Let’s Get Extubated!

When one is intubated, the machines do all the work. You don't have to breath or even move.

The bed will gently rock you to sleep to prevent any skin breakdown. The nurse will come by every hour to make sure everything is ok. If you need to use the bathroom, don't let that disrupt your slumber. A myriad of tubes and IV lines will take away all your worries. A cloud of opiate induced bliss matched with an amnesic benzodiazepine will make the days fly by. You don't have to worry about anything, and you couldn't if you wanted to.

But just like the TinyTunes, original Nintendo, and being able to go to dinner and a movie for $20; all good things must come to an end. And unless you are Caitlin Jenner, transitions are often the hardest part of life and medicine. Going from a medicine induced coma to the Full Monty of awake, afraid, and painful of being intubated can induce the kind of panic usually reserved for pilots who run out of fuel or skydivers who's parachute doesn't open. The shock for most is nothing short of horrifying. But don't worry, it gets better.

One of the natural tendency we all share as humans are the primary motivation to avoid pain. In fact, research suggests the avoidance of pain is a stronger motivation than the attraction to pleasure. Pain is not always a real problem, and I'm confident you can briefly reflect on your own life and remember times when the pain was mostly your perception than an actual damage or injury. Fear of pain is at times stronger than the pain experience itself; ask any toddler getting vaccinated or having to get dressed in the morning. Emotional panic is an expression of cognitive fear, often fueled by confusion and concern for the unknown. In times of transition, like getting a new job, moving, losing a loved one or breaking up with a long-term lover; the experience of being in between two realities is very painful. In one hand is a reality that is no longer possible, and all your assets and plans rest on an expectation that no longer applies. On the other hand is this new and often unexpected reality that is largely unknown. For my patients trying to transition from full assisted breathing to breathing on their own and talking, having to hold both of those realities at the same time is very frustrating and for many physiologically and emotionally excruciating. So how do we get this tube out of your mouth so you can go home?

In the hospital, we take our time and ease people into being awake. We give people time to come out of their opiate fog and (as I like to say) "let the hamster get back on the wheel". The keys to a successful transition are commitment, and fear of the unknown must be measured and mitigated. The very uncomfortable experience of the in between is nearly always worse than the new reality once the transition is over. So for my patients who are not ready, I have to be committed for them. I regularly wake them up and let them understand their surroundings, hold their hand and talk them through what is going on and how it is going to be ok. Once someone gets's their game face on and the hamster is back on the wheel, we give them some hours to breathe on their own, awake, still connected to the machine but doing all the work. I imagine this is the hardest part, a level of uncomfortable and alien that many of us can't even imagine. This is the time we see if the "patient will fly". Can they be aware enough to not fight the machine, pull out their lines, and can they control their breathing?

In my own life, I have had to stand in an uncomfortable middle ground. Between jobs, or waiting to get into school, or hoping I'll get to see my wife again after months of being away. That is the hardest part of my life; when the outcome is unclear, the opportunities are undefined, and the next event will change things in a major way. I hate the in-between. As a self-critic, in my own difficult times, I was more like the patient eager to get the process over with and would try to rip the tube out. I would quite a job before I had another one, or start a backup plan before my first plan had even a chance to get started. I've been very impatient in some key moments in my life, am thus the figurative tube is still in my mouth. For my patient we can not take out the tube until we are sure it's safe and that we know you will fly. For my life, if I had a greater patience to ensure success I would be much more ahead and much more evolved.

Medicine is an incredible stage where the darkest, the brightest, and most compelling of life's drama's play out. The random positive pregnancy test no one expected in the 15-year-old. The concerning mass found on a routine chest X-ray. The STD that now diagnosed must be explained to multiple "monogamous" partners. The 30 years of smoking that now makes a phone conversation impossible. The one last hurrah with friends that quickly becomes the last night with anybody. And to top all of these off; any of them could have been me. At any time I can make a decision that will introduce me to the injury or embarrassment that others have as life companions. These people are lighthouses to me. A lighthouse is a beautiful structure that stands tall and shines a bright light for all to see. The lighthouse stands at the edge of danger, warning the ships that where the lighthouse stands is where ships go to sink. Beautiful, respected, needed and appreciated; the "lighthouses" I meet in my life teach not just what to do, but also what not to do. I'm not sure if this is what Jesus meant when he said: "let your light shine before men, that they may see your [good] deeds, and praise our father who is in heaven."

So I share with you this tale of the process of extubation, a difficult and frightening process, that you would consider the transitions you are going through. Remember that simply being in transition, being in between two placed makes it hard. So don't be angry that it's hard or fearful of where you are at. Know it gets better. Know the whole point is that it is getting better. Be patient, and let yourself adapt to the new reality that awaits you. Find others who can support you, and keep you committed to the process. Remember the great thought leader Rodney Atkins who famously said, "If you are going through hell, keep on going. Don't slow down. If you are scared, don't show it. You might get out before the devil even knows you're there." And when you are ready, pull that tube.