Ventilator.

Yes.

Even the thought of moving probably moved the tube.

And the reality was he was moderately alterated, right? looked wonderful, beautifully white vocal cords, and pristine pharynx, no cuts, bruises, bumps, nothing.

I mean, just, if I took a picture of it and put this in a textbook, this would be the textbook case minus the ulcerations and ulceratus, okay? Yet what was really interesting is There were secretions, trace secretions, all around the bearings throughout the laryngeal vestibule, dripping down through the anterior commissure and then into the trachea.

There was never an attempt by him to cough, clear his throat, gurgle, a different voice, nothing.

I was carrying on a conversation with him the entire time during my laryngeal evaluation, and he did nothing.

CCU.

Yes.

It's the later stuff that kind of pushes all of this earliness off to the side, that the first time a therapist is called, physical, occupational, speech, or otherwise, and it's after extubation, they've already missed probably hours if not days of opportunity to orient that patient to a tube that's coming out, breathing on their own, that may very well reduce anxiety, depression, concern at a bare minimum.

Mm

... to be checked.

I think when you really r- get down to it, patient-centered care is the idea that protocol has, but I don't need to follow a specific protocol.

If I wanted to talk with the patient and do a language evaluation before I did a oral motor exam with them, that's fine.

Yeah.

So knowing that that's the treatment What can we do about the treatment that actually changes the factors on the back end? And the only modifiable thing that we can do is, at least at the moment, is change the size of the tube.

I've often quipped, and it's a little bit snarky, but I've often quipped that you don't put garden hoses down tubes where straws should go.

It's one of those things that if there's enough air, enough oxygen to maintain the life that's necessary, why are we making it bigger than is necessary? Huge arguments with regard to some intensivists who say, "Well, what if I do a bronchoscopy?" Which effectively means I want to put a very large endoscope through the tube to see what's going on in the upper and lower airways below the vocal cords while the tube is in and possibly wash out the lungs, get rid of mucus plugs, whatever it may be, and they need the size to be able to go down into that tube.

Make decisions.

Yeah, it's a mix of things.

I don't- You know, certainly in a well-run ICU with a multidisciplinary team, multiple inputs, um, you can't...

I'm gonna double, do a double negative here.