Panacea! December 17, 2007
Posted by keepbreathing in The Rules, airway management, combative patients, medicine, respiratory therapy, stupid people, tracheostomy, weaning.trackback
Sorry for the lack of content here lately. I’ve had a few days off and some family is in town for a visit, and last time I worked all of my patients were boring or crazy. I had one crazy woman who was out of it and believed me to be trying to kill her. For some reason a lot of delusional people think I am trying to kill them.
I had a delusional patient a few days ago who was involved in an MVA in November. He was busy smoking drugs when he crashed his car into some sort of obstacle and ejected himself onto the roadway, spattering his brains against the inside of his skull. But the brain-spattering wasn’t enough to kill him outright, just enough to make him a little loopy. When I saw him at the end of last week, he demanded that I stop trying to shoot him and then tried to strangle me, an attempt which was hindered by his wrist restraints. When he realized that strangling me was not an option, he settled for kicking violently at me and screaming. Now, his history with me was long and complex. He had been on the vent for a couple of weeks and given me endless amounts of trouble by being “difficult to wean.” He was a COPDer on top of his many problems and his respiratory status was suboptimal. A further complication was his psychosis; trying to treat a combative and insane patient is not easy for anyone, especially for mask-and-needle wielding RTs.
I left his room to a symphony of shouted profanity and threats. I covered my ears and closed my eyes, trying to make my patient-generated headache leave. As I uncovered my ears I overheard the trauma doc discussing when to bring the psychotic man to the OR to give him a PEG tube. My head continued to pound as the patient continued screaming his delusions. An idea formed in my head. I sidled up to the doc and insinuated myself into his discussion with the nurse.
“What’s going on? You’re going to take him and PEG him?”
“Yeah. He needs the feeding tube and I figure he’s too marginal to do him bedside, so I’m going to bring him to the OR and do it there.”
“You know, this guy was a pain to wean. It took us almost two weeks to get him off the vent and he’s just now recovering enough to be feisty. If you take him to the OR and reintubate him, he’s going to wind up right back where we started and we’ll be behind another two weeks. Why don’t you trache him while you’re in there anyway? It would save us all a lot of time and effort.”
“You think that’s a good idea?”
“Absolutely! I think we need to do more early traches here actually*. Why not begin with this guy?”
The trauma doc nodded and I excused myself. My work here was done. A day later the psychotic man was trached. Why, you ask, would I ask trauma to trache the psychotic man?
First and foremost, his respiratory status was marginal. If he had been intubated he would have stayed intubated and run up an enormous bill over the next several weeks which we would see very little of. He would have been more likely to get ventilator-associated pneumonia, sepsis, a worsening of his psychosis or some other ICU complication. With a trache he could be weaned from the vent sooner and then sent out to a chronic-care floor.
Second but equally as important: when you’re trached, nobody can hear you scream. And after days and days of being abused by this man, I didn’t care if he never spoke again. In this case a trache was a perfect panacea: it would sidestep a medical complication, it would facilitate the patient’s eventual transfer to another facility (placement comes first,) it would probably reduce his ICU length of stay and it would greatly reduce the amount of time I had to spend listening to the worthless garbage coming from his mouth. Respiratory Therapy: it’s all about problem solving.
* I really do advocate for early tracheotomy. Many studies I’ve read have indicated that after seven days of intubation, tracheotomy is indicated and can greatly reduce lengths of stay and medical complications. It facilitates ventilator weaning, facilitates airway management, and ultimately can lead to better outcomes. All kidding aside I really think we should be traching more people.
A trach is really indicated after 7 days on a ventilator? That’s interesting. My husband was on one for a little over a week. When they woke him up he came off the ventilator fairly easily. He walked out of the hospital a few days later. I guess he was really lucky. (Then again, I heard that he was really lucky to live.)
The trache is our friend. Our daughter spent a lot of time in surgery her first year, and somewhere along the way, she couldn’t been weened off intubation.
That’s when the trache joined our family. Given her compromised respiratory status, the trache was a literal lifesaver: gave her time to heal, a quicker route out of PICU (and, eventually, home), and allowed her body some breathing space to recover without the constant reinsertion/attempted removals of temporary breathing tubes. Trache-ing earlier might have moved us along faster.
Granted, she just managed to pull out her trache while sleeping tonight (now safely back in with some assistance from Mom). But we’re home and rarely see the inside of a hospital for respiratory-related reasons. Again, the trache is our friend.
One of my ICU mottos (and one of the few that can be repeated in polite company) was, “entubated men tell no tails.” I guess I will have to add a corollary: “but tacheostomatised men tell no tails better.”
good job advocating for yourself, and, the patient! Good solution
Our docs are pretty good about traching people who look to be difficult weans. Our policy is if they are on a vent for a week they usually get trached, especially if it looks like they will be on the vent a while longer.
I think it’s great that you spoke your mind, and even greater that that doctor respected your opinion, because you were right.