Wednesday, July 1, 2009

Sticky Situation I Found Myself In

A Patient is completely alert and oriented. She is intubated and has been on a ventilator for days, thought the initial problem had nothing to do with her lungs. Now she is awake and demanding to be extubated through hand gestures. Her vital signs look amazing. She has an order for a wean in the morning. But she insists on now. The family is called in to speak with her, and the family agrees with the idea of honoring her wishes. Her doctor, on the other hand, did not give the order, but did not tell us not to extubate, either, but simply made the statement that extubation would be at her wish and not his order. You put her on a t-piece and monitor her. There is absolutely no change in vital signs for 2 hours. You get a blood gas, and it is textbook-perfect. What do you do?

I'll tell you what I did. I pulled the damned tube, documenting heavily on her stability and the family and patient's wishes. Apparently, this has been the talk of the MICU. My director, critical care coordinator, and supervisor have commended my actions, saying I did exactly what I should have done in that situation. The director has even gone so far as to copy my charting to place in my personnel file along with a typed commendation from him. Only one pulmonologist has said anything. She wanted to know if it is "standard practice to extubate a patient in the middle of the night without a physician's order". Absolutely not. But to honor a patient's wishes while safely monitoring the patient's cardiopulmonary status...My intent throughout the whole ordeal was to watch for anything that would indicate that she would not be able to handle extubation. Had anything come up, I would have immediately had a discussion with the family regarding my concern. But nothing did. I could find no reason to leave her intubated against their wishes. And the outcome has been phenomenal. She hasn't needed so much as a breathing treatment since I did the deed.

So my Big Boss is recognizing me, stating that I have done a tremendous job for the hospital since I have been employed with them. Up until recently, I didn't even know if he knew that I work for him. But according to a phone conversation this morning, he has been getting a lot of positive feedback about me. Kind of makes my ears burn a little bit, wondering what has been said and when. But overall, it feels great to have your hard work recognized.

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