Medical Bytes, Thailand No 77; âLife Support and supporting lifeâ
By: Doc Martyn from Pattaya Medical Club, former Buriram Medical Club
Michaelâs mother-in-law, Yai, is in her mid-60. Michaelâs brother-in-law Sai, is 35 years old.
1. Michael contacted me on October 7th 2022. He asked me to see Yai.
The story: About 10 years ago, Yai developed the irregular heartbeat, Atrial Fibrillation (AF). She was treated appropriately by the Buriram Public Hospital and placed on the drug warfarin, which âthins the bloodâ, to prevent a blood clot in her heart moving to her brain.
In early August 2022, Yai collapsed. She hit her head when she fell and was knocked unconscious. The fall was severe and she bled into her brain. Due to the anticoagulant effect of the warfarin, the bleeding inside her head was excessive. The next day, the neurosurgeons opened her skull, a craniotomy, to decompress and stabilise the bleeding.
She remained in ICU, on Life support, for 2 months. She was discharged home at the end of September, when she was able to breathe spontaneously, see photo 1.
2. Michael arrived in Buriram on October 13th, I visited Yai that day.
Yai was very unwell. A tracheostomy, a bladder catheter and a naso-gastric tube, all required for Life Support, were still in situ. She was hardly conscious; her response to painful stimuli was minimal. The craniotomy had healed, but the bleeding into the right side of her brain had caused damage to her brain, resulting in a stroke; a left sided hemiparesis.
In addition, she had a fever, she was hypoxic and she was unable to cough to clear her lungs. Yai no longer needed Life Support, she needed her life to be supported.
3. Sai, her son, was her sole care provider. His care had been meticulous and loving. Nevertheless, In the two weeks that she had been home her general condition had deteriorated slowly. She was dying.
To support her life, I advised the following:
i. Her nascent fever of 37.6 deg Celsius, suggested a developing chest infection, for which antibiotics were started that same day. Her fever settled the following day.
Infections, especially in the chest and the bladder/kidneys, are common causes of death in such compromised situations.
I directed Sai to measure and record Yaiâs temperature 4x/day and forward the records to me.
ii. Her Pulse Oxygen (PO2) was only 92% (normal range 97-100%).
In accordance with the instructions from the hospital; âif she can breathe spontaneously, she does not need Oxygenâ, Sai had turned off the oxygen machine by her bed.
This was poor advice. A PO2 of 92% is grossly inadequate. The hypoxia was contributing to her impaired conscious level and it left her vulnerable to infection.
Hypoxia impairs the bodyâs ability to heal itself. We use hyperbaric oxygen chambers, used for divers with decompression illness, to heal severe wounds, for example; diabetic ulcers.
Yaiâs oxygen therapy was reinstated.
iii. Following her stay in ICU, Yai required adequate nutritional support. I extolled the virtues of Ensure, a scientifically derived total nutrition replacement used by hospitals in the West. I recommended this over the concoction supplied by the hospital.
The recipe for the concoction:
Carbohydrate 40%: Protein 20%: Fat 35%
Pumkin: 2 ladles
Chicken breast: 8 teaspoons
Soybean: 2 teaspoons
Sugar: 3 teaspoons
Salt: A little bit
iv. The urine in her catheter bag was to be checked daily. I was to be notified if there was any clouding or change in colour of the urine. Such changes would suggest infection.
v. Engage a local physiotherapist 2-3x/week to assist Yai to clear her chest and to mobilise her body.
vi. Source full length thromboembolic surgical stockings to prevent a DVT, blood clot. Full length stockings are preferable to below knee socks because the dangerous DVTs, which move to the lungs, causing a pulmonary embolism, arise from the thigh, not from the calf.
vii. Move Yai regularly to prevent pressure sores.
4. Sai followed these directions to the letter. His care was exceptional and fastidious. He even repaired the faulty oxygen machine when it failed.
5. Three days later, on 16th October Michael messaged me; âHer general condition seems a lot betterâ¦She is definitely more alert, eyes open more often and following things now, rather than the previous blank stareâ.
The reinstatement of her oxygen therapy had improved both her conscious level and her cognitive function.
6. On Monday, October 31st, Michael sent me this photo of Yaiâs progress, see Photo 2. Yai would survive.
7. But disaster struck. On October 29th Sai disappeared from home, into a bottle. Saiâs sister, Michaelâs wife, was furious. When he returned home, 24 hours later, he was still heavily intoxicated.
The psychodynamics of Saiâs situation: He is a single, unemployed, 35-year-old who still lives at home. His mother had been in the ICU for 2 months. Upon her discharge he assumed the role of her care provider. He had no medical or nursing experience, yet he provided superior care for his mother, who remained seriously ill. But, if she died it would, in his mind, rest on his shoulders.
When I became involved Sai followed my instruction with great facility. The standard of care that he provided was superior to that she would have received in hospital. Indeed, it was his care that supported and saved her life.
So, why did he go âwalk aboutâ?
Stressor 1: 3 months ago, his mother sustained a potentially fatal accident, from which there was no guarantee of recovery.
Stressor 2: Upon Yaiâs discharge, Sai became her sole care provider 24/7. He was responsible for his motherâs life. He was required to perform tasks that were completely alien to him; bed baths, changing soiled napkins, emptying urine bags, to name a few.
Stressor 3: He was afforded minimal advice about how to care for his mother. But, in his mind, if she died it would have been his fault.
With the correct management Yaiâs health improved. She was going to live. Then, Sai disappeared. He didnât disappear because he could not cope anymore, he disappeared because he needed, may I say, a well-earned break.
He saved his motherâs life. He should be proud of this achievement. He is a good son and a good man.
8.Â Â Â Â Â Â Since retiring to Thailand, I have been involved in three other similar cases. In each case, once Life Support was no longer required, the patient was returned to the family home. And in each case, there was little, if any, education for the family about supporting the patientâs life.For optimal outcomes; both âLife Support and supporting lifeâ are essential.