emails and this blog for the many requests he received for car repair advice and services!

Good thing I have not let out the word that Dad also fixed my refridgerator in mid-July - I had to send away the delivery guys who brought the new fridge I ordered! He actually established a commercial account with some manufacturer company to get the necessary parts for my GE fridge.

He also fixed my washing machine 3 weeks ago - he figured out and fixed the problem with the timing switch in less than 5 min. Of course this was after I had spent 3 hrs on the internet trying to figure it out on my own. Good thing there was no penalty for cancelling the service repair people I had scheduled to come out....I always feel bad that Dad's wish for repayment was "just make sure you get enough sleep".

The nurses have done a great job with keeping Dad looking handsome and skin moisterized - I also suspect someone trimmed a few of his flyaway gray hairs on his balding head. Only today by looking at him so closely did I realize that Dad has no wrinkles - I hope I got that gene.

Thursday, September 24, 2009

dad

I just realized when you google Matthew Huang - his book comes up in the automatic google search function. I'll have to tell dad later today. I think that is pretty neat.

http://www.amazon.com/Vehicle-Crash-Mechanics-Matthew-Huang/dp/0849301041

Day #4 - Sept 24

If you're wondering why this post is written so poorly, it's Kelly posting from a non-physician point of view! Dad's condition is stable, he made big improvements yesterday so we remain "cautiously optimistic" (good news but I am starting to really dislike that term). His pressors are way down -- only on one drug now -- and his ventilator support is at 60 percent -- which means he is breathing more on his own. We are still waiting for dad to respond to us and have been chatting with him and playing music. I told him this morning that David needs help with his Ford Explorer and that Mr. Cherng got his dishwasher working again. Thank you so much for the love, support, and prayers, really means the world to all of us -- especially mom.

Wednesday, September 23, 2009

Day #3 - Sept 23 PM update

Dr. Thomas Butler (hematology) saw Dad today - feels confident that the low platelets are a result of the overwhelming sepsis (infection) that Dad has endured. As the sepsis improves - so should his platelet count. Meanwhile - will continue with the platelet transfusions to keep him out of the dangerously low level (especially since he is on Xigris medication - which can make him more prone to bleeding). He has ordered other tests to ensure it is not related to something else (i.e. thrombotic thrombocytopenic purpura, heparin-induced thrombocytopenia).

The good news is that his bone marrow is responding and now his white count is very high (WBC 22K) - which is a more appropriate immune response to the sepsis.

The levophed pressor medication dose is even lower...12 mcg/min - and Dad's BP (blood pressure) is holding which is great!

We will continue with all his treatments - mechanical ventiltion for his lungs, continuous dialysis for his kidneys, antibiotics, Xigris, Calcium, Bicarbonate, and amiodarone infusions. Dad is even tolerating nutrition tube feedings which started late yesterday - and has been gradually increased.

Our nurse Mickey (the best nurse ever - he trained me when I was an internal medicine resident) tried to stimulate Dad for a response today - not much but maybe some basic reflexes - (eye flickering when Dad was turned or gagging when they suctioned the back of his throat). Mickey had a great impact on our mood today - especially on mom with his sense of humor and compassion. We are so lucky to have the excellent physician and nursing care that is being provided to Dad. (Mickey performed CPR on one of my friends who was severely ill and had a cardiac arrest - helped save his life with his monster-effective chest compressions - we will never forget him for that.)

Meanwhile - we brought in a portable CD player to play Dad's favorite music for him. He heard a little Iz (Somewhere over the Rainbow), other Hawaiian music that we played at Kelly's wedding, and a Johnny Cash album. Unfortunately we couldn't get his MP3 Chinese folk songs that he loves so much to play on the CD player.

Nurse Carol Marsh is on again tonight taking care of Dad - which makes me feel good. She was the one that took care of Dad the first night he came in...as well as last night during which she gave him a nice shave!

We will reassess again - taking Dad's condition one hour at a time...

Day #3 Wed, Sept 23, 2009

Some brighter news this morning.

Dad's atrial fibrillation rhythm converted back to a normal heart rhythm this morning which has greatly helped his blood pressure. He is been able to go down on 1 of the 2 pressor medications and is completely off the neo-synephrine! He is still requiring levophed at 20mcg/min - but this is certainly progress.

Dad has received his 3rd platelet transfusion this morning - unfortunately his platelet count did not go up - so another specialist from Hematology- will be added to Dad's team to evaluate and assist with this management. So far - he does not show signs or symptoms of bleeding problems.

Right now - it's a waiting period to see how things progress. We are cautiously optimistic. If there is one thing we know - Dad never gives up and will certainly put up his best fight. thanks for all the well wishes we've received - although we may not get a chance to respond - do know that it helps so much.

Tues - sept 22nd update

The cause of his illness is from a very potent bacteria called Streptococcal pneumoniae. Likely started off as a pneumonia, and then spread to the blood stream - causing dad to be weaker than usual --> fall and suffer an aspiration event in which stomach acid "burned" his lungs.

