Welcome Back, Robert

Sometimes there aren't any good decisions in caregiving. 

Mail call! A card and bookmark from Carol

Decision number one: Do we send Robert to the hospital?

Robert couldn’t walk.  I mean he couldn’t even turn his legs to transfer from getting out of bed to the wheelchair. I could see him thinking about it.  I could see that he really was trying to get his brain to tell his leg to MOVE! but the signals got crossed and he just couldn’t do it.  

I called his neurologist who had just seen him the previous week and explained that his decline was even worse than before.  Since they had suspected a compression of the nerves in his neck, I was advised to send Robert to the hospital.  It seemed to be the quickest way to get the MRI done in order to confirm that diagnosis and if it didn’t confirm it, to figure out what exactly was going on.

We all know how that went.

Every time Robert goes to the hospital there is a significant decline afterwards and a significant amount of work involved in getting back to baseline.  Usually he falls just short of baseline so we end up with a new baseline.

I don’t take sending Robert to the hospital lightly. Partly because I am selfish and realize the post-hospital decline not only affects Robert but me and Richard too.  (There has to be honesty and self-awareness in caregiving. It helps.)

Robert couldn’t walk so there really wasn’t a choice for me.  My concern was if there was a spine compression and he was losing mobility so quickly, what more could happen?  He needed answers as soon as possible so the paramedics were called and the ER wait ensued.

A wonderful surprise from a Guardian Angel!

Decision number two:  Do we take Robert home or find a rehab facility that provides physical therapy?

Um, he’s been in a hospital bed for over a week and couldn’t walk when he arrived.  I’m pretty sure he still can’t walk and has now lost muscle strength.

Richard and I were already past the point of being able to care for Robert.  The decline happened so suddenly (or felt like it) that we just did what we could to keep up.  Sometimes even to our own detriment.  Like the time Richard physically lifted Robert from the wheelchair and moved him to the bed (and then suffered through extra back pain for several days). 

Let’s go with a rehab facility.

(It helped tremendously that Robert was completely agreeable to this plan. Many times when making caregiving decisions, the caree and caregiver are at odds at what would be best.  That makes the decision-making even more difficult.  It’s just the worst.)

Decision number three: Which rehab facility do we use?

Our first option for Robert was to get him in the hospital in-patient rehab center. I was told some of the new doctors/residents don't even know about it.

Even though many of the nurses and a couple of the doctors and physical therapists raved about this in-patient rehab center they all warned me that Robert would have to be evaluated by a team and they would be the ones to decide if he could be admitted there. 

If he was accepted it would be so easy!  The hospital would discharge Robert and then wheel him to the rehab center (which was in the hospital but not considered part of the hospital). He would get checked in and they would do 3 – 4 hours of rehab per day!  Wow! 

The goal would definitely be to get Robert able to move and transfer so he could come home.

It felt like an exclusive, secret club and I wanted entrance granted for Robert. Please, please, please!

One doctor evaluated Robert.

Then he came back with another one.

They asked Robert questions, then asked me questions.  Dang it – I don’t even know what they are looking for so am stressed out about giving the “right” answers.  Plus I didn’t have time to study!!!

After a while I realized they were not going to accept Robert into the program. Wait – I want to change some of my answers!  “He probably won’t be able to meet the goals we set each week.” Could you please just try him out to see?  Maybe he’ll surprise you! 

In my heart, I knew Robert couldn’t tolerate 3 – 4 hours of physical and occupational therapy. I mean, his favorite time at Day Program is when it’s Recliner Day.

This now means we have to scramble to find a rehab facility.  The discharge planner helps with this and sometimes you get a really great discharge planner who goes the extra mile and sometimes you get one who just does things by the book. 

The entire hospital stay has been challenging so it did not surprise me that the discharge process was not smooth. I expected it to be smooth because I usually have a terrific experience at discharge but not this time.

The discharge planner gave me several options for Skilled Nursing Facilities that have physical therapy programs to accommodate Robert.  I asked her which ones she would recommend. She couldn’t say. 

Okay, give me a hint. Sounds like? 

Instead, she asked me if I had a particular one in mind. 

