#extubation

[graphicmedicalstuff]

[faofinn]

28. "I should've stayed home"

Part 1 | Part 2

Tom looked up at her, catching the urgency in her tone. He reached to rub at Finn’s chest, knuckles on bare skin. "Finn, come on, take a breath. You can do it."

"He's not going to, is he?" She murmured. 

"I've got the BVM. Do you want to update them and get the pads on?" Tom asked, swapping the masks over. "There we go, that's getting air entry there. Sats are coming back up. Should we intubate?"

Fao bit his lip, feeling his stomach twist. This wasn’t uncommon for Finn, but it wasn’t good. It was the end of their holiday, that was for certain, and they were desperately far away from their safety net. They had all his paperwork with them, management plans and everything, but it was still worrying. 

He forced himself to take a deep breath, wishing Finn could do the same. 

Finn ended up intubated, crit care travelling with them to keep him sedated and stable. While Sheila travelled with them, Fred and Fao had to follow in the car behind them. With the severity of the situation, they pre-alerted him in, travelling on blues and treating with diesel. It was straight through to resus when they arrived, teams swarming around Finn. As awful as it sounded, Sheila was glad Finn was sedated, he'd have been unable to cope with the fuss and everything on top of him. He was quickly sent for scans, thankfully stable enough to go to CT, but Sheila couldn't help the worry and nausea that curled in her stomach. They were meant to be on holiday. Finn had been doing so well, and now they were in resus, and he was very much not okay. 

The EEG done by bedside was positive, no signs of seizure activity during their test. Of course, they couldn't be sure if the epilepsy was the sole reason for the seizure, or if the head injury had played a part in it too. The MOI itself was concerning, a fall from any height could be dangerous, especially one head first. By some miracle stroke of luck, the scans were good. No new brain bleed or skull fracture, no c-spine (or spine in general) injury. His arm wasn't lucky, quite a significant break to his humerus, but bones could heal.

He was transferred up to ICU, the plan to slowly reduce his sedation see where they were up to. Calls were made to SGUH, an attempt to keep on top of things, and they happily agreed with the management plan. They'd cleaned his wounds while he was sedated, the fracture reduced and splinted while they could do anything. Of course, Fao was by his side the entire time, barely refusing to let go of his little brother's hand.

Fao hated it. At George’s, people knew him now, having done placements and spent so much time with Finn, Steve always spoke to him like a doctor, made sure everyone was in the loop, and knew Finn well enough to treat. The team here had been good, of course, but it wasn’t their normal. Everything felt wrong, Fao had gotten lost more than once in the short time they’d been there, and the ICU was unfamiliar. 

When the fuss had subsided, and Finn was left alone (or as alone as he could be), Fao sunk into the chair by his bed, forcing a deep breath. Fred and Sheila had taken five minutes to run to the shop to grab some lunch for the three of them, making Fao promise to keep them updated but not expecting anything. 

Finn’s sedation had been reduced, and he'd slowly started becoming more aware of his surroundings. It took him forever to realise he had something down his throat, forcing air into his lungs, and he hated it. He tossed his head, trying to breathe with it. There was a flare of pain as his arm moved, and he grimaced, trying to get away.

Fao looked up as Finn fussed, reaching to squeeze his hand. “It’s okay, you’re okay.”

Fao. That meant he was safe, wherever he was. It was easier to try to squeeze Fao's hand than to open his eyes, and though it was weak, it was there.

“I’m here, just relax, you’re okay.” Fao reassured, squeezing Finn’s fingers. 

He finally managed to work out how to open his eyes, fighting through the drugs pulling him down. As awful as it was, Finn had spent enough time in ICU to know how to breathe with the tube. He took a moment to try to relax, his teeth grinding on the hard plastic.

“That’s it, you’re okay.” Fao said, leaning forwards so his brother could see him. “You can breathe with it, you’re okay.”

Finn made to scrub his eyes, moving the arm not holding Fao's hand. The sudden spike in his heart rate was a clear indication of pain and panic, the drugs clouding his thoughts but not enough to stop the pain.

“Careful, don’t try and move too much.” Fao told him gently. 

The pain had him struggling against the tube, overwhelmed and fighting to catch his breath. He gripped Fao's hand tighter, the flash of fear in his eyes not going unnoticed. 

Fao instinctively reached out, running his hand through his hair. “You’re alright, you’re okay. You can breathe with it, just relax, I’m here. You’re just fine.”

He couldn't manage it, couldn't work out why Fao wasn't helping. He pulled his hand away, reaching for the tube. If nobody was going to help him, he'd sort it himself. 

“Leave it alone Finn, it’s okay.” Fao said softly. “Leave it, that’s it.”

As the monitors continued to alarm, the nursing team arrived to check on him. With Fao's attention on the staff coming in, Finn tried again, his fingers grabbing onto the plastic. He pulled as hard as he could manage, choking and retching as he did so.

