Hit a Rough Patch

On the first of March when returning from a trip to the bathroom about 3:30 am, Bob had a problem getting onto the bed and fell onto the floor with his head taking the brunt of the fall. So he skinned his head on the carpet. After getting to a sitting position on the bed, Magie bandaged the area to keep the blood off the pillow. After being less than successful getting the blood out of the carpet, Magie covered the area with wet wash cloths and joined Bob in bed.

The next morning we discovered that the wound had bled in the night and had soaked through the pillow case and the 3 zip covers on the pillow. The fact that Bob is on coumadin/warfarin aggravates the situation. Fresh bandages were applied. Magie went over to Steph's and borrowed the Hoover carpet cleaner.

Tuesday morning we found that the wound had bled through the bandages , the towel covering the pillow, the pillow case and the 3 zip covers. Wednesday morning Magie only needed to replace the bandage. Hooray!!

Wednesday afternoon Bob had an appointment at Dr. Galli's office to have his INR checked. Dr. Curatola asked about the bandage. After hearing what had happened, he recommended that Bob quit wearing his cap and to leave the bandage off because it would heal faster. The photo was taken after removal of the bandage.

Thursday morning (March 4) was the next to last rehab class. That afternoon the AdvantaCare oxygen people delivered an Invacare Homefill II oxygen concentrator, 2 small portable oxygen tanks with a pack to carry one tank over the shoulder, and 2 larger tanks with a wheeled cart to transport one of the larger tanks. Dr. Beck had gone ahead and ordered the oxygen since Bob had not gotten back to him Tues. afternoon after Bob had had a chance to talk to Pete about his supplier.

On Friday, 5 March, we went down to the exercise room at Sunnyvale Senior Center with a small oxygen bottle in the carrier and Bob was able to use a machine just like the one he has been using at the rehab class at El Camino Hospital. If there are people waiting to use a machine, the current user is restricted to 20 minutes on a machine. Bob was able to use the machine for 25 minutes. Part way through, Bob had Magie turn the oxygen level up to 3 (he had started with it set on 2). Magie had attached the oxygen carrier to the back of the arm rest on the machine since it would be inconvenient for Bob to have the carrier hanging from his shoulder while using the machine.

On Saturday, 6 March, Bob took a walk down to the corner of The Dalles and Wright Ave., with the oxygen attached, to put a couple of items into the mail box. That worked out just fine so he walked over to the school with the oxygen on Sunday.

Tuesday, March 9, was the last rehab class and Bob did the warm up exercises, 40 min. on the machine (with hospital oxygen), followed by the cooling down exercises. He does not use the oxygen around the house or when he goes grocery shopping. He also did not use it yesterday when he met his friend Sal for brunch at the Country Gourmet.

Progress has been made.

ICD checked & other info

Bob went to his regular pulmonary rehab class today and did 40 minutes on the machine. They hook him up to a tank of oxygen when he gets on the machine. He has three more classes to go.

After lunch we went to the cardiologist's office for the ICD check. The tech confirmed that Bob had had an episode of atrial fibrillation the day we went to Costco. After the ICD check we went to the car (which we had parked near Dr. Beck's office because there was no space in front of the bldg. where the ICD check was done) and I read a magazine while Bob took a nap. He was pretty tired from the 40 min. on the machine in addition to the warm up and cool down exercises.

Later we got out of the car and walked the short distance to Dr. Beck's office. Dr. Beck had a written message about Bob's oxygen need from one of the staff at the rehab class. After some questioning by Dr. Beck, it turns out that Bob (and I) had misinterpreted some information given out about inhaler use. Further questioning of Bob by Dr. B revealed that, after the class about maintenance and rescue use of inhalers, Bob quit using his inhaler as a maintenance device and only used it as a rescue device.

So Dr. Beck gave Bob a different inhaler (Symbicort) to use as a maintenance device and he will continue to use the Combivent inhaler as a rescue device. Bob is to go back in a month to discuss the results of using the Symbicort which is to be used 1 puff twice a day (every 12 hours). Dr. Beck also wants Bob to be on oxygen whenever he exercises at/from home. Since one of the guys in Bob's class, Pete, is on oxygen full time and comes to class with a small tank in a back pack Dr. Beck wants Bob to talk to Pete about the supplier of his oxygen to see if Bob would like to use the same supplier. So Bob will talk to Pete and then get back to Dr. Beck so that Dr. Beck can call A supplier and make arrangements for Bob to have oxygen here at home. He can use the oxygen when he takes out the garbage cans and brings them back in or goes for a walk or uses the machines at the senior center for exercise.

