Sometime last night while I was heading home from Austin from the last meeting with the lawyers and insurance carriers for Frontera (broker), Freshpack (shipper), King Soopers (retailer) and Primus (auditor), Herb Stevens took his last breath.
If I were a cynic, you could look at the justice delayed and see that the strategy of the corporations that sell you “fresh fruit” is to stretch the process out until all the victims are dead.
If I were a cynic.
His wife, Elaine and his four daughters will continue the fight to hold these companies responsible.
Herb Stevens was an 86 year old retired hydrologist, who worked for the U.S. Geological Survey. He lived in Littleton, Colorado with his wife, Elaine, with whom he has 4 daughters. Before Listeria, his hobbies included gardening and woodworking.
He and Elaine were looking forward to celebrating their 60th wedding anniversary in September 2011.
Elaine Stevens purchased a half cantaloupe, cut up at the King Soopers located at 100 Littleton Blvd. (Store #70), on August 10 and 24, 2011. Herb ate the melon that Elaine had purchased on August 10, but did not eat any of the melon purchased on August 24.
On August 24, 2011, Herb and Elaine were out of the house early in the day attending to some errands. Later, while at home, Herb developed some tremors or chills and became increasingly tired and weak—so weak that he was unable to get up from the toilet. Elaine summoned a neighbor to help and placed an urgent 911 call at about 7:45 PM.
The paramedics described Herb as awake, alert, oriented, moving all extremities and complaining of weakness and fever. In fact, he had a temperature of 101.7º F, and his blood pressure was 140/72. Heart rate was 110/min and irregular with a pattern consistent with atrial fibrillation, on the cardiac monitor tracing. The pulmonary assessment revealed slightly rapid respirations (24/min), diminished lung sounds, and hypoxia with an abnormally low oxygen saturation level (SaO2) of 86%. The portable serum lactate monitor showed a critically high level at 6 (NR:0.5-2.2). This finding, in conjunction with the fever, prompted a “septic alert.”
The paramedics administered oxygen via a non-rebreather mask and established an intravenous site for the administration of fluids (normal saline). He was transported emergently and arrived at the Emergency Department at Littleton Adventist Hospital just after 8:00 PM.
Littleton Adventist Hospital – Emergency Department Admission
The triage nurse assessed Herb and was aware that he might be septic due to the initial findings of fever and high lactate level. She elicited his medical history, routine medications, and obtained vital signs. His heart rate was still irregular at 88 to 110/min. His temperature had risen to 102.5º F and he remained hypoxic.
Within minutes, Emergency Physician, Phillip Mitchell, MD, arrived to evaluate Herb, who was able to converse without difficulty. He denied any chest pain or cardiac-related symptoms. Dr. Mitchell recorded that Herb was suffering from a persistent dry cough, fatigue, anorexia and generalized malaise. Herb’s physical examination was negative except for irregular heart rhythm, fever and lower extremity edema. A septic diagnostic work-up was ordered.
Over the next several hours, Herb received continuous intravenous fluid hydration with normal saline in accordance with the “sepsis resuscitation protocol.” His hypoxia improved with oxygen and nebulized aerosol bronchodilator therapy (Atrovent and Albuterol). His fever began to come down with Tylenol and IV fluid hydration.
Laboratory results revealed that Herb’s platelet count was low and his renal function studies showed chronic renal insufficiency with elevation of BUN and creatinine. His urinalysis demonstrated trace protein and 1+ bacteria. Herb’s serum lactate was improved to 2.6 (NR: 0.5-2.2).
Dr. Mitchell later returned to reassess Herb and review the lab results and imaging studies. Herb’s oxygen saturation was improved at 94% on oxygen. His temperature was 100.7º F. In light of Herb’s general malaise, weakness, and evidence of hypoxia at rest, Dr. Mitchell felt it imperative to admit him to the hospital. He called Herb’s primary care provider, PA Michael McCleery of Provident Healthcare, to report his findings and recommendations for further evaluation. The PA concurred and requested admission coverage by Critical Care/Pulmonary Consultants (CCPC).
Littleton Adventist Hospital – Inpatient Admission
Herb was admitted to a medical bed at approximately midnight, with a diagnosis of bronchitis, hypoxia and renal insufficiency. A pulmonary specialist, Dr. Benish, arrived a short time later and reviewed his current illness course and recent diagnostic findings. Bibasilar lung crackles were noted as well as 1-2+ pitting edema of the lower extremities.
