Judgment and Faith in Medicine

 One of the challenges of being a physician is making decisions with regards to a patient's care and well being. The decisions we make are oftentimes derived from both our training and the lessons we learn in residency and in the workplace. And sometimes the choices we make are not easy.
Two nights ago I was asked to admit a patient who had a syncopal episode in front of his daughter, got intubated at an outside hospital, and then transferred to my hospital for stroke workup and management. By the time he arrived at the ER and I got to see him, he was wide awake, following commands, and able to respond to simple questions by nodding or shaking his head. His chest X-ray was clear, and his ABG looked great. He looked like someone who could be extubated on the spot, and his RN agreed he looked like he could "fly," the term we use for patients who do well post extubation. The question: since the patient was in the ER, who makes the call regarding extubation?

I initially spoke with the ER doc who admitted him, saying that he was awake and alert (which he was NOT when she saw him), and suggested that he could be extubated. Unfortunately for me she was dealing with an acute CVA at the same time, and after speaking briefly to my patient's family, she said that because she didn't know why he became unresponsive (drugs, MI, CVA, etc), she was not comfortable extubating him in the ED. As far as she was concerned, he would remain intubated until he got to the ICU, where she wouldn't have to deal with him anymore.

I saw things differently. Whenever I did MICU rotations in residency, one of our attendings always ran through a checklist on each patient to see whether or not the patient still needed to be in the MICU (if not, call them out) or, if they were intubated, whether they could be extubated. My patient was awake and alert, and his chest X-ray was normal. I didn't know why he passed out, but I thought that most likely he was intubated prematurely. I was nervous, too, about extubating him in the ER with the possibility that he would crump shortly afterwards, but no matter what I couldn't justify sending this man to the ICU on a ventilator to spend the night in a propofol-induced sleep , then consulting pulm-crit in the morning just to extubate him. In the end, I had to go on faith, and believe that this man would do well. Taking a deep breath, I wrote the order for RT to extubate him.

I stayed in the ER and kept a close eye on the patient as RT extubated him, and his SpO2 was 97% on room air! He was placed on nasal cannula and was able to answer a few questions for me, saying that the last thing he remembered was talking to his daughter. He was able to move all four extremities, and the house supervisor asked, "You still want him in the ICU?" Not anymore. He was admitted to our IMC instead, which was good b/c there were only 2 ICU beds left in the entire hospital. In fact, I later learned that he was discharged home today.

So what did I get from all this? I had thought that the ER doc was too "chicken" to make a call regarding extubation, but now that I think about it, this was uncharted territory for her, too. Not many people come to our emergency room already intubated only to be extubated while IN the emergency room. In fact, I don't know how many of my partners would have made the call to extubate in the emergency department. Was I being too daring for my own good? I reviewed the case with a pulm-crit attending, and he assured me I'd made the right call. Thank goodness. I just hope I continue to make the right decisions throughout my career.