Gee I haven’t written about a good ole hospital admission for quite sometime. Since I just completed my 112th, maybe now’s a good time.
The theme for this latest admission is fun with steroid psychosis and why IV fluids should always be monitored closely.
The fun begins
The trigger to the flare leading up to this hospitalization was for once clear cut, I had picked up a chest bug, a bronchitis of sorts. Could’ve caught it on the plane ride a week earlier, but who knows, the flu is everywhere right now. It started as a sore throat that started reaking havoc on my asthma . I was producing and coughing up lots of ugly crap which I rarely do. Within 3 days my PFs and sats were dropping and I knew it was slammer time.
Entry to the Hotel-spital went smooth. I showed up in the ER huffing and puffing with a room air sat of 89%. The ER was pretty much empty so they took me right in and triaged me to a resuscitation room near the Nurses station. Within 5 minutes I had a cont albuterol neb slapped to my face and people hooking IVs up to my VAP. The ER doc came in, gave me the once over and asked the intubation question. I answered to the affirmative. He then cut to the chase and asked me if I needed to be hospitalized? …. I said yes. He said “Thank you, this saves a lot of time, I’ll call the on- call Pulmonologist to see you”
For the next 2 hours I continue sucking on the 20mg per hour alb neb while the xray dude took an xray and the EKG dude did an EKG. Because I had a low grade fever, the nurses drew blood cultures, swabbed my nose for MRSA and did ABGs. My gases came back moderately crappy with a Ph of 7.18 and PCO2 of 59 (not good for an asthmatic). My breathing is getting super bad now ,so time to bring the Bipap and continuous neb combo on board. I hate doing cont albuterol inline with Bipap cuz it’s too confining. Granted the albuterol opens your lungs up, but the humidity generated in the circuit makes me feel like Im suffocating. I was too tired to fight it so I just went with it and was totally miserable.
Its now 7pm and Ive been in the hospital for about 2 hours .The pulmonologist who was covering for my regular pulmonologist and who has taken care of me before, stops in and informs me that they have a bed for me in the ICU step-down unit…. what they call the “progressive care” unit. Ive been there many times before. The nurses are nice, but the place smells like urine. The hallways actually have carpeting, probably dating from the 1960s.
My 2nd blood gases come back and my Ph has improved to 7.25 , PCO2 down to 49 on the bipap. The Nurse though, says I look like pure crap and calls the hospitalist to come see me. Here we go again, another doctor who knows nothing about me. He’s nice enough though. He takes one look at me and says, yup I agree with the Nurse, you dont look good and I think we should transfer you to the ICU. 5 mins later they wheel the bed with me in it right over to the ICU and this is where I stayed for the next 4 days.
Steroid Psychosis rears it’s ugly head.
Ive now been in full blown status asthmaticus for 4 hours. Im on bipap with a cont albuterol neb running at 20mg per hour. Im tachycardic, breathless and anxious and hypercapnic. Ive already had 200 mg of solumedrol pumped into my VAP and that’s on top of the 60mg I took via pill early that day. In other words, Im on the verge of going temporarily crazy on all the roids and narcotics, but I dont realize it because Im too preoccupied with the breathing thing.
At 3am that morning my craziness apparent surfaces when I wake up from a semi sleep state on the Bipap and started accusing the Nurse who was taking care of me, of hanging out in my room and stalking me. I demanded to speak with a supervisor to have me moved to another room and a different Nurse. According to sources, I actually threatened to walk out of the hospital. Somehow I managed to calm back down and fell back to sleep. I wake up again a couple hours later to a huge reality check that the Nurse who I thought had been stalking me was just the nurse taking care of me. I felt super embarrassed, Im pretty sure I called her some pretty awful names. Hope she didn’t take it too personally, it’s just part of the territory.(NOTE TO SELF : On future admissions, remember to notify staff of possible psychotic rants while on high dose steroids).
After 3 days Im almost off Bipap
Out of the Dungeon.