Ever since the episode at Costco, Bob has been wearing a waist pack in which he carries the Combivent inhaler and a few other items.

About 6:30 tonight Dr. Galli called to tell us the results of the ICD check. He confirmed the episode of atrial fibrillation and indicated that it was at a lower level than other episodes. He said that nothing can be done about it and it will happen again. This was a minor/shorter episode compared with some of his previous incidents where he went to the emergency room.

Bob has an oximeter that he uses frequently to check his oxygen level. Recently, after he had made sure all the doors were locked before we went to bed, he took a reading with the meter. His oxygen level was 88. It needs to be 90 or above. So it doesn't take much moving around for him to get too low on oxygen.

The 6 Minute Walk

As you all know, Bob is enrolled in the 8 week Pulmonary Rehab class at El Camino Hospital. The class started on Tues. Jan. 12 and is held on Tuesday and Thursday each week. However, Tues. this week was the annual Cardio Pulmonary lunch at Michael's Restaurant at Shorline so the class will be extended to the 9th Tuesday so that they have a total of 16 classes.

A couple of weeks ago when Bob and I went to Costco, he got extremely winded pushing a grocery cart from the parking lot into the store. When he got into the store he pushed the cart to one side and leaned over the cart catching his breath. One of the staff wanted to help and said he could sit on one of the motorized carts. Bob declined and said he would be OK and continued to lean on the cart. In retrospect, he should have had his Combivent Inhaler with him and used it. After he caught his breath I led him to a place where he could sit down while I picked up the items we had gone there for. When we got home he tried taking his blood pressure and, at first, neither of the 2 devices would give him a BP reading. The 1st one just kept giving him the "Error" message. The other one finally gave a reading of 148/143 which is not reasonable. So he waited a while and finally got a reading in his normal range.

Since he keeps a log of his exercise activities for the class, he noted on the log that he had had a problem with his breathing and had therefore not done as much exercise as recommended. When he took the log to class apparently the staff wanted to know all about it and subsequently notified his pulmonologist, Dr. Beck, and his cardioologist, Dr. Galli because both offices called Bob here at home. So we set up an appointment with the Pulmonology Lab at El Camino hospital for him to have this "6 minute walk test" at 11 this morning. When I set up the appt. they indicated that the whole thing would take about 20 min. Since Dr. Galli's office did not call until about 5:30 Friday evening, the woman who called asked us to call on Tuesday to set up an appt. for an ICD check.

So Bob had me take him in for the 6 min. walk test. Since we were early they started the test about 5 min. early. The staff lady put an oximeter on Bob's finger. The meter was attached to a pack that she then put around his neck and resting on his chest and off they went. When 20 minutes had passed and they had not returned, I figured that they had probably had to put him on oxygen. Sure enough, when they showed up he was pulling an oxygen tank behind him and had the tubing attached to his nose. He sat down next to me in the lobby and the staff lady went in the back and had a male staff member (Thomas) come out to talk to Bob.

In the course of the conversation Bob revealed that in bed at night his fingers frequently get all tingly. Thomas indicated that tingling in the fingers is one sign of insufficient oxygen in the blood. Then Bob told him about the leg cramps that he had been getting at night but that he had been having less of a problem with them since he had been taking the rehab class. Thomas told him that a build up of lactic acid in the legs, caused by less circulation, was probably the cause of the cramps. He explained that, if the level of oxygen in the body gets too low, the system pumps less blood to the extremities and more blood to the vital organs so that the vital organs get the oxygen that they need. So lactic acid builds up in the extremities because the blood is not moving adequately. Thomas will inform Dr. Beck's partner of the results of the test since Dr. Beck is out of town until next Monday.

Next Thursday Bob has an appt. in the afternoon to see Dr. Beck and an appt. at Dr. Galli's office for an ICD check. It is highly likely that the episode at Costco involved some atrial fibrillation since neither blood pressure cuff wanted to give a BP reading until after Bob had been sitting in the chair for an extended period of time. The ICD check will tell them if there was atrial fibrillation involved.

Before we headed to the hospital for the 6 min. walk test, Bob had commented that he was feeling better today than he usually feels.

