Pacemaker leads infected - a pacemaker replacement with complications
Sandra tells Dorothy's story about finding out her pacemaker leads were infected - an unexpected ordeal
My mother, Dorothy, got her first pacemaker in 1986. it lasted eight years. She got her second pacemaker in 1994.
In July 2008, when she was almost 86 and her second pacemaker was an amazing 14 years old, she moved across the country to live with me and my husband. At the last pacemaker check before her move, she was told to have her next check before two more months had passed as the battery (although still performing) was well past its anticipated expiry date.
Finding a doctor in her new location was a challenge due to a shortage of family physicians, and so by the time we got to a pacemaker clinic, it was September 3, 10 days past the deadline for her check up.
I drove my mother to the hospital clinic and upon our arrival we were greeted by a most friendly nurse. She took us into an examining room and started by taking my mother's medical history. She did a physical examination and then began the pacemaker check.
This involved putting on a series of patches with electrodes (similar to having an electrocardiogram) and hooking her up to a computer. Although we shouldn't have been surprised due to the age of the pacemaker, we were still a bit taken aback to learn that her pacemaker had moved into backup mode. Her pacemaker had to be replaced - within two weeks!
Things moved quickly
Our nurse did a "teaching session" to prepare my mother for the surgery. She explained that it would be an outpatient surgery and it would be done with a local anesthetic supplemented by a pain killer and a sedative, both administered intravenously. If the existing pacemaker leads could be re-used (a very good possibility) the surgery would basically be a matter of removing the old unit and replacing it with a new one. She also told us that because the pacemaker was on reserve, it would keep Mum's heartbeat at a steady 70 bpm, whereas normally it would fluctuate according to activity and need.
Mum needed a physical exam by her physician, and some blood work before the surgery could be booked. As soon as we got home (after a stop for lunch and at the beauty salon for a cut and style for Mum - one has to be looking their best in time of stress!), I got on the phone and was able to get an appointment for the physical that afternoon.
At 3:00 p.m. we saw the doctor and got the required paperwork completed. I asked Mum, "Are you tired or do you want go and get your blood work done?" She said, "Let's get it over with." So our next stop was the lab clinic.
What a day! What a turn of events. Arriving home, Mum had a stiff brandy and I had some nice Australian Shiraz.
A date was set
The next Monday we got the word. Her surgery was scheduled for the following Tuesday. It was good to have a date set.
Although the pacemaker replacement surgery is minor, my mother was worried about setting her affairs in order. We had met with a lawyer just a week or so before to revisit her will, power of attorney, and advance directive. All that was left was to get things signed, and she wanted to do that before the Tuesday surgery. She was scared about the operation. We met with the lawyer on Friday to sign the papers.
That weekend we went up to our lodge to enjoy the early fall colors. Mum wasn't sleeping well. A couple of times she experienced some arrhythmia and some shortness of breath. In spite of this she sat out on the garden swing and enjoyed the view of the valley.
The night before the operation we had a wonderful dinner of baked salmon, brown rice with mushrooms, onions, and sun dried tomatoes, and a tossed salad. It was the anniversary of my father's death 16 years earlier so we raised our glasses in his memory.
Later in the evening I curled her hair (have to look good, right!) and removed her nail polish while mum enjoyed a Brown Cow - Baileys with milk. She couldn't eat or drink anything after midnight. Nor was she supposed to take her pills. Those we would have to take with us so she could take them after the surgery.
The big day
We had to be up at five in order to be at the hospital for 6:30 a.m. I stumbled out of bed and down the hall to wake my mother when the radio alarm came on. She was already up.
It was still dark when we arrived at the hospital. Mum was wearing the prayer shawl the church had given her. Right after checking in we were taken to the recovery room where she was given a bed and asked to put on a hospital gown. The nurse did all the required paperwork, took her blood pressure, and inserted her IV. She was the first in line for a pacemaker replacement that morning so she was on her way to the operating room before 7:30 a.m. The operation was going to be performed with a local anesthetic and a sedative.
About an hour later I went to the recovery room to see if my mother had returned. She was being wheeled in just as I arrived.
A surprise turn of events
As I entered the room I could see my mother on the gurney and she looked pretty chipper so I thought, "oh, good. Everything went smoothly." The nurse turned to me and said, "they canceled the procedure." I looked at my mum and she said, "It's a mess. My pacemaker leads are all infected."