No! I’m asking you for help to find a good one.  She did help by sending out an email to all SNFs, giving Robert’s info and asking if anyone had availability. She referred me to the www.medicare.gov site so I could check ratings. It was some help but it wasn’t anything extra. 

This would have been a good time to have someone doing something extra.  I was frustrated. It had been a long two weeks (or close to it) and I just wanted someone to make this decision easy for me.

That wasn’t to be so I got on the phone and called a few facilities.  I contacted Robert’s Day Program for references.  I called Robert’s case manager at his Regional Center. I checked ratings, checked availability and checked what the PT schedule would be. The last thing I want is to choose a place that is going to just let him lie in bed all day and do 10 minutes of physical therapy on occasion.

After all of this, the place I settled on is a place Robert has lived before. When I first moved Robert to Sacramento, he went to a SNF for about two months then I moved him into a Residential Care Facility for the Elderly.  He was there on a waiver and under an exemption (since he is in his forties).  Robert lived there for a couple of years and enjoyed it until we ran into some problems with the management and it was apparent that Robert and the facility were not the right fit for each other any longer. 

It was not easy choosing this facility but I knew he would be in the SNF portion of the facility and not the Assisted Living area.  I knew that management had changed since Robert last lived there (a few times, actually). I hoped that the familiarity of it would somehow aid Robert in regaining mobility.

I even thought the Universe was trying to tell me something.  The SNF had an available male bed; the PT department was stellar and could work with Robert two hours a day for 5 – 6 days a week (which seems doable for Robert); the location was halfway between home and work and there was a bit of comfort in going to a familiar place. 

Robert was on board with whatever place I chose.  He told me he remembered this place but I’m not sure he does. 

Once we arrived, I didn’t recognize anyone but the intake social worker remembered Robert. Robert said he remembered him too. Who knows if he really did but it makes me feel better that Robert at least thinks he remembers this place (and fondly).

Robert happily settled in while I pushed away the thought that if this doesn’t work out I have no one but myself to blame.  After all, I know the problems we had here before but I am optimistic the Universe knows a thing or two about what is best.

Decision number four: Having faith in the caregiving decisions I have made. 

Working on it. 

Comfort in a Diagnosis

Robert has declined so quickly this year and had so many different things going on, my head has been spinning.  I just want to find out what’s wrong!

 

Looks like Robert's appetite is back!

Questions have swirled this year: Why is he getting pneumonia so frequently? Do we use antibiotics when he has bronchitis and risk resistance to them or risk the bronchitis turning into pneumonia? (Side question: Why aren’t there any good choices?) Why does he now sometimes have both urinary and bowel incontinence?  Do we blame the antibiotics or is there something more going on?  What’s with the increased seizures? The irritability? The trouble walking? The sleeping 18 hours a day?  The eating half of what he used to?

We got a possible diagnosis of Cervical Disc Disease with Myelopathy at the last neurology appointment.  Boy, that didn’t sound good.  The neurologist needed an MRI to confirm what he suspected but Robert couldn’t tolerate the MRI.  They decided to do an MRI with anesthesia and wrote a referral for that.

Just a few short days after that, Robert was literally unable to move his legs.  Richard (yes, my husband with the severe and chronic back pain) had to lift Robert from his wheelchair to the bed. The day after that, Robert slept and slept and slept.

Neurology suggested we take him to the ER and get a CT scan done and then the hospital could do the MRI with anesthesia. It was a Tuesday afternoon.  How bad could the ER be?

Oh how naïve I am!

It was a very long day.

Almost as soon as Robert was settled in his hospital room he started throwing up and running a fever off and on.  What in the world?!  Day Program informed me the following day that other consumers had been throwing up lately. Great. Robert has a stomach virus on top of everything else.

And, it’s contagious. Thank you very much.

After several days of waiting for the MRI with anesthesia (we had to wait for the stomach virus to subside, then there was the 4^th of July and then a weekend and then a promise of “maybe we’ll do it Monday but for sure Tuesday”).

By late afternoon Tuesday, the neurologist was not hopeful and was as frustrated as the rest of us.  For whatever reason, the hospital does not actually schedule MRIs with anesthesia for people actually admitted to the hospital.  They “squeeze” them in between emergencies and the general public appointments (as in, if I had taken Robert home and then made him an appointment, he probably would have gotten it a lot faster).

