Saturday, March 19, 2011

Returning Home to Find Steve Sick Again

I spent one night in San Francisco - one night for a two-day training event. My son Tim was able to spell me for two of Steve's Peritoneal Dialysis treatments. And with a little coaching over the phone, Tim did great.

But when I walked in the door last night, Steve was audibly wheezing!

Our whole family has had colds. But Steve wasn't clearing his secretions well; I could hear him wheezing across the room.

I gave Steve Combivent treatments and started him working on the Incentive Spirometer - trying to encourage deeper breathing and better "pulmonary toilet."

It's hard to read Steve in the best of circumstances. We cannot get proper blood pressures on him in any consistent manner because of his bilateral arm fistulas and his poor lower extremity circulation. We cannot weigh him at home because of the logistics involved in moving him. Of course, Medicare doesn't cover a bed scale. Critical Illness Myopathy/Polyneuropathy hangs on as a formidable foe.

So we're left to assess volume by his subjective symptoms (e.g. degree of thirst, difficulty breathing) and objective observations of Steve's edema. He rarely gets swelling in his feet, of course; he doesn't walk and he spends most of a day reclining or in bed. 

When he is truly volume overloaded, we see extra fluid around the neck area, the backs of his arms. It's tricky, especially without comparative weights and blood pressures. But we've managed reasonably well thus far. It is - by no means - the usual standard for home dialysis. But Steve's circumstances are unusual.

So I asked Steve's nephrologist about taking him in to the ER to be evaluated. After all, I have no idea about his oxygen level or what a chest x-ray might show.

Dr. Thakur suggested a trial of a Peritoneal Dialysis run using a more concentrated dialysate. If Steve is really volume overloaded, the removal of a net 2 liters or so would be helpful in relieving symptoms. It it didn't, the ER would still be there.

And since Steve didn't look like Medic One material to me, it seemed like a reasonable idea.

Now, as I type, Steve is snoozing soundly - breathing much more comfortably after we tried Dr. Thakur's suggestion.

So far, so good. If this continues, we'll have avoided a costly, difficult afternoon for Steve. And, of course, if things change, we'll make a new plan. But for now, it's a great relief.

Take care,
Linda Gromko, MD

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