Day 32: Extubation

Copied and back-posted from our CaringBridge site for permanent record here.

December 19, 2020, written by Mama

By the conclusion of Saturday, Thomas was successfully extubated, although we did have to ride the roller coaster for one more bump. I'm sure Chris feels the same: I have continual opportunities in PICU to try to use my will (and ignore my protesting emotions) to unite myself with God's moment-by-moment will.

In the morning, the team addressed again whether Thomas could be extubated that day. There was concern about his PermaCath and was something wrong with it that the dialysis machine has always been glitchy, sounding off alarms numerous times per day for weeks? If the PermaCath needed to be replaced--requiring Surgery or Interventional Radiology--it would be much preferable to do so while he was still intubated than to have to re-intubate him later. Thomas needs continuous dialysis and we do not want that interrupted at length while we replace his access point.

Surgery, Nephrology, and PICU all had to examine him and study his x rays over the morning before deciding: Yes, Proceed!

Then we had a glimpse into how a PICU is run: There were several children who needed to be extubated that day and the PICU team did not want to be working on any children simultaneously. The time of extubation can be tenuous and emergencies can arise, so they wanted to do one child at a time, a process that can take several hours each.

A babysitter stayed with the children and Chris arrived in the early afternoon for our vigil. We ended up sitting quietly all day while the sedation drip levels were lowered by more than 50%. I made at least 100 pages of progress in Harper Lee's Go Set a Watchman--absolutely fascinating to read from the perspective of analyzing an author's personal and professional development.

Shift change came again and the PICU Attending had to inform us that we needed to pause on lowering any more sedation. There were several chancy situations among other PICU patients and there is less staffing on the night shift. Thomas would need the attention he deserves during extubation and the other patients would deserve the attention they deserve, too. Further, if he woke up on his own, we would have to ask the doctors: if it was a peaceful time in PICU, they would extubate, but if it was a tense or crisis time, they would give him additional medications to stay sedated.

Chris had to go home in late evening to relieve the babysitter.

Sweet Thomas actually started to rouse at 8:00 p.m. and it really looked like he was showing the signs they wanted for extubation. Just to show how the pragmatic aspects of running a PICU play a part, this was right after shift change and the doctors were not available for a non-emergency like extubation, so we gave Thomas PRNs of medication to sedate him back down just for a few hours. There has to be staff present and all priorities of patients must be weighed.

Rounds occurred around 10:00, at which time the team gave the green light for Thomas to be extubated, even on the night shift, which is more unusual.

The team walked away from Rounds, leaving the nurses and I in the room. Given that Thomas had had PRNs just two hours earlier, he was snoozing happily, not what they normally want to see: awake, responding to commands (open eyes, squeeze hand), and visibly uncomfortable with the tube in his throat. I asked the nurses, "It could still be hours yet till those meds wear off?" They said yes, so I announced I was finally going to get some sleep in preparation for being awake later.

I arranged all my blankies and pillows, laid down, closed my eyes, and in that moment, the room filled with doctors and the respiratory therapist. "Never mind, we're doing it now!" Apparently since Thomas's lungs have always been so strong and he'd been breathing over the vent set only to pressure support all day, it was perfectly fine to extubate him then. Those PRN drugs ended up being rather a blessing because Thomas did not have to go through the typical anxiety in the half hour or so before extubation nor experience the moment of panic when the tube is extricated.

Thomas was extubated at 10:30 p.m.! There were no problems, he was put on high-pressure oxygen through his nose, and he remained what we lay people would call "asleep." I asked the staff for the technical term for this degree of sedation on their scale and they said "lethargic"--but they told me not to use that word because it has negative connotations while there is nothing at all wrong with our Thomas right now! They are happy for Thomas to keep snoozing on Sunday and to have just one body system make big changes at a time. His lungs are strong and over just hours, his percentage of oxygen and liters of it were already being weaned down.

Thank you, Jesus! Thomas is one step closer to being held safely in Mama's arms!