Respiratory Therapy 101: Just Keep Breathing

Even when they’re tied to the bed, they can still find ways to attack. They can scratch, spit, head-butt, kick, and knee. Over my career I’ve been scratched, spit at, swung at, slapped at, kicked in the head (that one hurt) and now–kneed in the ribcage!

While I was drawing a blood gas today I took a knee to the ribcage, with a significant amount of force behind it. It knocked the wind out of me, but the force also knocked me forward and drove the needle into the patient’s skin way beyond the hub, and I swear I felt bone.

I probably shouldn’t, but I take some small comfort in knowing that while he may have hurt me, he also hurt himself. Perhaps some carvings on the bone will serve as a reminder that assaulting the man with a needle in your wrist is maybe not a super idea.

Anybody live in the Chicago area out there? I have some questions for you. Fire an email to anonymoustherapist at gmail dot com. Thanks readers!

I recently had a patient in the ICU who I really enjoyed caring for. He was a small and shriveled old man, but despite his shrunken old body, he was mentally acute. People like that are some of my favorite patients, because they’re usually nice if you treat them well and they can have some fascinating stories from the days of old.

When I came in in the morning, he was intubated but wide awake, huge glasses perched atop his nose. The massive eyewear and the long ET tube gave him the appearance of some kind of odd moth with a long proboscis.I introduced myself, explained out weaning process, and turned the old man over to CPAP/PS. I let him chuff away for half an hour and drew and ABG; given the nominal ABG results and some acceptable parameters for weaning, the physician decided to extubate the old man.

I readied my equipment, prepared the patient. “When I tell you COUGH, I want you to cough strong for me and that tube’s going to come right out of your mouth.” The old man nodded and I pulled the air from his ETT cuff and shouted at him. “COUGH! COUGH! SPIT IT OUT, DON’T SWALLOW FOR GOD’S SAKE!” The man hacked as I slid the tube out of his mouth and his nurse applied a yankauer suction device to his mouth. A few touch-and-go moments later and the old man was stable, holding his O2 sats on room air and breathing easily.

Later in the day as I gave him a nebulizer treatment, he expressed some concern to me that he was not doing well. I listened to his concerns and then talked with him, building him up, explaining to him that simply getting off the ventilator was a huge success. I explained to him that for an 85-year-old man to be able to pull 2500-plus on his spirometer was indeed impressive. I gave him a PEP device to encourage him to continue his deep-breathing exercises. I spent extra time and effort with him, talking him up and encouraging him.

At the end of the last treatment of the day, I told him I was leaving and that he’d see somebody else overnight. As I turned to walk away from him, he spoke.

“Hey kid.” I turned around. He was propped up in bed on a mound of pillows, looking like nothing more than a wisp of hair atop those huge glasses.

“Sir?” He spoke not, but instead closed his fist and held it up. It took me a moment before I realized that he was making the Fist Bump at me. I closed my fist and popped knuckles with the old man. He smiled and the two of us laughed.

It made my day.

Thanks to everybody for your responses to my massive existential head-banging post. A lot of useful insight and interesting perspective, which I very much enjoy. So, dear readers, thanks for your contributions; without them this would just be an exercise in pointless scribbling.

More posting to resume shortly. But I do appreciate the comments and the feedback. I have been struggling a little bit with my perspective and my attitude lately and am trying to change all that. I’ll keep you updated as long as you keep reading.

The Pime: 0705.

The Place: The Medical ICU at Sunny Flats Medical Center.

It was early in the morning. I was barely awake, sitting in the cubbyhole that the ICU lets us borrow, sucking down a hot cup of coffee while staring mindlessly at my worklist. A sudden commotion caught my attention, and I stood, stretched, and walked out to the unit. A shudder hit me as I saw Drama Nurse guiding a bed into an empty room. A befuddled floor nurse and a CNA pushed the bed from behind. The patient looked simply abysmal; mouth open, eyes rolled back, paradoxical breathing. I turned around, got an intubation kit and a ventilator, and rolled my way to the outside of the room.

When I got there, Drama Nurse was berating the floor nurse. “How can you not know what’s wrong with this man?” she screamed. Floor Nurse screamed back. “I just got here! I haven’t even gotten report! I can’t find the night nurse!” Drama Nurse scoffed and rolled her eyes, and Floor Nurse turned in disgust and stormed away. I rolled my eyes and tried to avoid talking to Drama Nurse as I wheeled the ventilator into the room.

“What is THAT for?” she asked me.

I stared at her blankly. “Really?” I asked her.

“Really! He doesn’t need that.”