The retching from his brother pulled Fao’s attention back to him, heart sinking as he pulled the tube. “Oh, Finn.” He mumbled. He let the staff work as much as he could, but gripped his brother’s hand again, trying to distract him. 

He'd dislodged it enough to be a problem, his monitors and observations screaming their displeasure. He was with it enough to follow their instructions, so they made the decision to pull it completely, in a slightly more controlled manner than Finn had attempted. 

It was nerve wracking, watching them pull the tube. Finn had a horrible habit of fighting it and then just refusing to breathe once it was gone, and it was hard to watch. He kept quiet, letting them do their work, and soon enough it was gone properly. Fao held his own breath as he waited for Finn to breathe again, his heart pounding. 

“Well done Finn, that’s it.”

Finn struggled once they'd pulled it, turning to look at Fao with fear as he gripped his hand tighter. He couldn't manage a breath in, convinced he was going to die.

“You can do it, you’re doing so well.” He encouraged. “You’re okay.”

His breath caught in his throat and he coughed again, the tube having irritated his throat already, and then him making it worse as he'd pulled it. With the cough came another, and then finally, finally, a breath in.  He took a few deep breaths, closing his eyes as he rested his head against the bed in exhaustion. 

“Well done.” Fao praised. “You can rest, it’s okay, you’re safe.”

The nurses adjusted the oxygen, reaching over to put a mask on. Finn cracked an eye open and glared at them, completely unimpressed at the situation. 

Fao couldn’t help but laugh. “Finn, don’t be a dick. You need it, it’s not forever, and it’s better than the tube.”

He turned his face away as they tried again, his eyebrows pulled into a frown. 

"Finn, come on. If you don't, we'll have to go more invasive again. Let me put the mask on, okay? We'll be able to take it off later."

Still glaring at them, he nodded in defeat. He didn't look impressed, but let them put it on, hating that he felt better for it. His voice cracked, barely there, but he tried.

"Thanks."

“Suits you.” Fao teased. 

Finn turned to him, his glare returned. "Fuck off."

“Hey, language.”

"'Urts?"

“What hurts?”

"All."

“Can he have some more pain relief?” Fao asked.

"We'll get you something, Finn. Aside from the pain, how are you feeling?"

He shrugged with his good arm. "Dunno."

“That’s alright.”

"Fuzzy." He managed after a while, glancing at Fao. He pulled his hand from Fao's, clumsily signing drink.

“Drink?” Fao echoed. 

Finn nodded, repeating the sign. His throat hurt, which wasn't surprising, but he didn't have the energy to fix it.

“We’ll see if the nurses can get you something to drink.” Fao murmured. 

"What do you want, Finn? Some juice? Water?"

He forced his eyes open again, giving a heavy sigh in discontent. He turned to look at Fao properly, waiting for him to answer for him. 

Fao stroked through his hair again. “Juice, yeah? Better than water.”

The corner of his lip twitched into a smile, and he gave a small nod. Fao always knew the right answer. 

The nurse gave them both a smile. "I'll go get you some juice, then."

“Thank you.” Fao said, settling back in the chair. “Mum and dad will be back in a minute, Finn.”

He cracked an eye open again, drink? Food?

“They went to go get something to eat, yeah.”

He nodded again, shuffling slightly to get comfortable again. The drugs were still strong, and despite the pain in his arm, he was comfortable and warm. His hand found Fao's and he tapped at him: one, two, three. I love you. 

Fao smiled, instinctively tapping back. “I love you too, Finn.”

Finn gave a sleepy smile, lacing his fingers with Fao's. He knew the pain relief and juice were on their way, but he was tired, exhausted from everything, and five minutes wouldn't hurt. 

“That’s it, get some rest.”

He was asleep almost immediately, quite content. His peace was disturbed by the nurse returning, bringing his juice and pain relief.

"Finn? Finn, sweetie, I've got your medicine." 

Finn startled, a moment of panic before his brain caught up through the haze. He nodded again, offering the nurse a smile. 

"Let me find your arm under there, eh? There we are. Just your pain relief." She hummed, giving it slowly. "There you go, all done. I'll leave your drink with your brother, but just small sips, alright? Just give us a shout if you need anything else."

Fao offered the nurse a smile, thanking her for everything before she left. Then they were alone again, and Fao sighed. “Glad you’re okay.” He admitted softly. 

Finn had already drifted, the drugs making the room spin. At Fao's voice he forced himself to look at him. Even though Fao was far from in focus, Finn gave him a dopey smile, squeezing his hand.

Of course Finn couldn’t really reply, but Fao appreciated the smile. “You’re okay.”

Finn was happy enough to drift, Fao's hand in his hair and the other holding his. He was pain free and warm, so slipped quickly. There was a slight commotion as Sheila and Fred returned, but he was too deep to really give much response. 

Fao turned to acknowledge his parents, offering them a small smile. “He tried to do their job and pull the tube, so it’s out now.”