Dr. Benish was concerned that the atelectasis evident on the chest films might represent an early pneumonia. Her overall impression was SIRS (systemic inflammatory response syndrome) with pneumonia. Empiric antibiotic therapy with Ceftriaxone and Zithromax was ordered (pending results of the blood cultures) as well as resumption of all previously prescribed medications. She also ordered urology, pulmonary, PT and OT consultations.
Herb had a relatively uneventful night and when reassessed by the nurse at 5:00 AM he was described as pale and oriented, but very weak, not feeling well, at moderate risk for falls, and unable to void. This required placement of a Foley catheter. Blood work that morning showed that his hemoglobin and hematocrit levels were slightly low and his platelet count had dropped, consistent with thrombocytopenia.
A physical therapy (PT) evaluation was completed and the physical therapist noted that his “bronchitis had resulted in decreased endurance, independence and functional mobility.” Treatment recommendations included therapeutic exercises for strengthening, balance and coordination as well as mobility and transfer training daily for 5-7 days.
The occupational therapist also arrived to evaluate Herb. The therapist interviewed Elaine and learned that prior to admission, Herb had been independent for eating, grooming, upper extremity dressing and toileting. Barriers to learning were identified as mild dementia, but Herb’s safety awareness was “intact.” Due to his impairments and the current illness, Herb had become limited in his performance of ADLs and functional transfers. A treatment plan was formulated to include skilled interventions for balance and coordination (daily for 5-7 days/week). The overall goal was to assist Herb in achieving moderate independence in all ADL’s so that he could return home.
At 8:30 PM Herb developed a worsening cough and a decline in oxygen saturation to 92%. His heart rate was normal, but his blood pressure was elevated at 153/71. Rales were audible in the lung bases bilaterally. His oxygen was increased and Robitussin was given for the cough and a breathing treatment with albuterol and atrovent was also administered. A chest x-ray showed further collapse of air pockets in the lungs (increasing bi-basilar atelectasis) with associated pleural effusions (excessive fluid in the lungs). Diuretic therapy with Lasix was ordered to help fluid removal, and IV fluids were discontinued.
August 26, 2011:
The lab records indicate that a gram stain on one of the two blood culture bottles (drawn at admission, on 8/24/11) showed gram positive rods. This result was called to the floor and the 2 specimens were sent to the Colorado Department of Health for definitive study. Dr. Benish was notified of the result and ordered “observe for now.”
Nursing notes report that Herb had a fair night and was slightly confused. His cough was somewhat improved after taking Robitussin, but he complained of weakness and his breathing was reportedly labored at the beginning of the morning shift. He received a nebulized breathing treatment with albuterol and atrovent by the respiratory therapist.
Herb’s respiratory status improved following treatment with bronchodilator therapy. The physical therapist arrived a short time later and transported Herb to the PT Department for a 25 minute session of therapeutic exercises. He complained of some soreness in his legs but, as was his nature, he was eager to participate.
Infectious disease specialist, Joseph Morroni, MD, evaluated Herb and made recommendations for treatment given the report of the positive blood culture. Herb said he was feeling better and denied any shortness of breath or chest pain, but that he continued to have a dry, harsh cough. The physical examination showed diminished lung sounds and bilateral lower extremity edema.
Dr. Morroni reviewed the current illness/hospital course and spoke with Elaine about the onset of Herb’s illness. She denied any new restaurant or potluck meals, exposure to ill contacts, recent travel, consumption of unpasteurized or poorly pasteurized dairy products.
Dr. Morroni suspected that Herb’s presentation and transient bacteremia (sepsis) was most likely associated with infection by Listeria, as there had recently been others in the area with similar signs and symptom, who had become infected after consuming cantaloupe from Jensen Farms. He discontinued the current antibiotic therapy (Cephtriaxone and Zithromax) and ordered repeat blood cultures. Antibiotic coverage for listeriosis was then initiated with intravenous ampicillin.
Given the risk of heart-related infections associated with Listeria infection, and because Herb had an implanted pacemaker, an echocardiogram (echo) was ordered to look for infectious complications such as endocarditis or valvular vegetations. Thus, a two-dimensional echo was performed at the bedside and compared to a previous echo. There were no new findings or evidence of further heart valve involvement. Herb’s ejection fraction was unchanged (abnormally low) at 40-45%.