I looked at the patient, folded my arms. I watched as the patient gasped away, the monitor ticking off 45 breaths a minute, a figure I confirmed by counting. The patient was O-sign positive, breathing hard, paradoxical abdomen movements with every breath. “Really. And what does he need?”

“Well, he probably just needs a treatment.” I snorted in disgust, noted an O2 sat of 85%, and put the patient on a nonrebreather. A passing intensive-care physician caught my eye.

“Hey Doc! I think you need to look at this guy.” The doctor ambled over to the room, looked at the patient, looked at the monitor, and said…

“I think he needs some incentive spirometry. Looks like he could use some lung expansion.”

What. The. Fuck.

I mean, I have a lot of WTF moments, but this was crystal-pure What-The-Fuckery.

Needless to say, the patient who was unresponsive and mouth-breathing at a rate of 45 did not perform well on the IS that the NURSE started with him. An hour later, when a competent physician had arrived on the scene, we intubated the patient and were able to correct his respiratory derangements.The IS has it’s role, but I can promise you that it is not going to cure your unresponsive mouth-breathing tachypneic patient with paradoxical respirations. Even if an incompetent physician says it will.

Signs of Imminent Admission.

Awesome.

I have lost all sense of meaning in my work.

Meaningful work is fulfilling–soul food, almost. Doing work that fulfills you and gives you rewards is something that everybody strives for. The reason most of us got into the “helping professions”…a label that I find laughably absurd now…was because the idea of helping other people get well was so promising. Think of the rewards, the satisfaction as someone you helped walks out the door.

Meaningless work, on the other hand, is pure drudgery and toil. For me, this work has progressed to the meaningless.

I used to believe that I would make a difference. I talked to my patients about their diseases, I educated them about what to do to get better, I tried to convince them to do things I knew would help. I gave smoking patients lectures on smoking cessation. I talked to COPDers about ways to improve their lives. I tried to listen and give my all to these people.

Instead of rewards or meaning or satisfaction, I got grief. Sure, there have been a few successes, notably one lady early in my career who I saved from the ET tube by arguing the ER doctor into ordering BiPAP instead. Now that I think of it, though, that same lady came back in, coded, and died a few months later…nevertheless I like to think I bought her a few more months of quality time with her family. But that lady was the last of the patients like that. It seems that the vast majority of the patients I see now are incurable, unwilling to listen or take advice, totally hopeless.

On top of that, I have begun to doubt that anything I do is indicated. The hospital I work for is a farce. We spout a lot of nonsense about “quality” and “appropriate therapy” but we give hundreds of un-indicated treatments a day. I give albuterol treatments to people with CHF because the doctor is too retarded to realize that it won’t do anything. I give smoking cessation packets to patients who crumple them up and throw them away in front of me. I give pressure therapy to people who have no indication for it. We talk about being “the best providers for our patients,” but my managers micromanage what I do and track productivity so relentlessly that I feel smothered and unable to do anything. We have protocols to manage our ICU patients, but our physicians often override them, leaving me feeling like a drone that writes down numbers and squirts useless medications into ineffective, cheap nebulizer cups.

I’ve given up on my patients. Most of them are ignorant, unwilling to change their lifestyles to get better. They just want a silver bullet that they can swallow to eliminate their health problems. They whine and complain and bitch and moan about everything. They spout accusations of malpractice because CNN had a show about it. I have come to loathe them.

When they called codes in the old days, I’d go running to try to help and see what I could do. Now, I finish my coffee, walk slowly to wherever it is, grab the bag from whatever moron has it hooked up to the air flowmeter, and squeeze it until they either die or go to the ICU, whereupon I will write down numbers and give them ineffective nebulizers.

That’s right. I have gone from feeling like Super RT, capable of inspiring patients and helping people breathe, to being a mindless number-writing med-dispensing drone. I feel zero reward from my work, apart from the paycheck (which I am grateful for.) In a word (two words), I am experiencing

SUPER BURNOUT.

Tell me, people, how do you cope with that creeping sense of hopelessness? I can’t be the only one out there who’s feeling this way. Help me sort this out before I go insane.

“Excuse me. May I ask you a question?”

I put my coffee mug down on the counter and turned around. A woman dressed nicely with a white coat on stood behind me. Administrator, I thought. What have I screwed up lately?

“Sure. Ask away.”

“Are you aware that it is only permissible to store 12 oxygen tanks in a patient care area?” Her pen was poised over a clipboard. I suddenly saw the JC MOCK sticker on her lapel. Our hospital has implemented a false Joint Commission to walk around and make sure that people are complying with the most recent additions to the giant dung-heap of irrelevant crap that is “The Regulations.”

I stared at the lady. I tried to display no emotion or cognitive awareness. Perhaps if I stand very still she will be unable to see me. I waited a moment to no avail and decided to answer her.

