|John Locke, empiricist.|
I recently received a call (at an odd hour on the weekend) from an otolaryngologist (ENT) regarding a patient from whom she had drained a large submandibular abcess. She was calling to tell me that she planned to leave the patient intubated in the ICU overnight and she wanted "help with ventilator management" (which of course the patient does not need - he can be managed with an endotracheal tube not connected to any mechanical ventilator). The patient did not have airway compromise or concerns thereof prior to surgery, but, she said, there was swelling noted after the case that (for her) raised concerns about the patency of the patient's airway if the endotracheal tube were to be removed.
(There is a second moral to this story: far too often, patients such as this are left intubated post-operatively not for their own safety, but rather for the convenience of surgeons and anesthesiologists who do not wish to spend the extra time awakening them from anesthesia and observing them carefully in the post-anesthesia care unit. It is far easier to not fret over the depth of anesthesia, atelectasis, oxygen levels, fluid status, and leave the patient intubated and send them to the ICU and let somebody else sort it out. If I had a family member undergo a relatively routine, even if urgent or emergent operation at an odd hour [holidays, weekends, after hours] and they were sent to the ICU post-op for no apparently good reason, there would be hell to pay. Note also that for the surgeon and anesthesiologist to save an hour of their time, another physician has to drive to the hospital to take over for them spending hours of his time, and also often a nurse must be called in from home to accommodate the unexpected post-op admission [as was the case here]. The sheer arrogance and egocnetricity of this is mind-boggling. But I digress.)
Back to the story. I naturally inquired as to what criteria we would use the next day to determine if the patient's oropharyngeal swelling had abated sufficiently such that we could safely extubate him. The ENT replied that she would scope (endoscopy) the patient again in the morning and if the swelling had decreased we could proceed with extubation (removing the endotracheal tube). Well and good. Or is it?