It’s day 4, Im off the cont nebs and breathing a little better. The covering Pulmo pops in, listens to my chest, makes that Im not so sure expression with his face and says they’re gonna move me out of ICU back into the step down unit. I told him again, it smells like urine in there, please transfer me to the regular medical floor. The rooms are brand new there and have they have spacious private bathrooms. He’s agrees and an hour later Im in my brand new, less hospitally looking room. Because my vitals are stable the telemetry is dc’d.. Good… less wires and probes to deal with.
The next next few days are all about recovering and getting the IV steroids decreased. I try to get out of bed a few times a day and walk around the ward to get my strength back. My room air sats still suck (90% at rest, dropping to 80 on exertion), but Im cool with that and am not about to start using the oxygen again.
The RT dept at this hospital has a weird protocol where they come around twice a day to nebulize Performost and Pulmocort followed by Albuterol. Either that, or the pulmo who was covering my pulmo was trying to show off his asthma skills. In any event considering all the IV steroids I had on board it’s doubtful the nebbed steriods would have any real effect. What I really needed were albuterol nebs every 4 hours instead of every 12, but i knew the RTs were super understaffed, so unless I got really tight , I just used my personal inhaler and didn’t bother then.
The daily rabies shot
Im sure sure you veterans can relate to this….
My biggest frustration at this stage of the game was that they kept sending the wrong diet tray at meal time. It may not sound like a big deal, but once you start to breath better after a severe asthma flare you actually get hungry. My first 3 days in the hospital I was NPO . Shortly after I was changed to soft/clear and then on the 4th day to a regular diet, but for some reason the regular diet order wasnt making it to the dietary dept and I kept getting salt and sugar free food delivered. Basically, tasteless food which I refused to eat, and after 5 days of eating nothing except ice cream cups and graham crackers and pudding I was getting super hungry. Feeling sorry for me, a super kind night shift Nurse raided the hospitals kitchen and brought me this massive spread. I was in steroid heaven 🙂
(It wasnt actually till the day of my discharge that they finally corrected the problem and severed me edible food. It was a beautiful cheese omelet that arrived 5 minutes before they wheeled me out the door. It simply didn’t have time to eat, but that’s another story)
Backtracking to day number 6 , they’ve just switched me from 360mg per day of Solumedrol down to 60mg of po pred. A bit drastic, but Im ancy to go home and am willing to put up with premature steroid withdrawals. So Im texting on my tablet, when the urge to pee hits. I get out of bed and it feels like I ripped something in my leg. Felt like I tore something. I pull the pajama leg up and to my horror, my thighs, calves, ankles and feet have swelled up about 3 times their normal size! I Couldn’t believe it.
What the F is going on? The skin was so tight around my leg and foot that there was clear liquid weeping through it. I was obviously fluid overloaded from the IV. Even though the IV was running just slow enough to flush my meds through, it had been running for an entire week and apparently no one was recording outputs ( including myself). I obviously wasnt peeing out as much fluid as I was taking in, so naturally I got overloaded and all that fluid ended up in the lower part of my body. Needless to say, I was not a happy camper. I complained to the staff and demanded that they do something to fix this. 36 hours later with the help of another super special Nurse and 3 doses of lasix, I peed off a total of 4.8 liters of fluid. That equates to over 10 lbs of water weight just in my legs. The following morning my legs were mostly skinny again and I was cleared to home. I came home 14 pounds lighter.
It’s now been 3 days since my discharge. My legs are still sore and scaly and my finger muscles are crammping like crazy , but Im able to walk a lot better. My breathing totally sucks again, but that’s to be expected as I haven’t found the right pred level to keep me comfortable. The biggest problem Ive had since discharge are the horrible opiate withdrawals which I know is mostly my fault. I never have a problem with Fentanyl, only Dilaudid. You’d think Id know better not to request the stuff, but it’s absolutely amazing what a rational person is willing to endure in order to stave the suffocation feeling that accompanies severe lung disease. Next time it’s Fentanyl only. No need to double suffer.
Other than the IV and diet screw up, the staff and medical care were pretty much excellent. I was pretty sick this time and still managed to escape the endotracheal tube, so I must be doing something right.