The bacteria has been identified and is being treated with the correct antibiotics - but now Dad is dealing with the aftermath of inflammation that this bacteria caused on his body (like the destruction that a tornado leaves afterwards).

Today started off on the lowest dose of pressor medications (still two pressors being used) since he was admitted - which was cautiously encouraging - Dad's BP (blood pressure) and oxygen status have been where they need to be.

He needed two transfusions of platelets today for his very low platelet count. but his white count has gone up from 2K -->10K today which is a good sign - means his bone marrow is now responding.

Unfortunately - dad went into an atrial fibrillation rhythm today - not unusual when someone is in septic shock. but the atrial fibrillation can affect the heart's ability to keep the BP up - which dad experienced later today.

Dad is suffering from severe cyanosis (blue hands and feet) due to the high doses of pressors he is on - so it's even more imperative we get the pressor medication off as soon as possible to prevent possible long term damage to his hands and feet. But understand that the pressor medication's use is keeping the blood flow to his heart and brain as first priority.

As his doctors stated: He is in a better clinical status than he was yesterday morning -but clearly not out of the woods by any means. Dad is tolerating all the treatments but clearly still on maximum support. However, many people do not survive what Dad is going through.

We know that Dad is tough, as my mom calls him: IronMan for having tolerated his parkinson's disease for the last 2o years - slowly robbing him of his motor function, particularly his balance.

Dad is persistent and stubborn and had plans "to live a long life"...so we are hoping his body can pull through this with our encouragement and support.

We are lucky that Dad, besides his parkinson's, was generally very healthy before this - we know his heart and lungs were in excellent shape - so these are things in his favor.



Current diagnoses - for our family and friends versed in medical knowledge:

1. Septic shock from Streptococcal pneumoniae (penicillin sensitive) bacteria that started with pneumonia and spread to bloodstream (on Zosyn, vancomycin, tamiflu, Xigris. Also on levophed 20 mcg/min, phenyleprine 200 mcg/min, hydrocortisone 100 mg IV q8. vasopressin tapered off)

2. Acute kidney failure due to profound shock (max creatinine 2.7) on CVVH.
3. Acute respiratory failure due to profound shock on maximal ventilator settings
-- (FiO2 100%, PEEP 16).

4. Rhabdomyolysis (CPK peaked at 5400 U/L)
5. Severe lactic acidosis (peak 9 mmol/L).
6. Encephalopathy due to sepsis - (not on any sedation - morphine as needed for pain).
7. Bilateral cephalic vein thromboses (from sepsis?)
8. Cyanosis of extremities related to shock and pressors - on topically applied nitropaste.
9. Thrombocytopenia - 13,000 - s/p 2 platelet infusions.
10. New atrial fibrillation (9-22-09) - started on amiodarone infusion. (depressed EF 35% due to septic shock -based on yesterday's ECHO).


Dad's team of medical doctors:

Pulmonary/critical care: Dr. Duhamel, Dr. Kruger, Dr. Wyckoff
Infectious disease: Dr. Michelle Ritter (dr. holman's group)
Nephrology (kidney): Dr. Thomas Rakowski, Dr. Kevin Lowery
Cardiology: Dr. Tony Parente
Vascular Surgery: Dr. John Garrett/Joe Kirby PA-C
Internal medicine: Dr. Anthony Rimicci

His wonderful ICU nurses thus far:
Carol Marsh (2 nights)
Jenny Beutler (2 days)
Leah Marks

What happened... 1st night in hospital.

(Caroline):

I rode in ambulance with Dad - seemed like longest 1.5 mile ride of my life to Virginia Hospital Center (where Caroline also has her endocrinology practice).

Was seen immediately in ER - and Dr. Smith determined Dad needed immediate intubation and ventilatory support. Was stabilized in the ER, then transferred to the Intensive Care Unit (ICU) for further care.

In ICU: Dad's blood pressure dropped and required aggressive support - he quickly started to required pressors (medicines to keep blood pressure up).

Because of Dad's severe breathing difficulties and maximal vent support which was still not giving adequate oxygen - Dr. Duhamel -the critical care/pulmonary specialist decided to do a bronchoscopy (look into his lungs with a small camera that goes in through the mouth) - he suctioned out a large volume of fluid from the lungs - fluid that looked like stomach bilious fluid - evidence that Dad had aspirated -likely after 2nd fall. this explained the rapid decline in his breathing problems.

Aspiration (the entry of secretions or foreign material into the trachea and lungs) is a known problem in people with Parkinson disease - due to the motor decline in swallowing function and ultimate inability to protect the trachea that lives next to the esophagus. Dad has had swallowing problems for a while - with food or his meds sometimes getting stuck, requiring more food to get it down.

Around 1am - Dad's condition seemed to have stabilized - but obviously in serious condition, still requiring the ventilator and pressor support. Advised by Dr. Duhamel to go home for a few hours to rest. Kelly took Mom back to Kelly's house to spend the night.