The neurologist did what she could and called hospital administrators (the hospital neurologist is not his usual neurologist).  They pulled some strings and we were on our way to the basement of the hospital housing the MRI machine.

It was miles away from his room and I did my best to keep up with the transport team pushing the gurney but I wasn’t about to complain.  We were getting this done and we will be able to actually find out what is wrong!! Woohoo!! 

Until I hear the word “cancelled” on the mikes hanging around the necks of the transport team and they stop cold.

Oh hell no.

We were no more than ten feet from the door leading to the MRI.  This test we have endlessly waited for.  A voice from the room said, “He has hardware in him still.” 

NO HE DOESN’T!

I made my way around the transport people and past the gurney into the MRI room.  Mr. Radiologist, MRI technician and the transport people looked as if they just might call security.

He does not have hardware in him.  The VNS and DBS have been removed.  I was assured by the neurology team at his former hospital – he can have an MRI. 

GET HIM IN THERE!

Mr. Radiologist towered over me but respectfully talked to me, even while I ranted and raved and told him he was flat out wrong.

He insisted there was a piece of the VNS still wrapped around the vagus nerve and that Robert’s nerve could be burned if he had the MRI.

But he’s had an MRI since the equipment was removed! We’ve waited for a freaking week for this test!  This is ridiculous!

All Mr. Radiologist could do was say how sorry he was.  He was not backing down. The transport team was already leaving with Robert, walking back to the room and I just threw up my hands and stormed back right behind them.

As soon as we got to the floor, I looked at the nurse – who was as surprised and disappointed to see us as I was to return – and said, “Call neurology!”

One of the neurologists from Robert’s team showed up within minutes. She was mortified and apologetic and by this time, I was in tears. A moment later, Mr. Radiologist peeked into the room and I dropped my head into my hands. 

I’m sorry I lost it but we need to find out what’s wrong.  We’ve been waiting for a week for this test!  I just can’t take this!

He was very sympathetic but again explained how dangerous it would be for Robert to have the MRI.  I told him I understood and appreciated him coming to the room to further explain his position. 

I get it.  I do.  I just want answers.

The lead neurologist on the team came in a short while later and apologized profusely. She missed the hardware on the CT scan. She should have seen it and didn’t.  She was kicking herself and felt absolutely horrible. She assured me the entire team would learn from this which really was of no comfort to me at that point.

What’s next?

She had a plan and for that, I was grateful. 

She decided the next best test would be a CT scan with myelogram.  

Will this get us a diagnosis?  When can we get this?  Can this happen tomorrow?  It’s already Tuesday night – we have been here a week and Robert is losing function by the minute. 

Please!

According to the neurologist, there were two options: Cervical Disc Disease with Myelopathy or Cumulative Traumatic Encephalopathy. The CT scan would be able to confirm or rule out the Cervical Disc Disease.

She made it happen and the next morning preparations were made for the CT scan.  By noon we were done and after waiting an hour for transport (perhaps the story of the lunatic sister was making the rounds and they were drawing straws for the job), we were back in the room waiting for the diagnosis.

The results were that there was some narrowing of the spinal column in the C5/C6 area but there was enough space left that they were comfortable ruling out Cervical Disc Disease.

The neurologist said she thinks all of Robert’s symptoms and decline are a result of Cumulative Traumatic Encephalopathy.  Since all I had was time at the hospital, I had done research on this so asked if it was CTE or CTEM. 

CTEM? 

I didn’t really mean to play “stump the neurologist.”

The resident on the team went to the computer to look it up: Cumulative Traumatic Encephameylopathy.

The neurologist confirmed it was CTEM, the slightly more aggressive and serious cousin of CTE.

This is not something that can be fixed and it is extremely serious and progressive (sort of like ALS, aka Lou Gehrig’s disease).

But it is a diagnosis and I find great comfort in knowing what we are dealing with.  While we can’t predict exactly how this will progress in Robert, it makes sense.  His lung muscles are getting weaker, he has a swallow disorder and his leg muscles are unable to get moving. His brain is forgetting to tell his muscles to work.

For me, not knowing what is going on or what to expect is worse than knowing. 