Sheila paused, her eyes narrowed. "When you say he tried to do their job, you mean he pulled it out?"

“Tried, didn’t do a very good job, just dislodged it. He panicked.”

Fred's heart broke. "Bless him. I know it's awful seeing him when he's in here, but I think George's had it right when they restrained him."

Fao nodded. “Yeah, it’s for his own good. They usually keep more meds on hand, too, but they were good. Got the tube out easily enough.”

"Oh that's good, then." Sheila smiled to herself. "Here, I've got you a drink and a sandwich."

“Oh, thanks.” He murmured, reaching for them. 

"He's been alright though?"

“In pain, but he’s just had some more painkillers.”

"His arm?"

“Yeah, I think so. Wasn’t making loads of sense.”

"Does he ever?" Fred joked. 

“That’s true.” Fao said with a grin. 

"You're not even wrong." Sheila managed a laugh.

“He’s okay, though. Communicated well enough.”

"That's good."

“Yeah. And good he’s got rid of the tube.”

"He still ended up here. He's not had such a bad status in a while."

“Yeah.” Fao murmured. “It’ll get discussed with Steve.”

"I hate that we're so far away."

“Me too. Everything is wrong.”

Finn stretched out with a quiet whine, frowning. His eyes flicked around the room, his expression changing to a grin as he saw his parents. 

"Mum! Dad!" His voice was still rough, barely there, but easily heard in the silence of the ICU.

“Yeah, they came back.” Fao said softly. 

Fred reached to pat Finn’s knee. "Hey, kid. How you feeling?"

Finn sniffed. "Rubbish."

“Gonna feel a bit crap for a bit.” Fao said gently. 

"'m sorry."

“Hey, don’t be sorry.”

"My fault."

“It’s not your fault.”

"It is." He scrubbed his eyes, his breath catching in his throat. "I'm sorry."

"Hey, Finn, baby." Sheila soothed, standing to move closer. "It's not your fault, these things happen."

"I should have stayed home." He managed. "I wanted to go out and I forgot to take my meds because Fao was ready."

"Oh, Finn." She sighed.

Fao made a noise, unable to be annoyed when his little brother just looked so upset. “It happens, Finn. It’s okay.”

"An'-and I threw up last night and didn't say 'cause I thought we'd have to go home."

“Oh, Finn.” Fao murmured. “You should’ve said, you must have felt rotten.”

"I thought you'd be mad at me."

“Never mad at you.”

"Of course we wouldn't be mad at you, Finn." Sheila sighed. "That's being daft, eh?"

“Always tell us things, and then we can help.”

The tears had started to fall and he tried to hide his face. "I'm sorry.c

“Hey, it’s okay.” Fao reassured. “You’re okay.”

[resus-icu]

IaF - DjÄ ep. 295

[what-are-even-humans]

So on one hand I got to participate in extubating a patient today but on the other hand I did get an E on my thesis which my advisor told us was "A or maybe B material" and that we were genuinely quite proud of.

[hold-him-down]

Hey

Share the latest med whump piece you enjoyed with us,please

i’ve been holding onto this for a little bit waiting to read something so good so i can answer with it but i haven’t read any med whump on here recently that i can remember, i feel like i am so out of it with reading so far this year! i do try to remember to reblog everything that i read and love, search med whump on my blog for the ones ive reblogged so far! a couple really great med whump pieces that come to mind, i’ve reblogged each of them several times over tho:

jaime’s surgery by @peachy-panic

danny’s recovery arcs and kauri’s surgery by @ashintheairlikesnow

aiden’s story by @distinctlywhumpthing 

this yves piece by @redwingedwhump

So, all that said, if you have med whump recommendations please please please add them here, because i am hungry for med whump and so is anon.

[drowsyanddazed]

last day rotating at the cardiovascular icu! everyone cheered!

[leafcabbage]

i write like theres a professional medical team that sits down and reads my fic together and deliberates over if i wrote the medical aspects correctly and if they decide i didnt they come to my house and shoot me

[faerune]

anyways i managed a ventriculostomy today pretty much all by myself

(also if u dont know what that is which is fair here is a pic)

[grandmafc]

work wife ended shift with “eh fuck it let’s do it” sir you’re a surgeon i can’t put that in the chart

[mrsballlegs]

My patient coded at home and was so lucky after going through septic shock, acute renal failure, crrt, alcohol withdrawal, seizures, to wake up a week later with a functioning brain and semi functioning body….. spent the whole night whining about stupid shit like literally complaining I wasn’t spreading her ass cheeks wide enough while wiping her ass. Then tried to say she wanted to leave ama at 2am because she missed her kid. I was like girl you’re still on precedex and you don’t even have a dialysis chair set up and no one’s told you yet that you seriously almost died and your life is never going to be the same again you can’t leave against medical advice bc you have not received medical advice and you’re still on sedatives. Also because you can’t walk and none of your family is gonna be dumb enough to come pick you up if you tried. But we CAN set up for you to go see your kids in the garden now that you’re doing better! Then she accused me of lying about that to shut her up…. Like what’s the point

[graphicmedicalstuff]

[faofinn]

26. Tickle In The Throat

@sicktember

Fao had been a state when they’d found him. He’d crashed his bike on the way back from a job, losing control and spinning off of the road. 