“Nope. I sure wasn’t.”

“Well! Consider yourself notified that 12 is the number of tanks permitted.” I stared at her in disbelief. I could feel my blood pressure rising. She continued her rant of absurdity.

“There are 17 tanks in the supply room. What do you plan to do about this?” My BP rose to the top and snapped. I stepped forward and narrowed my eyes.

“Absolutely nothing, since I am not the supply tech whose job it is to stock the stockroom.” I could hear my voice getting louder and sharper. I had a vivid image of my hand reaching out and slapping her across the face, her clipboard and pen flying. I wanted to choke her. I wanted to hurt her.

She stopped and looked at me. I took a deep breath and stepped back. I let my breath out and took another, coming down from the rage.

“I also notice that one of those tanks is not in an approved tank holder. That is not acceptable.” I flashed into madness again, opened my mouth, and then in a rare moment of clarity, closed it. I turned on my heel, wordless, and walked away. Just walked away. I don’t care what comes of it. If I had stayed I would have done or said something regrettable, and sometimes removing yourself from the situation is the only way to avoid catastrophe.

I think I need some anger management. Much as I hate the joint commission, and much as I know other people loathe them, this frightened me a little. I really wanted to hurt that lady. I have been having a lot more anger and a lot more of these flashes of rage lately.

Perhaps I could use a vacation. Or some haldol.

The trauma sounded bad. 29 year old male, multiple gunshot wounds, combative. I readied my ABG kit and my airway box, wrapped securely in my shell of lead and plastic. I adjusted my facemask, added a second layer of gloves, made sure that I would be as protected as possible from whatever fluids might be flying around on arrival of the patient.

The ER doors rolled open and the paramedics arrived. A young man flailed ineffectually on the stretcher; the medics had done a fine job tying him to the backboard, going above and beyond and really taking the cake for “spinal immobilization.” A torrent of obscenities came from his mouth and for a moment I could understand why he had been shot; five seconds in earshot and I wanted to shoot him. Several small holes with blood trailing from them lined his chest and abdomen. His shirt was mostly sliced off but his pants were on.

“29 year old male, multiple gunshots. Three to the chest, no exit wounds on his back, one in his abdomen. Very combative and uncooperative.” As if on cue the patient erupted.

“YOU MOTHERFU**ERS! LEMME GO! I KILL THAT SUNOFABITCH THAT SHOT ME!”

“Sir! Calm down! You are at the hospital now and we are going to take care of you.” Our chief trauma surgeon was leaning down and speaking in the calm and authoritative tone of a man wielding a syringe of paralytics.

“HUH-UH! I need to GO! I gotta beat his ass down!” The patient tried to get up off the stretcher but was thwarted by the straps. We pulled him over to the ER bed, and the nurses began to cut up his pant legs. A baggie of white powder fell from somewhere inside his thighs, then another. (Seems he was delivering the sugar for the coffee to his church social, as usual.)

“Y’ALL LET ME GO! I AIN’T STAYIN’ HERE! NO WAY!”

The nurse cut away the waistline of the pants, and suddenly began to laugh hysterically. She doubled over, dropped the scissors, had to leave. The trauma surgeon looked down and burst into hyena-like laughter.

“Hey, dude! Are those…are you wearing leopard panties?”

That got my attention. I looked down, and lo and behold, our 29-year-old, combative, drug-dealing multiple GSW victim, covered in tattoos and pierced in tough-looking ways…

…was wearing skimpy, leopard-print panties. With black lacy frill.

I snorted, then coughed, and then began to laugh. Tears filled my eyes. The room was awash in the sound of laughter. Even the medics were bent over their stretcher. The patient sputtered a denial, and then, feeling the breeze in his nether regions, realized his secret was out. He went from somewhat tanned to deep red. Mysteriously, he calmed down and began to cooperate with us, his tough-guy image shattered by his lacy black leopard-print panties.

Hours later he emerged from surgery bullet-free and is expected to make a complete recovery. But I bet next time he’s about to get shot, he’ll think to himself: should I go change my drawers before I get capped?

Man, all the drunks and overindulgers and traumas and whatnot from New Years have been working me out around here. I teeter at the brink of burnout and insanity on a daily basis, but lately, I feel as though I am truly beginning to lose my mind. The challenge and joy of the job has left me: it is now write numbers/give mostly ineffective treatment or possibly obtain questionably indicated lab/write numbers/next patient. My burnout is hastened by micromanaging nitwits who watch my (and every other RTs) every move and then fault me for minor slights. The micromanaging would not be so humiliating if not for the inability of the managers to talk to the staff.

In short? I’m losing my mind. Time for a break. Hopefully I can get one soon.