For me, there is comfort in a diagnosis.

For Robert, he knows he is going to get physical therapy for a few weeks at a Skilled Nursing Facility. He knows he is getting meals served to him and he’s looking forward to the activities at the SNF. 

That’s all the comfort he needs for now. 

Passing Time in the ER

Robert came into the hospital last Tuesday.

I am pretty sure today is Monday and, yep, we’re still here.

Rocky Road makes the wait much easier

Anyone who has spent any time at all in the hospital or visiting anyone in the hospital or knows anything about hospitals knows there is one constant: waiting. 

We are waiting for an MRI with sedation (because Robert has back pain when he is lying flat so can’t stay still during the test).

We are waiting to find out what is causing his rapid decline (why he can’t walk; why he is sleeping all the time; why he can barely circle his words on his Word Search puzzles).

We are waiting for doctors and blood work results and theories.

We are waiting for physical therapists, occupational therapists, answers and a plan.

On Tuesday we waited for eight hours in the Emergency Room before being admitted and getting wheeled to his current room. We have had longer waits in the Emergency Room so eight hours seems long but not unheard of. 

What kind of crazy world do we live in that an eight hour stay in the Emergency Room doesn’t seem too bad? 

I think the problem was we came into the ER on a Saturday night.  Oh, wait, no – we came in on a Tuesday afternoon.  A Tuesday afternoon and Robert was first put in a hallway and eventually a room. 

Where we waited and the doctors ignored my insistence they call the neurology team which is what his neurologist wanted.  She specifically told me the team would be notified before I even brought him to the ER!  Call them, please! 

It took four hours for the doctors to finally decide to call the neurology team and this was after me asking them to do so; telling them to call them; calling them myself and finally unloading on a medical student (who had repeatedly told me she was a fourth year med student).

Congratulations!  You’re in your fourth year of medical school! Let me just ask you to please, please listen to the caregivers when they give you information.  Caregivers know their caree.  Caregivers will give you all sorts of information about what is baseline for this person you’ve never seen before.  Since you’re a student, it is a good thing to learn early on that caregivers can be a huge help and resource to you!  Now, Please. Call. Neurology.

I felt better after giving my little speech.

And neurology showed up soon after.

While Robert and I waited in the ER, Richard arrived with new energy and a smile.

What a welcome sight!

Richard went to get us food which turned out to be the best grilled cheese sandwich I’ve ever had.  (Although it could have been the starvation influencing my judgment.)  Regardless, I was beyond grateful for Richard getting us the food so I wouldn’t miss the opportunity to talk to the doctors.

Robert tried to pass the time working on his puzzle book but had trouble circling the words.  He slept during part of the wait and I stepped into various hallways on a search for internet access.  I finally was able to text by creating the text then holding my phone up in the air in a particular hallway and sending.

Whatever works.

Waiting allows me time to find these creative solutions.

Waiting also gave me time to talk to Robert to ask him silly questions.  He had a purple band on his wrist which the hospital had put on him upon arrival. 

I like the color purple, Robert!

“I do too.” 

What is your favorite color?

“Blue. I like yellow too. And purple.”

I knew he loved blue but didn’t realize he liked yellow and purple.

What is your favorite food?  (Of course, I expected to hear “cheeseburger” or “combination pizza.”)

“Steak and Lobster.”

Wow! Someone likes to live high on the hog!

What is your favorite drink?  (This is an easy one – he’ll say chocolate shake for sure!)

“Sprite.”

What?  Anything else?

“7-Up.”

Well, okay, but I still think chocolate shake is his favorite drink!

What is your favorite dessert?  (Everyone knows this answer!)

“Chocolate candy.”

Oh goodness.  Robert must be really sick if he doesn’t even rank Rocky Road ice cream as his favorite dessert!

What about ice cream?

“I love ice cream.”

What kind?

“Chocolate.”

The long wait is obviously turning his brain to mush. 

What about Rocky Road?

Robert's eyes lit up. 

“I LOVE Rocky Road ice cream.  It is deeee-LISH-us.”

We eventually made it out of the ER and into a room.

Where we wait for an MRI with sedation and answers and theories and plans. 

And where I sneak in a little bit of Rocky Road to help with the wait.  