August 28, 2011:
Dr. Morroni came in to reevaluate Herb and review the lab results. Herb’s dry cough persisted and he was being continued on bronchodilator therapy to improve his breathing. There was no evidence of worsening sepsis involvement of the Listeria infection. Ampicillin was to be continued for a total of 2 weeks for full treatment of listeriosis.
Given his age, multiple underlying medical conditions and the need for IV antibiotic therapy, Dr. Morroni felt that Herb might be better suited for discharge to a skilled nursing facility (SNF) or rehab center, rather than sending him home. The Case Manager was asked to consult and make arrangements for discharge.
The OT therapist arrived shortly before noon. The therapist found that Herb was slow at performing activities, still generally weak and at risk for falls. He complained of leg pain, partially related to his very swollen lower extremities. The therapist also reported that Herb complained of fatigue but was agreeable to bed exercises. He participated in 14 minutes of therapeutic maneuvers.
August 29-30, 2011:
Over the course of the next two days, Herb’s condition was essentially stable. Labs demonstrated a slight improvement in the anemia and thrombocytopenia and WBC counts were normal. Further testing by the Health Department on the blood specimens obtained on August 24, 2011 confirmed the finding of Listeria species.
With assistance, the once spry Herb was able to walk about 100 feet. His endurance was noted to be limited and he complained of fatigue. Elaine reflects on Herb’s first hospitalization:
During this time period, I spent most hours during the day at the hospital. Doctors come at different times, and it is nice to get the updates from them. There was a lack of sleep at home and the stress of going to the hospital for our daughters, Jennifer, Paula and their husbands stopping to check on us two elderly people kept their lives busier with many extra duties. During this initial hospitalization, there were a couple of times when Herb did not know he was in the hospital. He asked Paula and me to make sure the dining room light was off and to let Christie (our dog) in the house. He had no appetite and had to be coached to eat.
Final arrangements came together for Herb to be admitted to Life Care Center of Littleton (LCCL). The Foley catheter was removed. A PICC line was placed in his right arm for continuation of intravenous Ampicillin for the treatment of Listeriosis. His cardiologist, Dr. Richard Mathe of Denver Cardiology Associates, confirmed that he would follow Herb’s coagulation studies and make adjustments in the Warfarin. Herb’s daughter, Jennifer Exley credits one of Herb’s doctors with saving his life: “When I look back on my father’s hospitalizations, I am surprised that he actually survived and I credit the infectious disease physician for thinking it was listeriosis, and initiating treatment with the appropriate antibiotic before the blood culture results were in.”
Life Care Center of Littleton (LCCL) – Admission (8/30/11 to 9/8/11)
On the evening of August 30, Herb was transported via ambulance to LCCL where Kelly DeBoer, MD admitted him. See LCCL Records, Attachment No. 6. In addition to his multiple chronic medical conditions, Herb’s admission diagnoses included systemic inflammatory response syndrome (SIRS) with Listeria bacteremia and bronchitis with a non-productive cough.
A comprehensive admission assessment reported that Herb was friendly, independent and social—”capable of making his needs known.” He was moving all extremities but required 1-2 person assist for ambulating, transfers, toileting and dressing. His abdomen was soft/bloated, and he had lower extremity edema of 3+.
Herb was interviewed by the “activities” coordinator, who spoke with Elaine and learned that his hearing deficit was more of a barrier to his social/leisure activity than the “mild” dementia. The assessment noted that generalized weakness, poor activity tolerance, and significant lower extremity edema represented the most pertinent barriers to social/leisure activity.
August 31, 2011:
Occupational therapist, Lisa Haneke assessed Herb and formulated a plan of treatment. The reason for OT referral included diminished ability to perform ADLs and self-care due to recent hospitalization for Listeriosis and declining medical status. His current problems list included short term memory deficits, decreased balance, endurance, strength and safety, all of which limited his ability to complete ADL tasks.
The therapist underscored Herb’s profound debilitation in the wake of his Listeria infection. She recorded that Herb lived in a tri-level home with a total of 12 stairs which he had been able to navigate before becoming ill with Listeriosis. She noted that he had been independent in all ADLs prior to hospitalization in August 2011: walking in the home and community without any assist devices, using a tub bench and hand held shower arm for bathing, and grooming and dressing himself.
