Big step

The ICU pediatrician came in to discuss the plan for today - preparing to take Alan off the ventilator. They are easing off the Versed and reintroducing the Propophol - Propophol is faster acting and will wear off more quickly when stopped. They want Alan awake and alert when they take the tube out so he will breathe on his own. He mentioned three things that might happen when they extubate - swelling along the airway (this has been checked and is not a problem), water in the lungs (his lungs are clear now, but once he's no longer on the positive pressure from the ventilator that may regress and the only way to fix that is to put him back on), and if the pain can't be managed at levels safe without the support of the ventilator (cross your fingers!).

Before they attempted this though, Doc L's fellow came in to change the dressing on his leg. The leg looked good, though they will still wait until the next dressing change on Monday make a decision on when to go back to the OR to close the wounds. Doc HJ's resident and Doc H also came in to check on Alan and were happy with what they saw. A nurse specializing in skin and wound care came by to check on Alan and gave some instructions to keep his recovery going smoothly. Doc KP came to work on the mixture of Alan's pain relief. She decided not to re-insert the catheter for the sciatic nerve block since the femoral nerve was the more important one and she didn't want to mess around his wound any more than necessary.

Once all this poking and prodding was over and Alan woke up, they turned off the ventilator and let Alan breathe on his own. He had been getting upset so we moved quickly, hoping that taking all those tubes away would make him more comfortable. He did well with the machine off, so they went ahead to pull the tube out. He really started crying then, despite Ultimate Pandas and then Madagascar playing on the TV. This crying looked to be due to pain rather than frustration, so they eased up the medication. The PICU doc was actually pleased with the energetic crying since Alan was taking deep breaths and this would keep the water out of his lungs. Alan was also shaking - he had been on narcotics all week, and he was going through withdrawal now they were being reduced. The PICU doc gave him Methadone and Ativan to help him feel more comfortable.

After the drugs had a chance to work, Alan switched to more frustrated crying, but was eventually soothed by the movie and water-moistened sponge swabs - he grabbed the swab out of my hand and rubbed it on his mouth himself. Our friend Becky had come to help today and he kept her busy dipping his swabs in a cup of cool water.

He watched Madagascar twice before we switched to Ice Age, then fell asleep for a nap with both hands tucked behind his head. By late afternoon, the PICU doc was quite confident that Alan would be able to stay off the ventilator. It was a long afternoon, but with great results!