Luckily, the ambulance crew who attended the scene recognised him (and weren’t phased by the gun on him) and took him straight home to Fred’s. They’d been focused on expanding their network in the last year or so, now they had Harrison back in England and their newly renovated basement treatment space. They had more scope to treat more serious injuries, negating the need for potential issues in public hospitals. 

Finn and Steve had worked hard to stabilise him, though he was in a bad way. A break to his right femur, broken ribs, a broken collarbone, dislocated shoulder and some significant abdominal bleeding. They’d intubated him when he’d arrived, as he’d started to decompensate. Neither of them had wanted to, but it was for the best. 

His internal injuries were significant, but they decided to simply transfuse and see if they were able to get away with non surgical management. Nobody wanted to get out of their depth with a abdominal surgery if they didn’t have to. Not when their only true gensurg was the one on the table. 

Neither felt confident with the femur, too, though they managed to reduce it decently with traction. They needed an ortho for that, and that meant waiting. 

One of Fao’s colleagues and friends (and a hook up, between Harrison and Ely) was doing more and more work for them, and agreed to come down quickly and sort it, provided he was deemed stable enough. 

Once she’d gotten over the shock, Ely had quickly stepped up to treat. She hated being useless more than she hated treating her boyfriend, and at least it kept her busy (and gave her an excuse to stay with him). She was happy enough with how stable he was, and Ollie was given the go ahead to operate. That went well, all things considered, and his abdominal bleeding thankfully resolved itself with TXA and additional blood products. 

They decided it was in his best interests to keep him sedated and ventilated whilst his body recovered, and review him in a day or so with a view to reducing the sedation and eventually extubation. 

Ely looked after him closely, as did everyone, but Sheila too. With Fred’s business so important, she’d let her own skills fall by the wayside, focusing on supporting her husband and running her own parts of the business itself. But as their own clinical network grew, she realised she wanted to be more useful to the boys. So she took a return to nursing course, and began to find her own skills again. She’d been dedicated to looking after Fao whilst he was out, in their own little critical care bay. 

He’d done well over the past day or so, and they’d decided his sedation could be reduced and they could look at extubating. They took it slowly, of course, Harrison in charge with Steve at work and Ely too emotionally overwhelmed to treat properly. Sheila was at his side, as she’d been for most of it. She hated to leave him, focused on making sure he was comfortable and properly looked after. 

Fao started to become aware of something after a while, but the drugs were too thick to fight through. Eventually it got easier and easier, and he was aware of pain, and the tube in his throat. Then he realised he couldn’t breathe, he had no control over it. His eyes blinked open and he reached up, clumsy and uncoordinated, trying to get at the tube. 

Sheila stroked through Fao's hair as they reduced the sedation, though that wasn't anything new. She hadn't left the basement since he'd been hurt, sleeping downstairs and praying he'd be okay. 

When he started to stir, growing more agitated, she kept murmuring to him, telling him to just relax, promising him he was okay. 

"Hey, hey. No, leave that." She was quick to hold his hands down, lacing her fingers through his. "It's okay, Fao. Just relax, you can breathe with it. You can, I promise."

Weakly he fought against her, frowning. His eyes flicked around the room, struggling to focus. The panic rose as he couldn’t free his hands, and he twisted to try and get away. 

"Hey. Fao, please. Just listen, okay? Focus on me. You're okay. Just relax." She said softly, cursing Harrison quietly. Of course Fao would come to while he was at the toilet. 

He whined, the way he moved just causing a flare of pain. Sheila’s voice finally got through to him, though, and he settled a little. It was still hard to breathe, his teeth catching against the tube. 

"Careful, careful, sweetheart. You're just fine, I promise. We're looking after you. Hars is gonna be just a second."

He retched against the tube a little, fighting it. He wanted it gone, he couldn’t just relax, despite what Sheila was telling him. Everything felt wrong, his body crying out. 

"I know, it’s awful. You're doing amazing. Just relax." She turned as Harrison appeared. "About time."

"Ah, shit. He’s awake?" Harrison hurried over, grabbing some gloves and quickly putting them on. "Fao? Hey, Wolfie. Back with us?"

Fao was convinced he was dying. Everything hurt, burned, and he struggled to get his hand free from Sheila’s, trying again to dislodge the tube. He heard Harrison’s voice, but it didn’t register with him, too panicked. 

"You ready to extubate?" He asked Sheila, swapping his hands for hers. 