At this time, Herb’s sitting ability was good and standing was fair. Functional mobility limiting factors included shortness of breath, oxygen requirement, coughing, poor endurance and bilateral lower extremity edema. Short-term OT goals for self-care over the next 2 weeks included stand-by and minimal active assistance in all dressing tasks, hygiene, grooming, toileting and functional transfers. In 6 weeks Herb was to be moderately independent in all ADL’s including bathing, simple meal preparation and laundry. He needed to demonstrate good balance, endurance, strength and safety, in order to return home.
The admission treatment plan called for continuation of IV Ampicillin until September 10. In addition to Herb’s daily medications, his Lasix was increased to 60 mg daily for the edema, and Coreg was ordered twice daily to decrease heart rates. OT/PT for treatment of generalized weakness and deconditioning was ordered daily for 1 week, followed by 6 times/week for 35 days. Therapeutic recreational activities were ordered daily as tolerated.
Physical therapist Lynn Foltz worked with Herb, who was only capable of 10 minutes of graded therapeutic activities due to his decreased functional activity tolerance and need for oxygen. Herb could only walk100 feet on level surfaces with a front wheeled walker and contact guard assist, due to his unsteady gait. The short-term goals were modest: 25 minutes of graded therapeutic activities daily, progression to improved bed mobility and transfers with only stand-by assistance, improved walking to 250 feet on a variety of surfaces as well as ascent and descent of stairs to facilitate Herb’s return to home.
September 1-8, 2011:
Kelly DeBoer, MD and physician’s assistant (PA) Michal McCleery were in charge of Herb’s care. Herb’s problem list was updated to include anemia, congestive heart failure (CHF), and elevated liver enzymes. He continued to receive intravenous antibiotic therapy with Ampicillin for treatment of Listeriosis, as well as his other daily medications. Herb’s heart rate was managed with a drug, Digoxin, and antihypertensive drugs to keep his blood pressures in the normal to slightly hypotensive range. His lung sounds remained diminished and oxygen was required continuously to maintain adequate oxygen saturation levels. His dry, non-productive cough persisted and was aggravated by exertion. Robitussin and nebulized breathing treatments were provided every 4 hours and Robitussin with Codeine was added as needed on September 3.
In addition to very poor circulation in his legs, Herb developed severe blistering of his swollen lower extremities, which were now too big to apply compression stockings. He was instructed to elevate his legs on pillows when in bed, which was almost all the time. Extra Lasix was added in an effort to remove more fluid. Bilateral generalized weakness persisted, affecting all activities, and was aggravated by fatigue. Associated symptoms included confusion, abnormal gait and unsteadiness. Part of Herb’s general problem was moderate malnutrition, common among those critically ill. A liquid nutritional supplement was added to improve total protein and albumin levels. And because patients with atrial fibrillation and decreased mobility are at great risk for deep vein thrombosis, anticoagulation therapy was continued with the blood thinner Warfarin.
Herb had some nausea and vomiting on September 6, which may have been due to his constant hacking cough. He also complained of some watery diarrhea. Since he had been on a prolonged course of antibiotic therapy, PA Michael McCleery suspected the diarrhea might be caused by Clostridium difficile. A stool specimen was obtained and submitted to the lab for cultures, but would later test negative. Kaopectate was ordered after each diarrheal stool.
Despite the increase in dose of the diuretic agent Lasix, there was only minimal improvement in Herb’s extreme lower extremity edema. Concerned that the extra fluid was affecting Herb’s lungs, his doctors ordered a portable chest x-ray, which showed “moderate pleural effusions, moderate CHF; no pneumonia.”
Herb’s cough was improved on September 7, but his nausea continued and the staff informed PA McCleery that this seemed to occur after eating. He ordered Zofran (anti-nausea drug) to be given 30 minutes prior to each meal for 5 days. Then, at approximately 9:00 PM, the staff noticed a sudden drop in Herb’s oxygen saturation level to 86%. He received a nebulized breathing treatment with Albuterol and Atrovent as well as 6 liters of oxygen.
At 4:30 AM on September 8, Herb was once again treated with Zofran for nausea and the staff discovered dry blood on his nose and lips. Dr. DeBoer requested a GI consultation. A hemoccult test on the stool was grossly positive for blood. As with many problems that occur during a long-term hospitalization, this one may have resulted from another treatment—aggressive anticoagulation with Warfarin was considered to be a possible cause of the bleeding.