Back in the Hospital

Robert is on Day Three in the hospital.  We got here by way of the Emergency Room but it really has just been a matter of time before he had to come in.  After all, Robert was hospitalized three times last year for pneumonia and sepsis and had bronchitis four times this year but without any hospitalizations.

The way things have been going he really was due for a hospital visit.

He isn’t here for pneumonia (although he has a bad cough and is starting to run a fever).  We brought him in because he can’t walk. 

That’s unusual for him. 

Robert has had a steady decline in his health since I took over his care in 2009.  I mean, that’s one reason I took over his care: he was declining.  Falling more frequently, not making safe decisions, not recognizing when he had a raging infection – even allowing a homeless woman to live with him and his companion. 

Yeah, he was declining. 

Since I’ve taken over his care, he has needed to use a walker at all times, has recurring pneumonia, needs to be cleaned after using the restroom, has urinary incontinence and sometimes bowel incontinence. He has a swallow disorder so is on a modified diet, has constant congestion and a cough, has increased his seizures and is on a new anti-seizure medication which (it pains me to say this) has reduced his seizures. (It pains me to say that only because I’ve blamed his rapid decline this year on these new medications.)

More decline.

This year I have needed to help him get out of bed, use a shower chair so he didn’t fall and help him put on socks when dressing. He slept until noon on the weekends.

The decline really seemed to be speeding up.

Three weeks ago, he had increased difficulty moving his legs. I put him in a wheelchair for Day Program. A few days later, we had to start using it at home too.  Richard and I helped him transfer from the wheelchair to the toilet or shower chair or recliner or dinner table chair. Robert slept until noon on the weekends but also needed to stay home from Day Program a couple of days a week to sleep in.

Each day after that, more help was needed until he could not move his legs – particularly his right leg.  I could see him thinking: Leg – MOVE! But it wasn’t listening.  It stayed firmly planted wherever he put it.  Transferring him became a real struggle. He slept until 3:00 in the afternoon and ate half of what he used to.

Now that’s a real problem!

His neurologist settled on a new diagnosis: Cervical Disc Disease with Myelopathy.

That doesn’t sound good!

Labs were run and an MRI was scheduled to confirm this new theory.  Unfortunately, Robert had a great deal of back pain while lying down for the test and couldn’t stay still.

An MRI with sedation was ordered but not yet scheduled and neurology cautioned we should go to the ER if he continued to decline. 

Robert slept all day at Day Program on Monday, even falling asleep in mid-sentence and during lunch.  I mean, he didn’t even eat his pudding!

By Monday night, he could not move from the wheelchair to the bed without Richard and me lifting him.

Okay, things are declining faster than I can even keep up. 

I let Robert sleep in on Tuesday but debated about taking him in to the ER.  I called neurology who agreed he should be taken to the hospital.  They thought he could get a CT scan of his neck done and then the MRI with sedation if needed.  It was Tuesday afternoon so I thought it would be a great time to take him to the ER. I got him cleaned up since he hadn’t been out of bed since the previous night and called the paramedics.  There was no way Richard or I could get him in or out of the car so the ambulance was the best solution.

Robert was agreeable about going to the hospital and our local fire department greeted us like old friends since we hadn’t seen them since last December. It is really nice when people remember us and I love our fire department but I really wish we didn’t have to have them on speed dial.

Can’t we just know them because we brought them cookies when the kids were little?   

Robert was loaded into the ambulance and was whisked off to the hospital.  I gathered my essentials (phone charger, note pad, logs for seizures and vitals and other symptoms) and kissed Richard and the dogs goodbye.  Richard planned to meet us in the ER later in the day. 

My optimism about a quick and quiet visit to the ER was squelched before I even made it to the emergency department check-in desk. Visitors and patients waiting to be seen were overflowing into the hallway and parking lot. I gave the front desk Robert’s name and was given a visitor pass with his room number on it. 

Which was a hallway. 

Robert was on a gurney hooked up to an EKG machine. The other patient in this hallway asked a passing nurse for crackers and juice. Goodness – how long has he been here? I wonder if a change of address form is going to become necessary.

We were in for a long afternoon. 

Next post: Passing Time in the ER