A good MICU stretch is receiving a patient on the ventilator in the morning of day 1 and by day 2 the patient gets extubated and downgraded. That almost happened to me the other day…

Day 1: I receive my assignment. Sixty something patient with ARDS. After a lung biopsy, it looks like an interstitial pneumonitis. Not a good prognosis here. She’s been on the ventilator for a week now, and we have been unable to wean her. But when I receive her, she is ready to surprise everyone. She survives her spontaneous breathing trial for much longer than we thought possible. The spontaneous breathing trial is the first big step towards extubation…

So she spends the whole day on CPAP mode. What this means is that she is initiating all of her breaths, the vent is just giving her an extra push. Her ABGs are improving, she’s looking more comfortable. We let her ride all day long and then at evening switched her back to the previous vent settings, so she could rest.

Day 2: I have the same patient assignment. She looks good. She looks up at me pleasantly. Assessing mental status on a ventilated patient is tricky. You don’t know for sure if they are oriented (they can’t really answer your questions) so you look at other things. Can she follow simple commands, like squeezing me hand? Yes. She appears calm and comfortable, no anxiety. I get the feeling from her comfort level that she recognizes me from the previous day. She goes back on CPAP mode and continues to do well. I am happy. I’m composing my next blog entry in my head and it’s entitled “A MICU Success Story.” A couple of hours later she is ready to be extubated. Hooray! Here’s one more patient that is going to make it though ARDS! No small feat considering ARDS has a 40% mortality rate.

But will she fly?

So the tube comes out and things start to look kind of iffy. She’s tachypneic. Her blood pressure is on the rise. But her 02 sats are holding steady. After 30 minutes I draw an ABG. The results look relatively good. I have been giving her family members time to interact with her and one of them comes to me and says, “I don’t think she’s really with it.”

Crap. This is a bad sign, especially when you consider that poor oxygenation could be the cause. So I go into her room. Now that the tube is out, I can really assess her level of orientation.

“Do you know where you are?” She laughs at me. She thinks this is a silly question. I tell her she’s in the hospital. She stares at me in utter disbelief.

“Do you know what year it is?” Again she laughs. Why would I be asking such a silly question? I encourage her to answer the question. “It’s um, uh, 19… 19 something.”

I ask her to tell me the names of her daughters who are standing around her bed. I point to one. She looks at her with some recognition but can’t tell me her name. I point to the other daughter. “Why, that’s Mary,” she says, without hesitation. I am thinking this is going to cause some serious sibling rivalry after all is said and done.

So now I’ve established that this woman is experiencing some sort of delirium. What next? I alert the physicians. Everyone automatically thinks of oxygen first, but that doesn’t seem to be the answer (her O2 sats and ABGs look good). So as long as she’s oxygenating, the physicians are okay with putting this issue on the backburner for the time being.

But I’m a little disturbed. This woman was so cooperative and pleasant when she was intubated. She even greeted me in the morning with a smile, and it’s pretty darn hard to do that when you have a breathing tube shoved down your throat. And now she’s looking at me like “who the hell are you and what are you doing in my room?” It reached a peak when I went in to give her a heparin shot. “Get your fat face away from me!” she croaked from behind her 02 mask.

I explained the situation to another nurse. Her theory was: “Maybe she thought you had kidnapped her, and felt it was in her best interest to be cooperative with you. When the tube came out and her family was there, she had no more reason to be cooperative to you.”

Ha Ha. But I think I know the real reason for this “change.” My previous assessment of her mental status was so subjective. She looked up at me sweetly and even kind of smiled with her eyes. I took that to mean she was oriented to the current situation. My instincts were telling me she was oriented, because otherwise she would have been completely agitated.

The moral of the story? Instincts can be useful at times, but you have to remain objective in your assessment. That goes back to Nursing 101.

So what was really causing this delirium? She may have been withdrawing from the narcotics we had been giving her. She had also been spiking fevers.

But here’s the worst part of this story. She had been cultured out the wazoo to find the source of these fevers. Nothing had ever grown out. Until now. The resident got the phone call from the lab after we extubated her… The result? She was now growing acinetobacter baumannii in her sputum. So not such a good day after all.