To add to his considerable misery, Herb developed an itchy rash composed of small red spots on his trunk, groin and arms, consistent with an allergic reaction. PA McCleery suspected that Zofran might have caused the rash and it was discontinued and placed on his allergy list. PA McCleery spoke with Dr. DeBoer and contacted Dr. Van der Leese at Littleton Adventist Hospital to discuss the case. All agreed that Herb should be further evaluated for gastrointestinal bleeding and anaphylaxis. He transferred via ambulance back to the ER at Littleton Adventist Hospital.
Littleton Adventist Hospital (LAH) – ER Admission
Herb arrived at the Emergency Department of LAH in the afternoon and was assessed by the triage nurse. He was hypoxic and with normal vital signs. His chief complaint was incessant itching.
A medical evaluation was performed by Ahmed Stowers, MD, who described Herb as “ill-appearing and notably volume depleted; quite dry with cracked lips and tacky mucosal membranes.” Intravenous fluids were started via the PICC line. A STAT blood draw was ordered and specimens submitted to the lab for comprehensive diagnostic workup. Herb’s lung sounds were diminished and additional oxyen was given via nasal cannula. A chest x-ray was also ordered.
An abdominal exam revealed Herb’s extensive rash and early breakdown of tissue around the perineum. Rash was also present on his chest and was described as urticarial (white, raised rash typical of nettles) with scattered petechial-type lesions on the upper trunk, back and lower extremities. Intravenous Benadryl 12.5 mg and steroids (Solu Medrol 80 mg) were given for treatment of the rash. Herb’s legs had 3+ pitting edema and blistering.
Labs revealed a mild leukocytosis with elevation of the WBC count at 12.5 (NR: 4.1-11.0). There was persistent mild anemia. The urinalysis was positive for trace protein and 1+ bacteria. The chest x-ray showed cardiomegaly, but did not demonstrate any acute findings when compared to the previous admission films.
Dr. Stowers felt that the rash was an allergic response to the Ampicillin and noted that Herb’s recent Listeria illness was the reason he was on Ampicillin. Additional diagnoses included a hyper-coagulated state and possible gastrointestinal bleed, notable volume depletion/dehydration, and renal insufficiency with a creatinine of 1.6.
Dr. Stowers’ overall impression was that Herb’s condition was serious, necessitating admission for further observation and evaluation. Three units of FFP (fresh frozen plasma) were ordered to treat the coagulopathy. Intravenous fluid infusion was continued. The 130 pound Herb now weighed 164 lbs. As Herb’s daughter Jennifer Exley recalls: “During the 2nd hospitalization, his legs and abdomen swelled to a size I had never seen them. His legs looked like balloons and he had gained approximately 34 pounds of water weight.”
September 9, 2011:
Elizabeth Benish, MD, of Critical Care and Pulmonary Consultants (CCPC) assessed Herb and noted the “impressive rash” and report of bloody stools. Her impression was marked coagulopathy due to overly aggressive anticoagulation and an allergic rash secondary to Ampicillin. A GI consultation was ordered as well as infectious disease consultation by Dr. Morroni, to determine which antibiotic agent to continue for treatment of the Listeriosis given the apparent allergy to Ampicillin.
At 4:45 AM, Herb was found to be confused and attempting to get out of bed. His oxygen, telemetry pads, pulse oximeter and night gown were off. Oxygen saturation was only 86%, which partly explained his confusion and disorientation. He was helped back to bed and placed on 6 liters of oxygen.
Hana Kraus, MD provided the gastroenterology consultation. Herb complained of fatigue and itching. A rectal exam revealed bloody stool. Dr. Kraus felt that in light of Herb’s multiple medical issues he was not a candidate for a colonoscopy. Instead, close observation was advised. Infectious disease specialist, Dr. Morroni, agreed that the rash was most likely associated with the Ampicillin and did not think Herb required any further antibiotic therapy for the treatment of Listeriosis. He ordered close monitoring for Clostridium difficile.
September 10, 2011:
Herb remained anemic. Dr. Erickson spoke with Herb and Elaine. They did not want him readmitted to LCCL and expressed their desire for him to be discharged home when he was stable. Dr. Erickson ordered daily Metolazone, a diuretic for fluid removal. Wound care was initiated for skin breakdown on the legs secondary to massive edema and blistering.
September 11-12, 2011:
Herb was improved when reassessed by Dr. Erickson and Dr. Williams over the next two days. Dr. Erickson noted that Herb’s lower extremity edema was worse in conjunction with the elevated BNP and CHF. Thus, he adjusted the diuretic therapy by lowering the Lasix and increasing the Metolazone dose. Herb’s leg wounds were closed with no signs of drainage. But he continued to complain of itching.