When my mother had her first pacemaker replaced 14 years ago they found problems with her pacemaker leads (wires from the pacemaker into the heart). She spent two hours on the operating table and in the end they left the old pacemaker leads in place on her left side and installed new pacemaker leads on the right side and implanted the new pacemaker.
Now it turned out she had infected pacemaker leads in the older set of wires and they would have to be removed before they could replace the pacemaker. The only outward sign of the infected pacemaker leads was a small boil or skin infection that had come up on Mum's chest two weeks earlier and for which her family doctor had prescribed an antibiotic cream. And now my mother was going to be admitted to the hospital.
Mum had some toast and apple juice, took her meds, and then fell asleep. I waited for the doctor.
The first doctor to visit us was a resident from infectious disease control - a charming, fresh faced young man. He did an examination, took a swab from the lesion on mum's chest, asked a bunch of questions about her medical history, then said he would be speaking with the medical team. He suggested that mum would need to be on a course of antibiotics for six weeks, and that they would likely have to take the infected pacemaker leads out before putting in new ones or replacing the pacemaker. He also said that until they knew for sure what the infection was, they would likely be treating it as a "super bug."
After a short while the head cardiologist, Dr. Williams, a slight man with salt & pepper hair and a pleasant face, came to see us. "This is a complex and serious situation," he said. "We don't know the extent of the infection but the old pacemaker leads are going to have to come out. We can remove them with laser surgery, but she's very frail and it's a very risky operation. She might not survive it. Ideally I'd like to take both the old and the existing pacemaker leads out and start fresh but we'll need to assess the situation carefully. We don't want to do more than she can handle. The first thing we'll do is admit her and try to get her heart failure stabilized."
Soon after this the nurse gave mum some Lasix (a diuretic to rid her body of excess water), some oxygen to help her shortness of breath, and a technician arrived to take blood samples.
About 2:30 the porter arrived to take my mother (by gurney) to a special room in the cardiac unit, where she would be admitted and observed around the clock. The room had four beds and bright sunshine flooded the room from large windows. They gave Mum the choice of a bed by the window, or close to the washroom. She chose close to the washroom (the diuretic had taken effect) and the nurses were just starting to transfer her when another nurse came in the room and said, "they want to do an echocardiogram right away." So rather than get settled, she was wheeled to the ultrasound area.
Soon after she arrived back from the echocardiogram, we had a visit from Dr. Rosser, an infection control specialist, and the young resident. After evaluating the situation, the team had decided on a course of action. They felt her infection had not likely entered her heart and that the current pacemaker leads had not been infected - just the old ones. Mum would have intravenous antibiotics for a few days and her condition would be monitored closely. If all went well, they would do a surgical procedure to clean the area around the infected pacemaker leads and to cut back those pacemaker leads as far as they possibly could. They were not going to attempt to remove the infected pacemaker leads as it was too risky for her age and her condition.
If all went well, they would replace the existing pacemaker at the same time, and then if all continued to go well well, she could go home, returning to the hospital once a day for IV antibiotics for at least two weeks.
This was better news to end the day on. I went home leaving mum in the care of the hospital.
The case of the missing momma
The next morning I went over to the hospital at mid-morning. I wanted to be there when the doctors did their rounds. When I arrived I went straight to my mother's room - but she wasn't there. I asked the nurse and she asked me to repeat the name several times.
Then she said, "There's no one here by that name."
So all kinds of things go through your head in a situation like that. Was I on the wrong floor? Did my mother die? What the !@#$%^ was going on?
I said, "She is here. She was in this room last night." Finally the nurse determined that mum had been moved to a regular room (she had been in an observation room).
The doctors couldn't say much more than we already knew. They had to stabilize things with the antibiotics, then they'd operate. That could be 48 - 72 hours away.
Thursday morning I went over to the hospital to catch the doctors doing their morning rounds. The doctor, a very pleasant young woman that we'd seen the previous morning as well, asked if we'd been told the results of the echocardiogram on Tuesday. We said no.
She told us that the test had revealed severely leaky valves - the tricuspid valve and the pulmonary valve. That was no surprise. Mum knew she had at least one valve that was leaking. But in addition, there was a shadow or movable mass by the pulmonary valve that they were concerned was infection.