I went back home, but couldn't sleep, felt uneasy and returned to the hospital around 2am. Within 30 min of arriving - the activity with nurses and medical housestaff started to increase around my dad. I called my mom and sister in a panic to return immediately to the hospital.

Dad's oxygenation was declining despite maximum vent support and BP (blood pressure) dropping despite the presence of maximum pressor support. His heart rhythm was entering a junctional pattern - a precursor to asystole. I saw the nurses flurrying around - pulling the code cart into the room - getting a back board under Dad - things which I knew meant preparations for an impending CODE for cardiopulmonary arrest.

The resident approached me as asked about code status (which was already addressed when he was admitted - i.e. are we to do all lifesaving measures if he stops breathing or if heart stops) - and encouraged me to consider not proceeding with any CPR if his heart was to stop as the hypoxia was not thought to be reversible.

I said - "Dad would want to be a FULL CODE" ...how could my dad not be a full code? he is only 67 y/o and otherwise quite active even with the motor limitations that his parkinson's lays on him. Was I being unreasonable? In my sobs of tears - I asked that Dr. Duhamel be paged to ensure that I was making the right decision - but as he called back...my dad HR stopped and CPR had already started.

Miraculously - Dad's heart rhythm returned with chest compressions, atropine, bicarb.
His oxygenation improved after about 1 liter of lung secretions were suctioned out.

We haven't left Dad at the hospital by himself since....

What happened...

We've created this blog to help keep everyone updated on Dad's medical condition.
We are so blessed to have so many friends and family who have been so concerned for him and us. Thank you so much.

The concern has been so great that my mom's phone has been ringing off the hook, so please use this blog as a place where daily updates can be found. Feel free to forward to any of our family or friends that I may have omitted.

Kelly and I want to ensure Mom gets her needed rest for the physical and mental strength she is going to need to get her through this period - so please limit calls to her - as she is refusing to silence her phone. We will ensure she checks her email and she will have also have access to the blog comments.
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WHAT HAPPENED:


Sept 16th - Dad started having dry cough that kept him from sleeping.

Sept 17th - because of new low grade fevers and without an already established primary care doctor (his new appt with Dr. Rimicci was scheduled for Oct 24) - Caroline sent him for a flu test - concerned that Dad caught the flu from grandson Collin (age 4) who had been diagnosed with the flu (presumed H1N1) Sept 4th. Flu test was neg.

Sept 18th, 19th, 20th - My mom checked his temperatures - all normal - but dad still with headache and decreased appetite and fatigue. B ut did feel well enough to go to Caroline's house to unplug her shower drain (despite Caroline telling him not to do it!) and then make it out to Home Depot to buy a new replacement shower head for their own bathroom. (he read that shower heads should be changed regularly due to build-up of mildew, bacteria, etc).

Sun - Sept 20th (Mom's 65th birthday):

Mom said Dad looked the best he had in the previous days - he got up and got ready for the day, and got out his new showerhead and tools that he was going to install. Because Mom and Dad had quarantined themselves away from the grandchildren to prevent them from getting sick....we hadn't seen them in several days. Since Dad looked better, Mom joined Kelly and baby Norah for a short walk to Caroline's house to spend a little time on her birthday with all the grandkids - Collin (4y), Cary (2y), and Norah (11m). and Dad wanted Mom to borrow tools from Caroline's house - ones that he realized he was missing and needed to replace the shower head.
A combined birthday celebration for Mom and Caroline was postponed until everyone was feeling better (Cary had been having a cold too).

Mom spent about 90 min visiting at Caroline's house - returning to the condo around 4:30pm.
When she returned she found Dad had fallen, lying on his back on the family room carpet (has happened in the past with his parkinson's, especially if he forgot to stay on schedule with his meds). He was lucid and told mom he just couldn't get up - it was evident that he had prepared a bowl of ice-cream for himself and appeared to have slipped off the chair in the eating area.
Mom helped him up and he walked to the couch. Because he looked so pale and she knew he had not eaten much in 2 days - she fixed him homemade chicken noodle soup and fed him that along with his afternoon Parkinson's meds - Dad ate the entire bowl. Afterwards Dad took a nap on the couch. Mom decided herself to get some rest too - so napped as well in their bedroom.

Around 7:30pm - Mom heard a loud crash and hurried out into the family room where she saw Dad had fallen again - he stated he was trying to get to the bathroom. He was still mentally alert and conversing appropriately - but obviously really weak. Because she couldn't get him up and was a little more concerned - called both Kelly and Caroline. Caroline advised Mom to call 9-1-1 immediately and both Kelly and Caroline headed over to their condo.

Mom said she told Dad: "Matthew, Caroline wants us to call 9-1-1". Apparently Dad said to her - "Don't call 9-1-1 - just call a taxi". Minutes later, Caroline and Kelly arrived to find Dad lying on the floor with difficulties breathing, not talking, and in more distress. He was able to squeeze Caroline's hand upon command. Paramedics arrived -he had a fast heartrate but in normal rhythm. During the 10 min they were in the condo - Dad deteriorated quickly in front of everyone's eyes with more labored "agonal" breathing.