Extubation Q

meandragonbrett · Jul 23, 2003

Originally posted by javajunkie
So I guess I missed the part about this board and its discussions being exclusive to nurse anesthetists only. I will refer to the policy.

Now you're being a smarty- pants. :rolleyes:

javajunkie · Jul 23, 2003

Attitudes are contagious, right?

piper77 · Jul 24, 2003

Oh boy...you guys are gonna love me. End of a long day with plenty of BS and I'm in no mood to take any more...so you might factor that in when you read my rantings....I actually don't know which tangent to rant against first......but I'll pick one.....

Let me start off by saying that I promise forever and ever to uphold the standard of cuff deflation via the syringe and in no way am promoting bad, sloppy, or unsexy habits; furthermore I entreat Laerdal, Baxter and all other ET manufacturers to please forgive me for engaging in the highly suspect practice of "cuff-line pulling" which I have engaged in many years ago in my sordid past. Let me say again...I'm with you fellers. Syringe it is, always and forever. That's the way the air goes in...makes sense for it to come out that way...

But.... a few directed rants....

1) Yoga - what is this "write back when you're a CRNA" crap? What a condescending load of BS!! You've been practicing a few years now....so be a mentor, not a jerk.....And they say nurses don't eat their young.........

2) Java, I have not always found Yoga's posts to be so uppity...please take that into account. But in my opinion, you are right on the money; you are exactly right. Keep on truckin.....

3) cuff pulling is a common practice, and no, CRNA,DNSc...it does not mean we should all jump off the Brooklyn Bridge. What it DOES mean is that if it is a BAD practice, we should document WHY it is a bad practice through RESEARCH and EDUCATE (not castigate) those who maintain it's practice, not through ANECDOTAL evidence (surrrre...I've got anecdotal evidence too.....I never saw ANYBODY pull a foley cuff tube with their bare hands, fedupnurse....did see a few cut....but I HAVE seen several foley cuffs not deflate....EVEN WITH A SYRINGE!! HA! My point....is NOT that we should propagate bad practice....rather that we should be able to document why we do things through research..and that (thank you wntrmute, right on...) is evidence-based practice. All Java was saying, is that if this is a common practice, there should be some research available supporting or not-supporting it's use. Yes, clinical judgement is supremely valuable...but unbiased research is one way we educate many people for safer, better (sexier, Tenesma?) practice. If anyone wants to read about some of the psychology behind believing what we know to be true (but is not supported in the least by any evidence), I can recommend a couple of books.........

4) Now to the fun part..... keeping the tube after you pull it just in case you have to re-insert it.....sounds good on the surface...but.......let's walk through the PACU scenario where we started this discussion.....So your case is done...patient is breathing on their own...maybe a t-piece in PACU, starting to move, able to follow commands, grasping your hands (yep, they BETTER have motor control).....You've suctioned, sats are good, time to extubate, you pull the ET (after deflating it with a syringe, of course :) ) and then......Tell me, OH please tell me... that you gingerly lay the slimy piece of plastic tubing next to the patient's head on the pillow, savoring it's presence JUST IN CASE you have to....what...? BLINDLY intubate the patient again with the same tube, using your bare hands and a keen eye....???? OF COURSE NOT!!! You pull the tube and dump it in whatever kickbucket is near you....TELL ME YOU DON'T! Of course you do! And if your patient starts de-satting, and you think they need an airway...you stick an oral airway in them until you can reintubate with that nice little thing called a laryngoscope...which is always accompanied on every tray, cart, shelf or wall supply by...guess what! more ET tubes...in all flavors!

So, I guess I'll get a few arrows slung my way after writing this...but .....ahhhhh.... I feel better. Time for a beer and a 5 AM wakeup to do it all over again. Java, don't let em get you down.....you're going to make a great CRNA someday.

javajunkie · Jul 24, 2003

Originally posted by piper77
4) Now to the fun part..... keeping the tube after you pull it just in case you have to re-insert it.....sounds good on the surface...but.......let's walk through the PACU scenario where we started this discussion.....So your case is done...patient is breathing on their own...maybe a t-piece in PACU, starting to move, able to follow commands, grasping your hands (yep, they BETTER have motor control).....You've suctioned, sats are good, time to extubate, you pull the ET (after deflating it with a syringe, of course :) ) and then......Tell me, OH please tell me... that you gingerly lay the slimy piece of plastic tubing next to the patient's head on the pillow, savoring it's presence JUST IN CASE you have to....what...? BLINDLY intubate the patient again with the same tube, using your bare hands and a keen eye....???? OF COURSE NOT!!! You pull the tube and dump it in whatever kickbucket is near you....TELL ME YOU DON'T! Of course you do! And if your patient starts de-satting, and you think they need an airway...you stick an oral airway in them until you can reintubate with that nice little thing called a laryngoscope...which is always accompanied on every tray, cart, shelf or wall supply by...guess what! more ET tubes...in all flavors!

OK, that was fabulous. I am still laughing. Good point! :lol2:

gaspassah · Jul 24, 2003

hmm...interesting to see how this plays out. :eek:

SCHMEGGA · Jul 24, 2003

Exactly piper77.

London88 · Jul 24, 2003

Things are getting vicious!

yoga crna · Jul 24, 2003

OK, I guess it is time for me to try to clarify what I was trying to say. First of all, let me apologize if I offended anyone, believe me that was not my intent. I respecti all of you who take the time to share your education, experience and dreams to become a CRNA on this forum. I look forward to reading the posts every day and learn from you all of the time.