"Oh no." I thought,"this is bad." I looked at my mum and I knew she had the same thought.
The doctor told us a cardiac surgeon from the University Hospital would see Mum the next day. The head cardiologist had requested a consultation. In the meantime, they planned to do a transesophegeal echocardiogram (TEE) to get a better look at what they saw in the regular echocardiogram. And they wanted to investigate her lungs via x-ray as they anticipated surgery and wanted to have a very clear understanding of her condition before proceeding. For example, they wanted to be sure there were no blood clots in the lungs.
She had the lung x-rays, with and without die, that afternoon. In addition to the IV antibiotics (Vancomycin) and Lasix, they injected her abdomen with Heparin and started Heparin by IV. Mum ate her supper, and I had a muffin and some cheese to tide me over until I got home. My daughter and granddaughter arrived for a visit around 7:00 p.m. so I slipped out then.
The next morning Mum had her visit from the cardiac surgeon at about 7:00 a.m. so I missed seeing him. She was supposed to go for her TEE sometime during the morning. I phoned from my office a few times to see if she'd gone for the test and finally when she still hadn't at 10:30 a.m., I went over to the hospital. I was just in time for the docs doing their rounds.
More bad news
The doctor told us that the lung x-ray had revealed clots in her lungs. That's why they were giving her Heparin to thin the blood. Another blow. When they did the TEE they would have a closer look at both her heart and her lungs to have a better understanding of what was going on. Then they would make their decision as to what to do but the doctor said she believed they still planned to only attempt to take out the top part of the infected pacemaker leads and treat the rest of the infection with antibiotics. She also said that they were going to take action sooner than later because the battery on Mum's pacemaker - the original reason we came to the hospital - was past its expiry date.
Lunch time came and poor mum still hadn't gone down for the TEE - nor had she had anything to eat or drink. The TEE has to be done on an empty stomach as they put the ultrasound camera down your throat. I headed back to my office and soon after she learned that the TEE was postponed until Monday because the doc had been held up with some emergencies. Mum was pretty disappointed so it was a good thing that a lovely woman from the church visited, and my husband dropped by to take her flowers. I think that gave her a lift. I went back about 4:30 p.m. She was looking very pale and tired and her hands looked purple. She was now wearing a wireless monitor that broadcast her heart activity directly to a monitor in the nurses' station. I know she was pretty worried about the pacemaker giving out so this would give her some confidence.
I went looking for the doctor on duty because I wanted to get a better sense of how dangerous the blood clots in her lungs really were. My husband and I had planned to go out of town for 24 hours - we'd be back the next day at suppertime - but I wanted to be sure that was okay.
I wanted to speak to the doctor privately but I neglected to tell the nurses that so the doctor arrived at my mother's bedside. I went ahead and asked him - perhaps a little less bluntly than I would have if it was a private conversation. He explained that the blood clots were a concern but that the Heparin would stop any new clots from forming. It wouldn't dissolve the existing clots. That would require a different medication and they wouldn't take that step until they had a better indication of the overall treatment plan. But he felt it would not be a problem to step away for 24 hours. Plus they could call me on my cell if necessary. I would only be an hour and a half away. Mum's supper arrived so I gave her a kiss and a hug and left.
So we headed out to our lodge, arriving during a spectacular sunset at about 8 p.m. It was so wonderful to be there. We had a relaxed evening and a very laid back morning on Saturday. In the afternoon I took advantage of the warm fall air and sunshine to apply a coat of stain to the back deck, then we headed back into town to see Mum on Saturday night.
On Sunday I spent a few hours with her in the middle of the day. She was unhappy because the nurse had washed her hair with soap (!!) and as a result it was flat and lifeless , so I took in some shampoo, a curling iron, and hairspray and we did a wash and set. She looked and felt so much better as a result!
Monday was supposed to be when she had the rescheduled TEE. But it was postponed again to Tuesday. That was discouraging. When I got to the hospital Monday morning Mum had the chills. She looked terrible and said she felt awful. She seemed to be in a downward spiral and that scared the you know what out of me.
I had a hard time concentrating at work all afternoon. When I went back after work I was pleasantly surprised to find her sitting up at a chair eating her supper and looking much more chipper. She’d been for an x-ray during the afternoon.
Hospital life is a lot of waiting. Waiting for more information. Waiting for test results. Waiting for the body to respond to treatment. And, waiting to determine the next steps.