"Let me grab gloves." She murmured, quickly turning away. "Right. Let's get it out, he's just getting himself worked up."

"Fao? Fao. Can you look at me? Come on, you can do it, just relax. Can you squeeze my hands?"

Fao’s gaze settled on Harrison, blurred and unfocused. He struggled, but managed, and somehow through the haze of the drugs he realised who it was. Hars. He wouldn’t hurt him, right? He gripped his hands tightly, fear in his eyes. 

"That's perfect, Wolfie. You're doing so well. I need you to listen, okay? When I say, you need to try and blow your air out, okay?"

It took him a little while to process, but eventually he managed to nod, his body slow and unresponsive. 

Harrison glanced over to Sheila, happy she was set up too. He nodded to himself, told Fao to take a deep breath out, and extubated him. 

Fao just about managed to breathe out, retching as Harrison pulled the tube. He rubbed at his face, frowning and coughing, trying to adjust to breathing without it. 

Sheila slipped the mask over his face, apologising as she did so. She stroked his cheek, relieved he was slightly more with it.

His chest heaved, pain pulling at his attention now. He frowned, but leaned into Sheila’s touch. 

"There you go, sweetheart. You've done so well."

"Fao? How are you feeling?" Harrison spoke up, sitting on the edge of the bed. 

Fao cleared his throat, struggling. “Pain?” He rasped. 

"You're in pain? Where? Chest?"

He nodded. His chest, but everywhere, too. He couldn’t place it, overwhelmed. 

"That's okay. Sheila? Thanks. Do you know where you are?" He asked softly as she grabbed meds. 

He looked around. It looked like any old hospital sideroom, but if Harrison and Sheila were there, maybe he was at home. “‘ome?” He asked after a long while. 

"Yeah, you're in the basement." Harrison said gently. "Can you remember what happened?"

Something must have happened, that’s why it hurt so much, but Fao didn’t remember anything. He shook his head, frowning. 

"Alright, that's okay. Can you squeeze my hands for me? Both of them?"

Fao did as he was told, squeezing Harrison’s hands in his own. 

"Thank you. You're doing amazing. Can you feel me touching here?" He continued his assessment, trying to gauge any deficits.

Fao did the best he could, following Harrison’s instructions and answering his questions. Despite the pain, it was proving difficult to stay awake, his eyes drifting shut without meaning to. With the arm that hurt less, he rubbed at his face, groaning. 

"I'll stop being an arse in a second, promise. I just want to check what damage you've done."

"I've got meds. Sorry it took so long." Sheila murmured. "You look exhausted, Fao."

He nodded. “Am.”

"You've been napping for ages Fao, you shouldn't be tired." Harrison teased.

Fao grumbled, but watched Sheila with a tired kind of curiosity as she gave his meds. He was so tired, why wouldn’t Harrison leave him alone to sleep? He’d answer his questions later.

With Sheila finished with meditation, Harrison gave up. Fao needed his rest, and he was happy enough there were no neurological or physical deficits they hadn't already known about. He leaned forward to press a kiss to Fao's forehead, running a hand through his hair.

"Get some rest, Wolfie."

Fao made a happy noise. The meds had already started to work, making him even more tired. The pain was harder to focus on now, and he soon fell asleep. 

Sheila refused to leave again, playing with his hair, stroking his cheek. She was glad he'd settled, and that the tube was removed. It wasn't nice to see, not in the slightest, but she knew it was for the best. 

"Can I get you anything?" Harrison asked, making sure everything was written down. 

"No thanks. I'll wait until he's awake again."

"I'd never have guessed." He rested a hand on her shoulder. "Just remember, you need to take care of yourself too."

Fao slept for a long while, stable and his monitors happy enough. The meds certainly helped to keep him comfortable, though he eventually woke again. Coughing, he struggled to clear his throat, which was raw and scratchy. That made him whine, his lips chapped and dry, too.

Sheila jumped as he woke coughing, immediately in overdrive. She squeezed his hand encouragingly, the other stroking his cheek.

"Fao? What's wrong?"

He cleared his throat again, frowning. “Sore throat.”

"Oh, sweetheart. Of course it is. Let me get you some water."

He couldn’t get rid of the stupid tickle in his throat. “Throat sweet?” He asked, his voice rough. 

"Just water for now." She said softly, passing him the cup. She didn't let go, though, holding on to guide his hands as he drank. "Little sips."

He took the cup in shaky hands, wincing in pain. He appreciated Sheila’s help, sipping the water slowly. It helped to soothe a little, but didn’t fix it. “Why no sweet?” He asked, fumbling a little over the words. It was hard, trying to use his brain. 

"I want you more awake first." She told him. "The last thing we need is you to choke after all our hard work."

He frowned. “Wouldn’t choke.”

"When you're more awake."

“Hurts.”

"Your throat?"

He nodded, sipping his water again. “Yeah. Fix it?”

"I wish I could fix everything, sweetheart. Hopefully your sips will help, yeah?"

