Clinical Pearls: Is It Time To Extubate, An Objective Approach
I spent a lot of years working at the bedside in the ICU. I can tell you one thing a nurse won’t tolerate and that’s an agitated and intubated patient. IYKYK. It’s scary, it’s physically taxing for you, and it’s not good for the patient. So naturally I would immediately call the provider with the “can we extubate” query when they woke up fighting. In my mind they were awake, right? Let’s liberate them from the ventilator!
This is only one scenario in which the clarity I gained in NP school blew my mind at how naive I was as a nurse. Maybe naive isn’t the right word, uninformed perhaps? IDK, I think my point is I didn’t realize there was a systematic approach to assessing extubation readiness. I didn’t properly think through all the reasons why a person would need a vent, nor appreciate all the ways in which a person can fail an extubation attempt. One key factor I learned is that objective medical analysis of the diagnosis and current exam is crucial in predicting risk and then weighing the risk/benefit ratio to determine what is safest for the patient. In this post I’ll walk you through the step by step process of performing this assessment to eliminate as much doubt as possible and set your patient up for success. Skip to the end for a bedside checklist.
Clinical Pearls: Weird COPD Labs
I recall sitting in my ninth grade biology class and feeling awed at how perfectly our bodies are designed. It is infinitely complex at baseline - just keeping the status quo. True magic happens when badness ensues and the body begins to change it’s patterns to compensate. Must. Keep. Things. Going. It’s amazing to me. That’s the moment I knew I would go into the healthcare field.
To this day I remind myself that just because modern medicine offers the capability to tweak things, sometimes the best thing we can do is just stay out of the way. First, do no harm. It’s tough though, because when things are hitting the fan, the instinct is to look at a set of patient problems and try to optimize them. If you fail to recognize when an abnormal finding is actual a new normal in a chronically abnormal person you may jump to fix things, unintentionally worsening things. That’s a heavy use of the noun things, but you get what I’m putting down right?
COPD is a perfect example of this phenomenon so in this post I will discuss the normally abnormal derangement’s that can occur in a patient with COPD. Why they occur, how to interpret them, when to intervene, and when to leave them alone.