I just wanted to get my mother home again.
Tuesday morning I went to the hospital early in the morning to see my mother. She was still asleep in a darkened room when I arrived but woke up soon after. She was in good spirits and happy that the TEE was scheduled for that morning. We had a good visit and then I left for work.
She went for the TEE mid-morning. I hadn’t spoken with the doctors about the results but they must have been pretty positive because - surprise, surprise - they did her pacemaker replacement surgery that afternoon. I arrived late in the afternoon and although she was tired, she looked great and was very upbeat. She ate well at supper - in fact she probably had the best appetite since she arrived in the hospital a week ago.
There were still many unanswered questions. What did the TEE show? When could she go home? Did they remove any of the pacemaker leads? What were the risks for the infection recurring? And more. I hoped to get some answers from the docs the next day.
But in the meantime, I was feeling very buoyed by the day's events and looking forward to getting her back home.
Wednesday morning I got to the hospital in time to have a good chat with the attending doctor. He said Mum’s new pacemaker was installed successfully, that the transesophageal echocardiogram showed there were indeed blood clots in the lungs, and that the heart looked clear. They couldn’t get a good look at the pulmonary valve where they thought there might be some infection. He said there was a lot of puss around the infected pacemaker leads (wire) and it was evident the infection had been going on for some time.
They removed some of the infected pacemaker leads (full removal of the pacemaker leads was not an option in my mother’s case), cleaned up the area, and installed a shunt to allow the infection to drain off.
He said he was going to have infection control doctors come to see us to discuss the next course of action. He told us that he'd prescribed coumadin (warfarin) and that this was essential to prevent further blood clots in the lungs.
He also said that Mum was going to have a tough road ahead getting her strength back because at age 86 you lose strength rapidly and it takes a lot to get it back. He suggested home care would be required, and that she needed to start getting up and walking to build her strength.
Mum seemed in good spirits when I arrived in the room. We had a nice visit and then a team from infection control arrived. They reiterated that there was still a lot of puss around the infected pacemaker leads (this after a full week of intravenous(IV) antibiotics).
They said the bacteria had been identified as coagulase negative staphylococcus (CNS) not staphylococcus aureus which I had been concerned it was. The CNS, while still not a good thing, is not as virulent as S. aureaus so that’s encouraging.
The treatment would include six weeks of IV antibiotics (Vancomycin). I asked about the risk of recurring infection on the pacemaker leads. They agreed that was a significant risk. I asked if there was an antibiotic that could be given over the long term in a lower dose as a suppression therapy. They said the CNS bacteria is resistant to any oral antibiotics plus the fact that the infection was growing on the pacemaker leads meant the body couldn't attack it the way it can when it’s in the tissues. There was one oral antibiotic (Linezolid), a new drug that appeared to have some effect on CNS but it had other nasty side effects and shouldn’t be taken for more than two weeks - they said this was not something they would recommend for my mother. It was also about $400 per day!
We could have a home-based IV program - my husband and I could be trained to administer the Vancomycin each day, initially under the supervision of a home care nurse. This was great news since she would have to be on the antibiotic for at least six weeks. It meant she could have a “normal” life at home.
All in all, things were sure looking up. I knew it may be borrowed time that we’d gained, but I was just fine with that.
Whew. What a journey.
On Friday afternoon my husband and I went to the hospital at 2:30 p.m. to meet with Mum and Barb from the home IV program. She explained the program and showed us the IV pump and bag and how it worked. Mum would have to have the antibiotic every day at about the same time and it would take about two hours to administer. We would have some training on how to hook up and disconnect the meds and what issues to look for with the IV line. We would also have access to a home care nurse should we run into difficulties plus they would come in every three days to change the line. There's not doubt this was a big responsibility but it beat having to go to the hospital every day for two hours!
After Barb left, I told mum we had a surprise for her. I curled her hair and she put on some lipstick and we got her into the wheelchair. She was tired because the physio people have been making her get up and walk - just within her room so far - but she is very weak yet. This was the first time in almost two weeks that she'd been outside the room other than for medical tests or procedures.
I wheeled her out into an atrium area and there was my husband with Jed, the beautiful black Boxador.
My mother is very fond of the dog and had been touched to know that he'd been to her bedroom several times to "find" her so we had asked the hospital if he could visit. To our surprise and delight they said yes, we could bring the dog to see her.