His memory was hazy, and he coughed again, turning his head away as he tried to clear his throat. “Why does it hurt? Why so scratchy?”

"You came off your bike, sweetheart. Had an accident. You got brought back here, Finn…Finn had to intubate you. You had some internal bleeding, but that's settled down, and you've broken your femur. Ollie's been in and fixed it up for you."

He frowned, clearing his throat. If he’d been tubed, that definitely explained his throat, and coming off his bike explained the pain. He vaguely remembered Harrison that morning, and panic. Had they just pulled the tube? Maybe. That explained a lot. “Oh.”

"You're recovering now, that's the main thing. You just need to rest and we'll do all we can for you." She told him, patting his hand.

[detectiveconnor]

@jericholeader​ sent a meme but actually this didn’t turn out to be a response to the meme because i ended it here. but here is a this.

It was called a Spontaneous Breathing Test. It was a prerequisite for extubation, which Connor had been told he’d failed twice in the past (he believed them, though he had no memory of the attempts and rarely failed anything at all), a period of two hours where they switched off the ventilator and waited to see how well his body breathed on its own. There were criteria to fulfill for an SBT and many of them were right at the start: the first breath in, the ability to cough “adequately” (whatever that meant), whether it was harder to draw air off a ventilator than it was on it.

He was past the first hurdles this time. The first breath was a little delayed, but he drew it in with a rasp and then a cough, hand grasping at Markus’ (he could not lift his head to find him). The focus it required worried him. Like he might somehow forget to breathe if he wasn’t paying close attention, but the alternative was staying intubated. Nobody had said much about it, but Connor was a Detective. He did not need to be able to lift his head to catch the feel of the room when they considered leaving him intubated longer still, longer than it had already been.

Shit, was what Connor would have said, if he had been able to speak, at this point. Breathing for himself, even with a tube down his throat, made a lot of it sharper somehow. The way his ribs ached, the cuts and scratches on his hands and neck (some of them defensive wounds; some of them a murder attempt), the bone-deep tired that probably had taken those memories of the first two attempts, and may well take this one. The fact he wanted Markus there, and it was a shame he could not see him. Instead of swearing Connor squeezed his hand, now, and Markus returned it, murmuring something patient and warm. This must have been awful for him. It was unfair, vastly unfair, that they were here, when Markus should have been moving on from time in an ICU room and courtrooms and being scared.

Connor rolled his head just that fraction of a distance that meant he could find Markus, now, sitting behind him and close enough Connor could see the much-later-than-five-o’clock shadow that he’d been feeling every time Markus pressed a kiss to his knuckles, or temple, or hair. Likely Markus just hadn’t considered it much of a priority, but he liked him like this, Connor thought. He had always liked when Markus’ facial hair got a little longer. Scruffy. A little bit scratchy. Maybe not to keep, but it was nice, to see it every once in a while. He would see many more of Markus’ five-o’clock-shadows, probably.

It was warm to think about. He remembered very recently thinking he would not see Markus, or anyone, again.

Two hours wasn’t long at all, Connor decided, when Markus leant forward to brush a thumb over his cheek and offer a book, or sketching, to fill in the time. Connor liked to watch him sketch. It was easier to follow than the cadence of Markus’ voice as he read aloud, though he had the sense Markus had done that quite a bit, these last few days (days? weeks?). Time had a way of disappearing inside hospital rooms, and so far breathing was maybe a little uncomfortable, but not hard. The difficult part would be staying awake the whole two hours, and he would not -- did not -- have to do that on his own.

[alketaire]

okay maybe this is the best job I’ve ever had because I’m heading into a shift with The New Vet who is so quiet when he speaks English that I’ve shared like two words with him and who has shadowed one (1) surgery here so i have no idea what his habits/expectations are but my brain is like “fun adventure. :) good times!”

[gardenstateofmind]

i wish my patient would've kicked the doctor but unfortunately i had to step in because the doctor was not even going to attempt to stop this elderly man from jumping out of bed and breaking his back even further

[daytonicuconsulting]

Unplanned Extubations: Dispelling the Fear and Understanding the Reality

When I think back to how I started my career as a nurse, it really does seem like a date with destiny.

I could have gotten a job at any ICU, but for whatever reason, I landed my first nursing gig at a high acuity medical-surgical intensive care unit in Salt Lake City, Utah, which just so happened to be an Awake and Walking ICU.

While I was interviewing for the job, the nurse manager asked me if I’d be willing to help patients mobilize during mechanical ventilation.

At the time, I had no idea what that meant, but I enthusiastically nodded my head and said, “Yes. Of course!”

Little did I know that this first nursing job would lead me down a path toward what I now feel is my life’s purpose, and it’s so inspiring to reminisce about how things have played out since that fateful day.

In any case, standard practice in this Awake and Walking ICU was to allow patients to wake up right after intubation and mobilize shortly thereafter, unless there was an indication that the patient needed to be comatose, or a contraindication to mobility.

