I added yet another “M” to the title. I’m going to run out soon!

Since my primary field and time investment is the medical field, it’s natural that I’d derive some motivational moments from my work. Without such moments of fulfillment, it would be difficult to keep going with the intensity and time commitment that’s required. While these are quite far and few between the daily nonsense that goes on during this portion of my training (internal medicine residency), I hope that writing about these moments will put them to the forefront of my mind and remind me of the diamonds that can be found only by working within this field.

A Very Successful Extubation

^{Image Source: https://www.bjanaesthesia.org.uk/article/S0007-0912%2820%2930172-0/fulltext}

Patients can be intubated for a variety of reasons. Intubation is the process of placing a tube through a person’s mouth so that they can have a machine do the work of breathing for them, and this is sometimes necessary because a person is unable to breathe on their own, is at risk of swallowing food/saliva into their lungs, would not survive without the support of the machine, or is going for a major surgery/procedure.

More complex medical conditions that require intubation reduce the chance that someone will be able to get extubated (having the tube removed and subsequently resuming normal breathing). I recently had a case in which I successfully led the extubation of a patient who had a complex enough case that failure was certainly on the table.

This patient was a diabetic that developed a urinary tract infection. The urinary tract infection caused her to go into a condition known as diabetic ketoacidosis, which is the buildup of a very large amount of acids within the bloodstream in association with very high levels of blood sugar, and it’s usually caused by stress on the body (in this case, the infection was the stressor). The high acid levels caused her breathing to become compromised, and she required intubation. It’s also possible that the infection itself caused shock to her body, compounding the effects further.

The diabetic ketoacidosis was treated and stabilized, and I was tasked with making sure that she came off of sedation (medication(s) given to induce sleep) before extubation. A successful extubation requires that a person is able to follow commands and breathe, to at least a slight degree, on their own.

I had a strong feeling that it would be possible to lead the extubation myself, overnight, so that the patient could complete swallowing tests and make further progress during the daytime the following morning. I decided to take a chance.

I took her off of sedation and she gradually woke up. I checked that she was able to recognize her names and follow simple commands, such as blinking. I called the respiratory therapist to extubate her. Initially, the respiratory therapist who attempted the extubation deemed her stable enough to breathe on her own. Over the course of the next hour, however, our patient started developing heavy wheezing and felt extremely short of breath to the point that she was almost getting out of her bed.

This is the point where a fair portion of doctors would say, “let’s intubate her again. She’s not ready.” It’s the safe route, and easier. However, I believed that the patient would be capable of recovering.

I listened to her wheezing both when inhaling and when exhaling, and figured out that she likely has a bronchospasm, which is the spasm of muscles inside of the tube leading to the lungs. When that tube’s muscles spasm, it makes breathing much more difficult. By treating the muscle spasm, the breathing would improve.

With the collaboration of a nurse and respiratory therapist, I chose a series of medications that would help reduce this spasm, and I stayed by the patient for an hour, carefully listening and observing as her wheezing became better and she became calmer. It was certainly a difficult extubation, but when I returned a couple of hours later, she was able to talk to me and smile, saying that she feels better now.

Yes, only a couple of hours after this difficult extubation, and she was already talking and smiling! I was overjoyed. What a terrific success.

What happened next?

The next day, our patient went into diabetic ketoacidosis again; however, it was caught and treated early enough that it did not cause her to go into a coma or have any symptoms. Additionally, she had laryngeal edema, which is inflammation of the tissues inside of throat.

Initially, she couldn’t swallow food or water, but over the course of the next couple of days, her blood sugar levels were under much better control and she was able to start eating. Today, she’s talking, eating, drinking, and stable. She’ll likely be downgraded from the intensive care unit today.

Conclusion

Another memorable, successful moments in my budding medical career! During more difficult times, it’s useful to reflect upon and write about these little moments of victory. Now that I recalled this successes, I’m feeling a touch more confident again. It’s fuel for further self-improvement. 😁

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