Prior to the Costco episode Bob had ordered an oximeter for home use and he has been checking his blood oxygen level a lot.

After Bob sees the doctors next Thursday I will do another post.

Good News on the Blood Sugar front

This afternoon was the follow up trip to see the nephrologist because of the spiking glucose on his previous blood test. She had the results of the blood test he had last week and his glucose is normal which is lower than it has been since the doc has been with the Palo Alto Medical Clinic. Before the spike his blood sugar had been flat but a bit above normal. So no diabetes.

The bad news was that he lost another 2 pounds. So the doc said to add another Glucerna and nuts to his diet (to try to gain back some of the weight he has lost). An extra Glucerna (Ensure for diabetics - only 6 grams of sugar vs 23 grams of sugar) will add 250 calories a day and nuts should add a few more calories.

Also, he seems to be getting soome of his energy back. We took a walk yesterday morning before it got too warm.

The Latest Checkup

Rader Bob visited Dr. Cho Monday and the reports are all good. He is very happy with Bob's hand and the fact that he won't need to do surgery on it.

He used the liquid nitrogen on a number of places on Bob's arms, head and face. This is to freeze any pre-cancerous keratoses before they go bad. Magie has had a bunch of these done over the last several decades. It's no big deal. It makes a little blister that is really, really annoying for about a week.

He has sent a prescription to Medco for a cream for Bob to put on his face for the Rosacea (non-specific, rosy-red rash) plus some stuff to use to wash his face. After a couple of months (according to the brochure we picked up) the redness should be receding from Bob's face. He does not think Bob will get any reactions from these new items like he did from the other stuff.

More Info/Clarifications

Sort of in response to Magie's post of yesterday(?), I thought I'd clear up a couple of things.

INR = International Normalized Ratio

This is a calculated number based on a test for the time it takes your blood to clot. For normal, everyday, walking-around-healthy humans, this number should be around 1.0, but could be in the range of 0.8 to 1.2. The lower the number, the faster the blood will clot. This number will vary in that range on a day-to-day basis for everyone depending on their diet, liquid intake, and a number of other factors.  If a normal, everyday, walking-around-healthy person had an INR of over 1.5 (or under 0.8), their doc would definitely start paying attention.

For people with "clotting issues," this number needs to be driven higher with medications. Examples:

• As folks get older (and more sedentary and less cardiovascular and have more clogging in their arteries), they are more likely to develop blood clots. These could be in the form of Deep Vein Thrombosis (DVT) from sitting on that long drive or long flight to visit their grandkids or just sitting in their recliner feeling generally crappy for a few hours. This is why most docs have their elder patients start taking "baby aspirin" (81 mg) daily, because aspirin has an anticoagulant effect for protection from clots. The smallest of clots that get to the heart will cause a heart attack or, if they get to the brain, will cause a stroke.
• Folks with specific medical conditions such as Atrial Fibrillation (AF, like Rader Bob has experienced a few times) will be prescribed a stronger anticoagulant like Coumadin (aka Warfarin or "Rat Poison") to get their INR up into the 2.0 to 3.0 range. (AF tends to cause clots to form in the atrium because the blood is not being actively moved through the system.)
• Folks who have had heart attacks or bypass surgery will also be prescribed with anticoagulants to keep their INR up around 2.5 to 3.5.
• People with mechanical hearts will be given strong anticoagulants to keep their INR up around 4.0. (The mechanical heart is more likely to damage blood cells and induce clotting.)

So, with Rader Bob's history of AF and his INR down at 1.1, his doc has asked him to increase his dosage of Rat Poison and to get his INR checked again in two weeks.

Hope that helps!

s

30 Packets Have Been Used

Last night we applied the 30th packet of Aldara to Bob's left hand, left temple area, and head. The part applied to the hand was mixed with some Tazorac. As you can see from the photos, the pharmaceuticals have been doing a real number on the areas where they have been applied. As you could guess, the areas are quite tender and Bob is very happy to not have any more applications.

Today Bob had his INR checked at Dr. Galli's office and the reading was 1.1 where they want it to be between 2 and 3. (Dr. Galli may change his coumadin dosage but he was not in when the test was done.) That is probably why the displacement of a scab on his arm yesterday (when we went to the audiologist) caused blood to run down his arm onto his watch band. We were waiting for the audiologist to get back from lunch when I noticed the blood. Fortunately we were able to take care of things with a tissue and it has not bled any more.