02/28/04

Author: Ron Faoro
Subject : Impressions of Dan

On Saturday I spent a good deal of the day with Dan on the fifth floor at Cottage Hospital, now that he has been moved out of ICU. It was the second time I've been with him since the accident. The other time was Tuesday for about a half hour. Dan's mom, his brother Robert, his daughter Kim, and Robert's wife were there. They were kind enough to allow Sharon Sweeney and myself to be at bedside both in the morning and the afternoon. Dan now has a tracheotomy and a feeding tube in place to facilitate his recovery.

Dan was not as responsive this morning as he had been at times in the last week. There may be several possible reasons for this. One is that he has an airway infection and is bringing up a fair amount of mucopurulent exudate through the tracheotomy tube. Another is that he is receiving both morphine and fentanyl narcotics. Primarily, these are given when his heart rate or blood pressure or both exceed desirable limits, probably in response to pain. Dan frequently lifts his left hand up to the top of his head as if he is feeling discomfort there (small wonder). He is opening his eyes, but the pupils are typically small, although they do vary in size. At times he opens his eyes quite wide, as if in astonishment. He was moving the right side of his body more than he was on Tuesday. But, in my opinion, he looks physically good. His color is pinker and he seems fairly fit considering the circumstances. He squeezes hands at times. He rolls his head to the side where he hears sounds, but he does not appear to be able to see much.

The neurologist thought that his signs warranted an additional CT scan. Dan is on an anticoagulant, heparin, to reduce the possibility of a pulmonary embolism. These could arise from blood clots that have been detected in his right arm and right leg. A pulmonary embolism would likely be fatal. The down side in the use of heparin is that it could induce a cranial bleed, hence the CT scan. The good news is that the CT scan at 11 AM was negative.

Somber words from the neurologist about the potential damage to Dan's frontal lobes, temporal lobes and corpus colossum saddened the family greatly, especially Kim. I was also discouraged when I went home for lunch while the CT was performed. I spoke with Dan's Elizabeth early in the afternoon. She has noticed that he is often unresponsive in the AM (when the neurologist typically examines him). In the afternoon, he seems to have slightly better cognition. Still, Elizabeth says it takes her about an hour to get Dan to respond to verbal commands.

At 3 PM, I found myself alone with Dan. Sharon had taken a very sad Kim home; the rest of the family was taking a break as Dan seemed a bit agitated. Dan's eyes were open most of the afternoon, unlike the morning. There seemed also to be more of an attempt to focus as opposed to just a rolling of the head from side to side. I steadily talked to Dan for an hour. At around 4 PM, I asked Dan to "give me one finger." He did! I said, "Make it two fingers, Dan." The second finger came up, then he made a fist. I had asked him to do things countless times in that hour; finally, he apparently responded. After that, Dan had a bit of a coughing jag. He was turning red with the effort and I asked his nurse, Daphne, to suction the tracheotomy tube. She did. This causes Dan a lot of distress. His blood pressure went up significantly. So he received another 2 mg of morphine and that put him to sleep; he was seemingly unaware of a visit by Bob and Sarah. But during suctioning, Daphne asked him to stick out his tongue. Although he couldn't do it, he clearly tried in both my and Daphne's opinion.

Obviously, Dan has a long way to go. But his brief responses to commands are very encouraging to me. I even think his apparent awareness of head pain could be a positive sign. The neurologist has seen only reflexive behavior. It's easy for hope to mislead one in evaluating Dan's condition. But there is a strong sense that Dan is in that dark recess trying to climb out. His endurance remains. Both the trauma physician on the ward and Dan's nurse mentioned to me that the "more stimulus, the better." So it may be good for people to visit him (those not afflicted with cold or flu) when he is moved to an assisted living facility next week, as they have said they plan to do.

 

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