Hi All,

Saw Forbesy on Sunday and had a good catch up. He’s definitely looking thinner as he has lost a lot of the muscle bulk in his upper body. That said, he is able to use his biceps on each arm to bend at the elbow but relies on gravity to extend at that joint. He feels he’s making some progress with his arms which is positive but the full extent of any functional movement won’t be clear for quite a while yet – he has to learn how to best utilise these gross (large) movements of his upper arm to help him with finer activities such as driving an electric wheelchair.

Michael has had some fevers and generally felt unwell during the later part of the last week. He has been commenced on some antibiotics and was somewhat improved on Sunday. In the work-up for his fevers, Forbesy was found to be colonised with VRE, a hospital bug that has necessitated a change in his room and some extra hygiene precautions. I want to spend a few moments explaining the significance of this because as visitors you may notice that he has a single room and health care workers are wearing gowns and gloves when they enter the room. I’m an infectious diseases registrar and this is part of what I deal with every day so I know that the general public, as well as the nursing and allied health staff, and even the medical staff can have a variable understanding of what this means.

The E of VRE stands for Enterococcus, and this is simply a normal bug that lives in the bowel of every one of us. When it stays there, it doesn’t make us sick. If it gets into the urinary tract or bloodstream, it can make us sick, but it is uncommon for this to happen. In fact, this bug most commonly causes illness in people with a poorly functioning immune system (ie not Forbesy). The VR stands for Vancomycin Resistant, and implies that one drug that is used to normally treat enterococcus is ineffective in killing it. Newer, (sometimes) more toxic and definitely more expensive drugs can be used to treat it, and for this reason when someone is found to have VRE, efforts are made to limit its spread around the hospital.

It is a sad and somewhat distressing fact that many of these bugs are created because we use too many antibiotics. Most of my job is actually stopping the inappropriate use of antibiotics. Resistant bugs are then spread by people having direct contact between patients. As such, one of the many ways to prevent the spread of these bugs is for the hospital staff to change gloves and gowns when going between patients. This has now been instituted for Forbesy and he has a single room to facilitate it.

Note earlier that I said Forbesy has been colonised with VRE, and not infected? The difference is that while VRE has been found amongst the normal range of bacteria that you would expect all of us to harbour, it is not making Forbesy sick and it has not been isolated from anywhere it is not supposed to be (eg urinary tract or bloodstream). Hence he is colonised but he does not have an infection from VRE. As such, while he is receiving antibiotics at the moment, they are not targeting VRE. Sounds complicated I know, but the take home points are that he has a single room, hospital staff are gloving/gowning, and we should not be concerned when visiting but just remember to use the antimicrobial hand rub before and after visiting.

Hope this helps. Please feel free to email me or write a comment if you need any clarification or I can help out in any other way.

Cheers

Sam Hume
schume@yahoo.com

Hi Crew,
well, the man is on the mend. Slowly but surely. We visited Mike again yesterday in the spinal ward of the Austin, where he has a little way to go yet before he can get to the rehab ward.

Physical

Mike has his trachy out, which is a step in the right direction for getting to rehab. Unfortunately, he is having an issue with his swallow, which means he will be delayed in the spinal unit until they can get to the bottom of this problem. The nerves controlling swallowing and it’s co-ordination emanate from much higher than Mike had damaged in his accident (they come from the brainstem, and are called cranial nerves). You’ll notice that his voice has a slight hoarseness and changed character when you visit him. This should resolve with time, along with the swallow. The nerves which control swallowing may have been bruised during the surgery which fixed the bony damage to his neck. Mike has a speech therapist helping him with his swallow, and they’re doing all sorts of weird and wonderful investigations like passing a camera into the back of his throat to watch the muscles work! Lucky Mike!

In the meantime, he’s working on a whole lot of other aspects of his recovery- physiotherapy especially. You can read in the other updates the fun and games he’s had trying to control a wheelchair with an unseen and unfeeling hand. He is using the muscles of his shoulder to control the chair through his hand being strapped to a cradle. Mike reports the concentration required for this fine control to be difficult and exhausting! At this stage, he has movement of his biceps, but without the triceps to help counter that muscle he has problems placing his hand where he wants to. The analogous stage for Mike at the minute is learning to change gears- he’s got all the gross motor control to move a gear stick, but has to learn to be smooth to change gears without grinding them! It’s a frustrating time- but he’s got the motivation and courage of a lion.