September 13 – 15, 2011:
Lab results over the next three days demonstrated normalization of serum creatinine and improvement in Herb’s GFR. Herb reported that he was feeling and breathing slightly better. There was still a significant amount of leg edema and he continued to complain of itching on the chest and torso. Hydrocortisone ointment and oral Benadryl were continued for treatment of the rash and persistent itching. The PICC line was removed and a peripheral IV site was established.
On September 14, Herb suddenly developed hypotension with a drop in blood pressure to 77/36. He denied any chest pain, shortness of breath or dyspnea on exertion. Lasix and antihypertensive medications (Coreg/Lisinopril) were placed on hold and a cardiology consultation was requested.
Cardiologist, Bonnie Scheckenbach, MD, evaluated Herb. His blood pressure had normalized. She closely examined Herb’s legs and noted 2-3+ edema with blistering. She could not detect pulses due to the amount of swelling. Dr. Scheckenbach concluded that the lower extremity edema was not simply related to fluid overload; rather, it was multifactoral, secondary to a combination of valvular heart disease, left ventricular dysfunction and chronic lower extremity venous stasis. In fact, she noted that Herb had lost 14 kg (30.8 lbs) since admission. It is hard to conceive of this tiny, 130 pound man repeatedly gaining and losing this massive fluid weight, but that was just another of the many types of suffering Herb endured.
For Elaine, Herb’s second hospitalization stretched her to the breaking point:
Again, there were many days spent at the hospital and grandson Brent came from Bend, Oregon to stay with me, help and to visit Herb for a couple of weeks. This hospital stay was eleven days. The day of the transfer back to the hospital was particularly hard because his health was declining at the Life Care Center of Littleton and the day of transfer was our 60th wedding anniversary. I did not expect that our 60th anniversary would be celebrated in a hospital room…which really was not a celebration at all. He had very swollen legs and they swelled to at least twice his normal leg size, due to an accumulation of fluids. His stomach was also swollen and the next several days in the hospital were hard emotionally, as his oxygen needs rose from 2 liters of oxygen up to 9 liters of oxygen. Medication changes were made. Again, much time was spent making sure I was there to speak with the doctors.
September 16 – 19, 2011:
Herb was closely followed by Drs Dobranowski and Scheckenbach and gradually improved over the course of the next four days with gentle diuresis. His blood pressures and heart rates stabilized. At the same time his lower extremity edema decreased and he lost a lot of fluid weight. But he also developed stage 2-3 pressure ulcers in the region of the perineum and buttock folds.
Given Herb’s persistent generalized weakness and deconditioned state secondary to two acute hospitalizations and the need for intensive rehabilitation with skilled nursing management, it was the decision of the treatment team that he could not yet return home. Arrangements were made for admission to Christian Living Communities, a unit of The Johnson Center.
Herb’s second hospitalization showed the amazing toughness of this octogenarian as his daughter Jennifer observes:
When he had to be transferred back to the hospital for his 2nd hospitalization, it was on my parents’ 60th wedding anniversary, not a way they wanted to spend this happy occasion. For me, the second hospitalization was a rollercoaster of emotions, because my father was much frailer and the possibility of him dying was something I was not prepared to think about, or rather, something I did not want to think about. He had been a relatively healthy person, and then this sudden illness happened and my thought process had to shift. In the end, he surprised all of us and was transferred to another nursing home for his rehab.
Christian Living Communities (CLC) – SNF Admission
Herb felt good except for weakness when he arrived at CLC, which was remarkable given that his admission diagnoses included edema, joint stiffness, CHF, atrial fibrillation, chronic pulmonary obstructive disease (COPD), heart disease, muscle weakness, abnormality of gait, senile dementia, sinoatrial node disease, anemia, and open wounds of the buttocks.
The nurse who did the initial assessment noted Herb’s history of Listeria bacteremia, bronchitis and GI bleed; coagulopathy, hypoxia and hypotension. She described Herb as alert, oriented to person and place, cooperative, but very unsteady on his feet. Bilateral lower extremity edema and multiple areas of bruising were noted on all extremities. His weight was now 123.5 pounds.
