To Tube or Not to Tube

Case Study: To Tube or Not to Tube

Mr. Cowell is a 72-year-old patient who fell and developed a subdural hematoma in the right side of his skull. The patient had emergency surgery to evacuate the hematoma. He came out of surgery connected to a ventilator, intubated with an endotracheal tube. The standard extubation protocol is 12 hours postoperation, provided the patient meets the necessary criteria. Two days postoperation, the neurosurgeon decides to discontinue the ventilator and extubates the patient, even though the patient has not met the full criteria. After extubation the patient is put on a nasal cannula. Shortly after extubation, Mr. Cowell’s oxygen saturations decline, and he complains of difficulty breathing and is unable to cough effectively. The respiratory therapist increases his oxygen, gives him a breathing treatment, and suctions him per hospital protocol. After 2 hours of observation, the nurse and respiratory therapist come to consensus that the patient is not showing significant improvement. The nurse and the respiratory therapist recommend the patient be intubated; however, the neurosurgeon insists that the patient needs to be breathing on his own 5 days after the operation. The patient continues to deteriorate, and 2 hours later the attending anesthesiologist reintubates the patient.

Discussion Questions

1. Who are the members of the interprofessional team in this case?
2. What specific communication problem(s) can you identify and how did it contribute to the poor healthcare outcomes?
3. Which specific Sub-competencies, from all four Core Competencies, could have improved the healthcare outcomes for the patient in this case?
4. Which other healthcare professionals might have joined the interprofessional team to consult during the initial decision-making process regarding tube removal? Provide your rationale.

1. Interprofessional Team Members:
   • Neurosurgeon
   • Respiratory Therapist
   • Nurse
   • Attending Anesthesiologist
   • Other potential team members (not present in this scenario but could have been involved):
     • Intensive Care Unit (ICU) physician
     • Pulmonologist
     • Speech-language pathologist (for assessing swallowing and coughing abilities)
     • Physical therapist (for mobilization and chest physiotherapy)
2. Communication Problems:
   • Lack of consensus among the team regarding extubation criteria and patient management post-extubation.
   • Ineffective communication between the neurosurgeon and the rest of the team regarding the patient’s condition and the neurosurgeon’s insistence on the specific timeline for the patient to breathe on his own.
   • Failure to escalate concerns when the patient’s condition deteriorated post-extubation.

These communication gaps contributed to the poor outcome by delaying necessary interventions for the patient.

3. Specific Sub-competencies from Core Competencies:
   • Interprofessional Collaboration: This involves effective communication, shared decision-making, and mutual respect among team members, crucial for optimizing patient care. In this case, better collaboration and communication might have prevented the delay in necessary interventions.
   • Patient-Centered Care: This competency focuses on individualized care, considering patient preferences and needs. If the decision-making had been more patient-centered, it might have included a more comprehensive evaluation of the patient’s readiness for extubation rather than following a strict timeline.
4. Additional Healthcare Professionals for Consultation:
   • ICU Physician or Pulmonologist: They could have provided valuable input regarding extubation criteria and the patient’s respiratory status, potentially aiding in making a more informed decision about the timing of extubation.
   • Speech-language Pathologist: This professional evaluates swallowing and coughing abilities, which could have been critical in assessing the patient’s readiness for extubation and the risk of post-extubation complications.

Including these specialists might have offered a more comprehensive perspective on the patient’s condition and readiness for extubation, potentially preventing the complications that arose after the premature extubation.