Now, for the issue at hand. I was asking why there needs to be a policy for everything and isn't professional judgement better than having a policy that may or may not cover all contingencies. It doesn't have anything to do with deflating cuffs prior to extubation, it is much deeper than that.

You all don't know much about me, but I will tell you that besides being a CRNA for over 40 years in active practice, I also have a law degree, published two anesthesia books, many journal articles and received two national awards for excellence in anesthesia. Having been on the lecture circuit for many years, I have been to every state in the nation and have lectured at several international meetings. I have also been an educator and have encouraged many good RNs to go into anesthesia. Where is all of this leading?

The majority of CRNAs I have met have clearly stated that one of the reasons they went into anesthesia was to get away from the restrictive nursing culture, where there is a policy, procedure, order or dictum on just about everything. Even though you think you can use your own judgement on nursing matters, there is always someone who questions your right to do so. That culture simply does not exist on the same level in anesthesia. We must make our decisions on what is best for our individual patient based on our knowledge, education, experience and best practices. It is different to realize that there is no standing order to calculate and administer an anesthetic and related drugs. Only after you are in that position do you understand that distinction.

I may not be very eloquent in my discourse, but I do take offense to being accused of "eating our young" and not mentoring students. I have a lot of students, CRNAs, surgeons, RN colleagues and patients who can attest to my passion for the profession. So Piper, if you had a bad day, don't take it out on me. I am open to better ways of doing things, as long as they really are better and above all, do not harm my patients.

YogaCRNA

keermie · Jul 25, 2003

Evidence based learning is not a way of saying that we have been doing this for years. Of all people an acclaimed CRNA of 40 years who has their law degree, is published, and has been an excellent resource on this board; should support evidence based research. I completly understand that in this issue "common sense" should be the rule, but to get away from the restrictive nursing culture? I do not agree. Many methods in the past have made common sense and have been proved to be otherwise via research. It can be overkill though, so I understand where you are both coming from with your arguments. It's just that comments such as: write back when you are a CRNA can only be taken one way; as can comments made after a bad day. My answer is that it is not the best practice, obviously deflating the cuff to make sure is a fail safe way. I'm sure this will now give someone a great new grant proposal, ending up ultimatly taking away from patient care, to derive the common sense answer. This is maybe more about frustration, hence comments. I don't want to speak for anyone, merely attempt to clarify. If I've read into this to far or misinterpreted, please speak up . . . like I had to tell ya'll.

piper77 · Jul 25, 2003

To everyone -

I apologize for my flippant mood the other night, and especially Yoga, to you, for taking you to task for an inadvertent comment. You obviously have led a life worthy of respect, and I apologize for not giving it to you.

Yoga, I think we are probably more in agreement than not. I too, am against "policizing" (I think I just made up a word....) every action a nurse takes. Unfortunately, the policy manual in most hospitals has become much more than what it used to be when you and I started nursing years ago. Because of advances in technology and greater practice boundaries for nurses, not to mention differing approaches by hospitals and equipment manufacturers, the "policy and procedure" manual has become more of a resource manual, where nurses learn not only how, but why they perform certain functions; they cannot possibly learn all of these practice-area specifics in nursing school. I say unfortunately, because the P+P manual is also the practice standard manual to which nurses are held accountable. And as litigation mounts, it evermore puts burdens on the practitioner, rather than the institution, to standards of care that may or may not be reasonable. So...I agree....I'd rather see less policy-making and more clinical judgment - abetted by sound, up to date research - , and, yes, that is one reason I am pursuing anesthesia nursing.

Unfortunately in nursing, I see all too often the trend to minimize scientific rationale, and also to minimize efforts to teach; after all these years, you still get " because that's the way we do it here....". I see nurses fresh out of nursing school excited to practice, only to be incredibly frustrated at the "let's just get the job done so we can get home" mentality. I think the reasons behind all of that are too complex to get into here, but it angers me to no end to see an advanced practice nurse, one who is in a teaching position, to not be able to provide any hope of finding an answer to a very valid question a new grad asks (I am speaking of what I witness daily where I work, not about anything on the board here). It frustrates me to see those in leadership positions fail to lead, fail to advocate, and fail to provide hope and inspiration to those under their charge. So, you might understand what buttons got pushed the other night in my "rant". I see medical and surgical fellows take first year residents under their wing and walk them through their cases; and I wish that nursing would not only emulate that in theory but in practice. (I realize many do, and many of you great nurses are on the board here.) Anyway.....just a bit about where I am coming from.........

loisane · Jul 25, 2003

Even aside from the emotions expressed in this exchange, I think this thread is a great example of how one seemingly straightforward question can become a catalyst for discussion of underlying issues.

There is value in these discussions. Not simply to answer the question "What is the proper way to deflate a cuff?". But to also answer "How do we decide what is proper technique?".

An observation that might apply here---the distinction between "policies and procedures" and "professional standards of care".

Nurses are traditionally employees, and are used to being held accountable for adherence to policy (in addition to accountability for maintaining professional standards).

The practice of CRNAs, being among the first advanced practice nursing specialties, has evolved a pattern similar to the medical staff. While it could be argued that everyone should follow institutional policy, I think you will find many physicians and CRNAs who feel they should only be held to their own professional standards of care.

So "P&P" doesn't have the same meaning in nurse anesthesia as it does in mainstream nursing, IMHO.

loisane crna

loisane · Jul 25, 2003

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