Herb’s problem list was impressive. It included potential dehydration due to the need for diuretic therapy; cardiac status changes due to atrial fib and hyperlipidemia; ADL deficits and decreased mobility due to weakness, shortness of breath and mild dementia; discomfort and constipation due to decreased mobility/bed rest; and increased fall risk secondary to weakness and gait disturbances. A treatment plan was formulated to include PT/OT for improving ADLs, transfers, hygiene, grooming and toileting, strength, endurance, balance/coordination and a front wheeled walker to assist with balance and gait.
Michael Todd, MD, ordered resumption of all previously prescribed routine medications, lab studies, oxygen via nasal cannula to keep oxygen saturation at 90% and above, nebulized breathing treatments as needed, and intensive PT and OT.
Physical therapist Gregory Young made a note that Herb was previously independent for bed mobility and transfers with no assistance, cues, or supervision. The therapist identified additional underlying impairments impacting Herb rehabilitation and activity tolerance. These included oxygen impairment, kyphotic posture with head forward, and pitting edema of the lower extremities. Cognition, gross motor coordination, sensation and visual spatial perceptual skills were intact.
Therapeutic exercises, activities and gait training were planned five times/week for nine weeks. Short-term goals with a target of October 8 consisted of an increase in bilateral lower extremity strength and stability in transfers; increased independence in mobility; increased balance, gait safety and to reduce fall risk; and improved walking for mobility and independence. Herb’s long-term goals included regaining moderate independence in all indoor and outdoor mobility with minimal fall risk. Ultimately, the goal of PT was ensure that Herb was able to return home safely with Elaine. Given his high prior level of function, the therapist thought Herb had good rehabilitation potential.
An assessment of Herb’s basic functional skills reflected his deterioration. He now required stand-by assistance and supervision for safe, self-feeding and one or more cues for the majority of that task. His hygiene and grooming required 25% hands-on assist. Modified (25%) hands-on assist was needed for bathing and 30% hands-on assist for toileting. His upper body dressing required 15% and lower body dressing required 40% hands on assist. This once proudly independent man now required someone to shepherd him through all basic daily activities.
The occupational treatment plan included therapeutic exercises, activities, and self-care management and training five days a week for nine weeks. Herb also received instruction in compensatory strategies and adaptations, which were to be implemented for safe performance of self-care. For instance, a raised toilet seat and grab bars were provided to assist him in achieving modified independence when he went to the toilet.
Nursing notes reported that Herb was very friendly, cooperative, pleasant and interactive despite the difficulty of his circumstances. He was continent and able to walk to the bathroom with assistance, using a urinal at night. Tylenol was given for generalized body aches and control of right upper and lower extremity pain or discomfort.
Richard Mathe, MD, a cardiologist, evaluated Herb’s heart on October 4. Herb’s blood pressure was acceptable and his heart rhythm was stable and the rate well-controlled. Warfarin was continued at the current dose. The massive swelling in Herb’s legs had finally decreased to 1+ and this enabled the use of compression stockings (TED hose). Dr. Mathe concluded that Herb was clinically stable and had done quite well despite the stress of his recent illness. He wanted Herb to follow-up in three months.
Reports provided by therapist Gregory Young, his PT therapist, reveal that on average, therapeutic sessions lasted approximately 55 minutes a day from September 29 to October 20. Following completion of the first 10 days, Herb’s bilateral lower extremity strength had not improved but he was able to transition from sit to stand with stand-by assist.
With continuous therapy and intensive training over the next two weeks, the gritty Herb gained strength in his lower extremities to the goal of 4+/5. He was able to walk further and his balance slowly improved though he was by no means as physically able as he had been prior to his Listeriosis infection. When walking, Herb required a stand-by assist; he was able to carry his oxygen canister on the walker. Moreover, he had met the goal of stair-climbing with contact guard assist, which would enable him to return home to his tri-level house with stairs. The therapist reported that Herb’s prognosis for maintaining a continuous level of function was excellent with strong family support.
A month of occupational therapy had improved Herb’s ability to perform the activities of daily living considerably. But he still needs assistance for most activities whether grooming, walking or eating. Prior to discharge from The Johnson Center, Infinity Rehab Services visited the Stevens’ home to assess for any structural/interior impingements and modifications that would be necessary before Herb’s discharge home. Recommendations included a bedside commode at night, a toilet frame in the bathroom and grab bars in the shower, removal of all throw rugs and placement of all kitchen utensils, dishes and microwave oven within reach for a person in a wheelchair. A central oxygen concentrator was advised for use of oxygen tubing throughout the house.