Otherwise, intubated patients would always be up and cruising around.

At this point, you might be thinking that this doesn’t sound like a real high acuity ICU, or that these patients were all on the ventilator long-term, but nothing could be further from the truth.

Even during COVID, they insisted on allowing patients to mobilize while intubated, unless there was a need for them to be sedated, or they couldn’t oxygenate with movement.

And believe it or not, this ICU team went over two years without a single unplanned extubation.

But why is that?

Well, with any luck, you already know the answer, but if you’re not quite certain, or you just want to learn the truth about unplanned extubations, then you should definitely keep reading.

Unplanned Extubations and the ABCDEF Bundle

The main reason why this ICU was able to go so long without an unplanned extubation is that it adheres to the evidence-based practices in the ABCDEF Bundle.

This set of tools is meant to help clinicians customize and optimize patient care, particularly when it comes to early mobility, delirium prevention, and limiting sedation.

If you work in the intensive care unit, then I hope you’ve heard of it, but sadly, in spite of all its benefits, it’s not as well-known as it should be.

So, for the benefit of those of you who aren’t familiar with it, I’m going to explain how it works.

The ABCDEF Bundle works by prioritizing:

Family members being involved, which improves patients’ overall well-being and creates a need for them to be awake and communicative

Early active mobility, meaning patients will be able to get up and walk around while intubated, unless there’s a contraindication

Delirium prevention, assessment, and treatment, with the focus being put on prevention, which goes hand in hand with early mobility, as it’s known to prevent delirium

Considering our choice of sedation and analgesia, which not only encourages us to limit the use of benzodiazepines, but also to determine if sedation is even needed, and if it is, to always go with the safest sedative, at the lowest dose, and for the shortest duration

Both spontaneous breathing and awakening trials, which help clinicians to make a better assessment of exactly what a patient needs, while considering any delirium they’re experiencing and how best to treat it

Assessment, prevention, and treatment of pain, which is much easier when patients have not been sedated, and are actually able to communicate their needs, and what sort of pain they’re experiencing

These practices also encourage clinicians to avoid restarting sedation as soon as they witness a patient with delirium or agitation. This perspective helps them to understand that sedation is often responsible for patients being delirious or agitated, so it’s best not to sedate them unless it’s absolutely necessary.

The image below offers a perfect example of how beneficial these practices can be, as more than likely, the only reason that this man, who was a COVID patient, was able to remain awake long after being intubated, and still have enough energy to strum a guitar, is that he was treated using the practices outlined in the ABCDEF Bundle.

If you want to learn more about the ABCDEF Bundle, and the devastating effects of not adhering to these evidence-based practices, you can read my article on Susanne’s Story: How to Improve ICU Patient Outcomes with the ABCDEF Bundle.

And if you’d like to learn even more about unplanned extubations, you should check out Episode 112 of my Walking Home From The ICU podcast.

The Unnecessary Fear Surrounding Unplanned Extubations

Unfortunately, for many ICU clinicians, the idea of having patients awake and mobile while on the ventilator is actually quite scary.

What I often hear from clinicians who are skeptical of these practices is that they believe they’re unsafe because the patient could extubate themselves.

Now, unplanned extubations are a legitimate thing for clinicians to be concerned about, and they can have dire consequences, including everything from hypoxemia and hypotension to respiratory failure, aspiration pneumonia, or even death.

But when we look at the evidence, it’s actually very rare for an unplanned extubation to take place as a result of early mobility. One meta-analysis that included over 14,000 activity sessions showed a rate of adverse events, such as cardiac arrhythmias, hypoxia, hypotension, falls, and unplanned extubations, of just 0.6 percent.

And when we compare this to something as innocuous as bed baths, for instance, where unplanned extubations are one of the most common events, this is when things really get put into context, and we realize that the fear of unplanned extubations happening during mobilization is completely blown out of proportion.

Sure, unplanned extubations can happen while a patient is ambulating, and this can cause serious complications, but it’s no more likely to happen during early mobility than it is during many other routine practices in the ICU. In fact, it’s quite the contrary.

So, which one of these practices is more dangerous in the context of unplanned extubations? Bed baths or early mobility? I think the answer is obvious, but I’ll let you be the judge.

And when we look at the risk factors for unplanned extubations, this is when everything starts to make sense, and we realize that delirium is one of the main reasons why these unfortunate events occur.

In fact, several of the risk factors for unplanned extubations are directly related to patients experiencing delirium, and how they got into that state in the first place.

Some of these risk factors include patients’ restlessness and agitation, the use of Midazolam to decrease that agitation, the use of physical restraints, which has a correlation with delirium, and issues related to nursing staff, such as inexperience and inadequate staffing.

And when I think about the fact that I’ve personally witnessed thousands of patients who were awake and mobile on the ventilator, and these situations almost never resulted in an unplanned extubation, I realize how important it is for me to relate these risk factors to what I’ve experienced in the ICU.