She stroked his head and I couldn't help but think about the healing qualities of stroking a pet. It can decrease your blood pressure, cholesterol and triglyceride levels, and feelings of loneliness. And, they just make you feel good with their unconditional love.
Our visit was brief because mum was tired but it lifted her spirits. She said that when I told her we had a surprise, she thought it might be Jed. And so it was.
A set back
Saturday I spent a pretty lazy day. We went over to the hospital around 4:00 p.m. to visit Mum. We took various items she'd requested from home and as a special treat we took a premixed brown cow (Baileys and milk). All I had to was add ice. It was happy hour time and she was thrilled. She said it was far too long between drinks!
She'd had a rough night and an unpleasant day. She was running a fever last night and ended up drenched in perspiration. That morning she'd struggled with a gastrointestinal upset. She said the incision around the pacemaker leads was still draining a fair amount. She was looking pale and tired and she was back on oxygen.
Before we left, she got up and sat in her chair and her color improved. Supper arrived and so we left for another day. I was back to feeling very worried.
Sunday we went to the hospital in the middle of the afternoon. It was a beautiful fall day. The sky was brilliant blue against the yellow and orange leaves.
When we arrived, Mum's curtains around her bed were closed and she was sleeping. Frankly, she looked awful. I thought "oh, no." I went to the nurses station and inquired how she was doing. "Actually," said the nurse,"she's not doing too badly today." We asked a few more questions and then went back to the room. Mum woke up when we walked in and said she thought I was there. I asked her how she knew and she said she just felt like I was there. She said she'd been up all morning and had just gone back to bed in the afternoon for a rest.
She perked up. I washed her hair and set it and she put on some lipstick. She was sitting in the chair when three more guests arrived, my daughter and two granddaughters. We had a lovely visit.
Being the weekend, there was nothing to report or to catch up on from the doctors so we were back into a holding pattern until Monday. I felt a lot more confident when I left that afternoon than I had the previous day.
Monday morning I made it to the hospital to catch the doctors' rounds. I found Mum in bed with a heated blanket wrapped around her. She'd had the chills and she'd had some burning pain on urination. This, plus she hadn't slept well as they'd increased her dose of IV diuretic the night before because she was having trouble breathing (fluid in the lungs). They'd taken her for a chest x-ray first thing in the morning and did more blood work. Essentially they were concerned that the infection from the pacemaker leads had spread in her body or that she'd picked up another infection. It was clear she wouldn't be going home on Tuesday or Wednesday as previously planned.
The roller coaster
On Tuesday morning Mum was sitting up in her chair and quite chipper when I arrived. She said she was feeling good. When the doctor came to do his rounds she asked about going home. He said there were still a few things to be sorted out and that she needed to have the drain taken out of the incision (was scheduled to be done that day). He also asked if she was getting up and walking. She said she was so he said, "let's see you walk."
Because she's tethered to an IV pole, it takes a bit of maneuvering - she took the walker and I followed with the pole. She walked purposely over to the door of the room. The doctor was impressed and said in jest, "if you can make it to the exit, you can go home." Mum continued out of the room and said, "bye!" She walked down the hall a way. I asked her if she wanted to rest but she carried on. Then she started to chant,
"Left, left, left, right, left. I had a good job but then I left." She was almost marching!
When she got back to her bed she was a bit winded but pleased with her performance. She got into bed. The doc said they hoped she could go home on Thursday. Yay!
I came back in the late afternoon and she looked terrible. She'd been walking some more with the physiotherapist and perhaps had done just too much too soon. She was trembling, exhausted, and short of breath. She was spent. And she was terribly disappointed because they never came to take the drain out of her incision.
The calendar turns
Wednesday morning was the first day of October and what a brilliant and beautiful autumn day it was. I arrived at the hospital and again found Mum sitting up in her chair and feeling good. Good sign. But... she told me she'd had fever, chills, and sweats during the night. This was not a good sign.
There was some progress. Her blood levels had reached the point where she no longer had to have the IV Heparin so she would no longer be tethered to the IV pole 24/7 - she'd only be connected for her antibiotics for a few hours a day. The drain in her incision where they cleaned up the infected pacemaker leads was confirmed to come out that day (for sure!) and when the doctor asked to see her walk again, she walked even further than the day before.