On October 20, Mike Todd, MD, performed a comprehensive physical evaluation. Herb, who was scheduled to be discharged the next day, reported feeling stronger and ready to go home. He denied any adverse heart-related symptoms or shortness of breath. His congestive heart failure and atrial fib were clinically compensated and felt to be most likely at baseline. Lower extremity edema was limited to 1+ at the ankles only. A dramatic improvement in Herb’s level of deconditioning was noted due to the intensive rehabilitation therapies and Herb’s determined efforts to get better. Dr. Todd concluded that Herb had reached his maximal rehabilitation potential and was clinically stable for discharge.
Herb finally made it home against all odds, as Jennifer notes: “The staff at the nursing home believed he would never be able to go home, and he surprised them as well, because he is living at home now. However, this could not happen without someone living there with him.”
Elaine lives the reality of Herb’s condition:
Being a full time caregiver takes time and energy. There are appointments, more than usual than in the past, with doctors, dentists, and the Fit Club at Life Care Center to travel to and attend. Additionally, Herb must now ambulate with a walker, which complicates leaving the house further – loading and unloading the walker, plus managing his portable oxygen (which he did have prior to the Listeria). We have a tri-level home, so there is a walker at the top of the stairs (bedroom area) and one on the main level. We also have handrails on both sides of the stairs. He can no longer be left alone for long periods of time and he cannot be unattended when at doctor’s appointments, physical therapy appointments, etc. On January 12, 2012, he turned the wrong way leaving the Fit Club class and it took staff members 45 minutes to find him. While he did have some memory problems prior to the Listeria, they have become worse. He is dependent on me for many things – getting clothing out, telling him when he needs a bath/shower, and meal preparation….daily simple tasks.
Herb’s follow-up medical care to his death:
On October 24, Herb’s CBC showed very mild anemia, and a normal platelet count. His BUN was elevated at 42 (NR: 8-27) and his liver and renal studies were normal. Serum electrolytes and GFR were also within the normal range.
Herb followed at the anticoagulation clinic at South Denver Cardiology Associates from November11, 2011 to April 2, 2012 for INR monitoring. Adjustments were made in Warfarin dose by his cardiologist, Dr. Richard Maithe, to maintain INRs within the therapeutic range to prevent embolic and thrombotic events.
On February 10, 2012, Daniel Kitei, MD evaluated Herb for memory loss, using the Mini mental status exam (MMSE), on which Herb scored of 17/30, consistent with moderate dementia. A motor exam was normal for muscle bulk and tone, with no evidence of atrophy or fasciculation. Manual muscle testing demonstrated 5/5 strength including proximal and distal muscles of the arms and legs. Dr. Kitei’s assessment was memory loss, secondary to cognitive impairment. Herb was instructed to continue Aricept and return for follow up in one year.
Jennifer Exley offers a matter of fact assessment of what Herb’s listeriosis has done to him and the family:
As I look back over the past several months, I realize now that my dad, Herb Stevens, will no longer be the same as he was prior to eating cantaloupe and being diagnosed with listeriosis. Prior to August 24, 2011, the date of his initial hospitalization, my dad was fairly independent. The only thing my mom provided for him was transportation, medication management and preparing more complex meals. His recent memory was not great, because he has dementia, so he would also need prompting and verbal cues to “jog” his memory from time to time on such things as what the schedule was for the day. His remote memory was intact and stories of his childhood, his days in the army and his work history could still be told. Before the listeriosis, my father walked independent of any aids.
Now, 7 months post the listeriosis diagnosis, my father is dependent on my mom for many more things. He now ambulates with a walker, because of balance issues, can only be left alone for short periods of time, has to be told when to take a shower and basically given direction/supervision on a 24/7 basis. He could not live independent of my mother or another person, and if not for my mother, would have to be in a nursing home.
The listeria has affected our entire family. My mother is totally exhausted from being a caregiver, not a spouse, but a caregiver. She has taken on the responsibility for both of them, the house, the dog, paying the bills, etc. Friends have commented to me on how frail she appears now, and I would concur with them. For us, (my sister and her family and my family), many more trips to my parent’s house are needed to assist with my father’s care needs, assist my mother, and to provide house maintenance chores.
His daughter Jeni emailed me this morning about Herb’s passing. As she said:
His health has slowly been declining since the Listeria and his quality of life not so great. He is now at peace.