Because in my experience, unplanned extubations have tended to occur when patients are restrained, and when they were restrained, it’s because they were delirious.

Aside from my own observations, this is also shown in the literature on unplanned extubations, especially when you look at newer studies on this topic.

For example, an Asian Nursing Research study from 2017 found delirium and agitation to be two of the biggest risk factors for unplanned extubations in critically ill patients, with delirium increasing unplanned extubations by 11.6 times, and agitation increasing them by nine times.

Still, even today, in spite of this kind of research being widely available, clinicians don’t seem to understand the seriousness of delirium, or the risk factors that can go along with it.

But the fact of the matter is delirium is a symptom of acute brain failure, and a life-threatening medical emergency.

That being said, there are many different reasons why delirium occurs, and despite the good intentions of clinicians, unfortunately, we often contribute to the development of delirium with many of the outmoded protocols that are still being practiced in ICUs to this day.

For instance, when sedating a patient, many clinicians believe that this is the most benevolent and humane thing they can do. The prevailing ICU culture has led them to believe that sedation is sleep, and that sedated patients are as calm and comfortable as they appear to be as they lie motionless in their beds.

But this just isn’t true. And if you look at the research, and listen to the agonizing stories of patients who’ve gone through the experience of being sedated for long periods of time, you’ll learn that sedation is not sleep, and it’s not sparing patients the stress and trauma of being in the intensive care unit.

On the contrary, it’s actually a form of sleep deprivation, and one that’s known to cause trauma, not mitigate its impact.

The truth is, the experience of being sedated can be incredibly traumatic for patients, many of whom experience horrible nightmares, or worse, for days and weeks on end as they remain sedated, and this is yet another reminder of why we should never sedate a patient unless it’s absolutely necessary.

I’ve documented the testimony of many patients who’ve experienced this for themselves, and if you’d like to hear some of their stories, you can skip to the 17-minute mark in the video below.

https://youtu.be/_LC527FV25c

The Costs of Delirium in the ICU

Regardless of all the well-intentioned, yet erroneous beliefs about sedation that still persist in ICU culture today, the fact is, sedation is known to cause delirium, and patients with delirium are:

Three times as likely to die within six months after discharge, and with each day of delirium, there is a 10 percent increase in their risk of death (Ely, 2004)

Likely to spend more time in the ICU, and more time hospitalized (Dziegielewski, 2021)

Prone to increased time on the ventilator (Arumugam, 2017)

At increased risk of line and tube removals (Tilouche, 2018)

More likely to die one year after discharge (Pisani, 2009)

Less likely to discharge from the ICU (Klouwenberg, 2014)

Two times as likely to die during admission (Salluh, 2015)

What’s more, failing to manage delirium can also create serious consequences for our healthcare system, as well as individual ICUs and the clinicians who work in them, including:

Increased risk of workplace violence from patients experiencing delirium (Jakobsson, 2020)

Higher healthcare system costs of up to $152 billion per year (Leslie, 2008)

Up to 39 percent higher intensive care unit costs (Milbrandt, 2004)

Increased workload for clinicians (Sieber, 2021)

So, as you can see, by following outdated practices, like deeply sedating all ICU patients, we’re not doing them any favors. We’re actually putting them at a much greater risk of suffering from delirium, and all the risk factors that go along with it, like unplanned extubations.

And as clinicians, we’re not doing ourselves, our industry, or our reputations any favors either.

Now, before I conclude, I’d like to summarize a story from Dr. Wes Ely, who is the creator of the ABCDEF Bundle.

This anecdote involves a 27-year-old wheelchair-bound patient who had returned to an ICU where Dr. Ely was visiting after having been there two years prior for bleeding in her lungs.

The reason she was in a wheelchair is that as a result of being sedated and immobile for so long in the ICU, she had suffered severe muscle loss in her legs and could no longer walk, even two years later.

Dr. Ely asked the clinicians who treated her why they kept her sedated and in bed for so long, and they said they were afraid she would self-extubate, to which another doctor asked, “But what if she never walks again?”

It’s stories like this that show just how important it is to avoid sedating ICU patients whenever possible, and how blown out of proportion our fears about unplanned extubations truly are.

With that in mind, I’ll conclude by saying that although unplanned extubations are a legitimate concern, we should not fear things like early mobility. What we should be afraid of are outdated practices like automatically sedating every patient who comes into the ICU, or keeping patients sedated for long periods of time.

Because sedation and immobility are the main modifiable causes of delirium in the ICU, and when it comes to unplanned extubations, delirium is one of the most well-known culprits.

But by doing whatever we can to prevent ICU delirium, we can keep patients safe from the risks of unplanned extubations.

Are you interested in implementing the ABCDEF Bundle in your ICU? We can walk you through the entire process, so please don’t hesitate to contact us.