But the fact that she had fever spikes several times over a few days indicated she either had a secondary infection or that the pacemaker leads were still significantly infected. The former was manageable - once they knew what it was they could prescribe the appropriate medication and she could get out of the hospital and move on with her recovery. The latter - infection on the pacemaker leads - was more serious. So they couldn't let her go home until they had a better idea what was going on. That was so discouraging.
Sitting in her chair that morning, lamenting on how all she really wanted to do was to go home, Mum said, "You know, what I really could do with is a Baileys. No, I want a Scotch and soda!"
She still has some spunk in her.
Yet another setback
On Thursday, we went to the hospital at 1:30 p.m. to meet with a nurse from the IV home program to get trained on how to administer the vancomycin at home - just in case Mum got the go ahead to leave the hospital. The nurse, who had the biggest ice blue eyes I've ever seen gave us the run down, went over the procedures that must be followed to ensure a sterile environment, explained how the pump worked, then delivered the unexpected triple whammy.
The PICC (Peripherally Inserted Central Catheter)line, the IV line through which Mum's Vancomycin is administered, was not positioned properly. This was discovered in the chest x-ray on Tuesday. The line should deliver the antibiotic to a large vein just above the heart where it would be quickly diluted and spread through the bloodstream. Her line ended somewhere between her armpit and her heart, just below the clavicle. The wire pacemaker leads (the ones that were infected and had caused all this drama in the first place!) were pressing on the vein and stopped the line from going further in.
Vancomycin is so strong that it is very hard on the veins. So potent, in fact, that the nurse said it was like pumping battery acid into the vein.
The line was delivering the drug to a narrow vein. The nurse made the comparison of delivering the drug through a garden hose (the large vein leading into the heart) versus through a tiny straw. The long and the short of it was that using that line for a home IV program was too dangerous. We had three options.
None of the options were particularly attractive.
The nurse said she would talk to the doctor about installing a new PICC line on the other side. She said they could arrange for a sedative so it wouldn't be as painful. She didn't know when they'd be able to do it but thought perhaps the next day, which was Friday.
When we were leaving Mum, we saw one of her doctors at the nursing station. We stopped to ask him when she might have the PICC line installed. He said, "I need to think about this. I'm not comfortable with going in on the other side. I really need to think about this."
Friday morning I couldn't make it to the hospital so my husband went to be there for the rounds. He learned that the doctor had decided it was too risky to install another PICC line but they had consulted with the pharmacist and they thought Mum could have the Vancomycin every second day at the hospital. She could go home that day after her antibiotic was administered. She'd be ready to go at about 6:00 p.m. This was good news!
I was giving a talk at a conference that afternoon so I was tied up until the end of the work day. I met my husband at home and then we went to pick up my mother. She was coming home!!
At the nursing station, Beth, the unit nurse who had been so wonderful all through this experience, went through Mum's discharge papers and instructions with us. I went down the hall, for what I hoped was the last time. Mum was sitting in her chair but not dressed. She was still connected to the IV pole although it appeared the Vancomycin had finished dripping through. I helped Mum get dressed (as much as we could with the IV still connected) and then we got the nurse to come an disconnect her. The nurse took a look and said, "Oh, no." Then, "Oh, my gawd."
The PICC line, which was supposed to be in place for six weeks had broken off just before the connector. Fortunately this must have happened after all the antibiotic had gone through as there was no evidence of leakage. "She won't be able to go home," the nurse said. She got sterile bandages to cover the open end of the line (essentially a path for bacteria to enter Mum's body) and said she would go and call the IV clinic. She said she'd NEVER seen this happen before.
Mum looked at me and said, "I'm going home anyway. I can come back tomorrow, but I AM going home." The nurse came back, put mum in a wheelchair and took her off to the IV clinic.
After what seem liked a very long wait, they came back from the IV clinic. The PICC line couldn't be repaired so they'd taken it out completely. Mum would have the Sunday dose through a regular IV line at the hospital, and on Monday they'd put a new PICC line in the left side.
But she could come home!
We got out of there as fast as we could before something else happened to stop us from leaving!
Home at last at about 8:30 p.m. Mum had some soup and then off to bed - in her own bed. What was supposed to be a simple outpatient procedure had turned into an 18 day stay in hospital.
This story isn't over yet but at least Mum's at home.