Additionally Mike has been trying to sleep in a hard collar and unable to have his bed head raised above 45 degrees without said collar. These collars are very uncomfortable, but it may be the case that he can do without in the near future (according to Mike). I’m not sure if that was wishful thinking or a near reality, if there is a cracked bone high in his neck to protect, it may be a few more weeks with the collar to come.

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Hi All,Naant and I saw Michael, Mon, Lesley and Bruce yesterday on the spinal ward. Overall, my impression is that Forbesy is actually doing quite well. His mood seemed high and he was having increasing awareness of which muscles and skin areas had retained function.

Physically, he has had a roughish week with a few minor setbacks. The metabolism of a young, super-fit male is not something that is easy to estimate and Forbesy has probably not been getting quite enough fluid and nasogastric foods for the first few days on the spinal unit. Consequently, he was fatigued, somewhat light headed when he sat up, and felt generally sub-par. This has been corrected and he was actually a lot better yesterday.

The tracheostomy is out and Michael is talking freely. His swallowing however, is not yet safe. We all “micro-aspirate” to some degree, where fluid and even the occasional bit of foodstuff enter the airways during day to day life. This is not a problem when you can cough and clear the fluid/food from your airway, but becomes a problem when either excessive amounts are aspirated, or you are unable to cough it up. Chest infections can result.

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Hi Gang,
Progress! That’s what the world is about! Mike has moved to the Spinal ward which is a half-way home before heading to Royal Talbot for rehabilitation. In reality, it’s a pretty frustrating place to be- because it’s a place where the staff try and ascertain whether there are any road blocks preventing Mike graduating to full rehab, plus where there might be some waiting time for a bed at Royal Talbot (near Kew Bvde), while Mike says, “Let me gooooo tooo Rehhhhaaabbb!”

Physical
Not too much to report at this stage. His biceps are curling nicely, which might allow him to have enough control to scratch his nose, shoo a fly or feed himself. Being able to raise your own hands to your face is very important for self esteem and independence, so great for him to have these muscle groups still functioning.

There was a slight hiccup on Wednesday with his lung function, after he had an absolute gab-fest with anyone who was willing to listen. The reduced capacity of his respiratory system, especially in the context of lying flat for much of the day, plus the effort of weaning from the respirator, meant that he required some time listen and not talk! Funny how they make you have a rest when you’re running on 50% capacity!

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Hi Crew

Sam, Bridie and myself went and visited Mike again today to check status, and he was jumping out of his skin. His improvement has been unexpectedly good in the last 48 hours, largely due to his excellent respiratory function. So good that he’ll be moving to the spinal ward tomorrow, with plans to remove his tracheostomy on Monday or Tuesday next week.

Mike & Dr Mitch – click here for larger image

Physical
Mike’s breathing is the best it’s been since he had his accident. He’s blowing numbers for the physio in the mid 2000’s, which is about 1L better than when he was a bit under the weather last week. The physio is also being tested to the limit by Mike’s well hardened work ethic, plus the recent addition of trash-talking added to his armoury! He has a fenestrated tracheostomy tube, which is supposed to be open for 45min or so (so he can talk), then closed to give him a rest. When the nurses tried to change it back to silent mode, he put the foot down (metaphorically) and has been yapping ever since. He has become the biggest talker of anyone in the ICU- well of the patients anyhow! This augmented communication has buoyed his spirits tremendously, plus the fact that he no longer requires the ventilator to assist his breathing. His large breaths are about 50-60% the size of our big breaths, so he still has to complete regular physio to prevent infection and strengthen the breathing muscles he has left (essentially the diaphragm).

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Mike is keen to see people over the coming days, weeks and months. At this point a trickle of visitors each day is perfect to provide him with enough distraction and support to get through the day, whilst allowing him enough time to rest and recover from his injuries (plus give Mon an opportunity to go and get a coffee).

ICU is a difficult place, and the aspects of day to day care are exhausting when you’re sick. There’s the washing, ablutions, meals, nursing observations, doctor consults, physiotherapy, orthotic specialists and handover times to fit in with family and friends visiting.

Please get in touch with Mon or the ICU if you are keen to see Mike. There’s opportunity to visit, but to avoid disappointment it has to fit it in with his complex schedule!!

Please bear in mind that ICU only allows two bedside visitors at a time, so if you come after work or on the weekends, you may have to spend some time in the waiting area.

Dr Mitch