Practice Makes…BetterF. Amos Bailey, MD Oct 22, 2019
While rounding in the hospital, I met Joel. Joel had a complicated illness that required a prolonged period of time on mechanical ventilation which had led to him living with a trach – you know, that tube coming out of his throat that is used to hook to the breathing machine.
Joel had been in the hospital for a long time and he just wanted to get out – even to a nursing home – just anywhere but here. When I looked at the trach, I realized that it was the same one that had been placed about 6 weeks before and the balloon was still inflated! He was coughing, spitting, trying to suction and forced to communicate by writing notes.
Interdisciplinary and Interprofessional Team care is a goal in palliative care but it is complicated. In the case of Joel, he was told that he needed to stay longer. His face fell. I wondered, does he still need this trach? Could he at least have a cuff-less trach? Would that help with secretions and would that allow him to talk? ENT was asked to evaluate and after the resident saw Joel, she discussed strategy with the attending. 24 hours later, a new cuff-less trach showed up and the ENT resident came to change it out. With the new trach, Joel was swallowing and now had a speech valve, so a respiratory therapist reevaluated his oxygen needs and provided new trach care education. Four days later, Joel would leave the hospital for the nursing home – able to communicate, eat a little, and breathe a little safer – but it was all because of a fluke.
Some 25 years earlier, I had cared for a patient that no nursing home would take because he had a trach. After attempting persuasion and subsequent angry phone calls, the nursing home admin still wouldn’t back down. Defeated, I came to visit him one day and asked myself: “Does he really need this trach?”
With lots of trepidation, we tested him with a cuff-less trach, then a red button over the stoma, and finally took out the trach. The opening closed in just a few days and he was discharged a few days after that. My personal experience allowed me to consider the possibility that Joel might not need this burdensome trach but it was just dumb luck that I was the one who happened to see him that day.
I am sure that there are others who have left the hospital with interventions, like a trach they didn’t need.
Practice is not making “perfect”, but I would settle for “better”.