Respiratory Therapy 101: Just Keep Breathing

I often suspect that medical numbers are sort of made up.

<a href=”http://dilbert.com/strips/comic/2008-05-07/”><img src=”http://dilbert.com/dyn/str_strip/000000000/00000000/0000000/000000/00000/5000/500/5651/5651.strip.gif” border=”0″ /></a>

I think this exact scenario happens a lot more than we’d like to admit.

It is no measure of health to be well adjusted to a profoundly sick society.

~ Krishnamurti

For once, news about healthcare that seems to be positive. I refer to an article in todays Times about Kendal at Hanover, a nursing home affiliated with Dartmouth-Hitchcock Medical Center way up in New Hampshire.

Kendal at Hanover is apparently not your usual nursing home. For one thing, they apparently focus on giving the elderly a choice in medicine that they may not even know they have: the choice to say “no.” According to the article, the staff at Kendal are very assertive in speaking with residents about the choices they face at the end of life and the implications of those choices. I quote (emphasis mine):

Slow medicine, which shares with hospice care the goal of comfort rather than cure, is increasingly available in nursing homes, but for those living at home or in assisted living, a medical scare usually prompts a call to 911, with little opportunity to choose otherwise.

At the end of her husband’s life, Ms. Gieg was spared these extreme options because she lives in Kendal at Hanover, a retirement community affiliated with Dartmouth Medical School that has become a laboratory for the slow medicine movement. At Kendal, it is possible — even routine — for residents to say “No” to hospitalization, tests, surgery, medication or nutrition.

Charley Gieg, 86 at the time, was suffering from a heart problem, an intestinal disorder and the early stages of Alzheimer’s disease when doctors suspected he also had throat cancer.

A specialist outlined what he was facing: biopsies, anesthesia, surgery, radiation or chemotherapy. Ms. Gieg doubted he had the resilience to bounce back. She worried, instead, that such treatments would accelerate his downward trajectory, ushering in a prolonged period of decline and dependence. This is what the Giegs said they feared even more than dying, what some call “death by intensive care.”

First: the right of patients to refuse treatment. This is a right that I think many patients don’t even know they have. I can’t count the number of times that people have demanded to know why they “have to do this,” only to be totally surprised when I tell them that they have a right to refuse care. The principle of patient autonomy dictates that we should not force treatment upon people who do not desire it, and while we are very good at following this principle most of the time I think we could do a lot better if healthcare providers were a little more aggressive in informing people that they have a choice.

We could also do a little better about talking to the families of those who have been incapacitated. Often, families make a choice that the patient would not want because they are not ready to let go. This is a difficult situation at best, but what the patient wants should come first; the family is an afterthought.

Second: death by intensive care. This describes probably half of what we do in the ICUs where I work. We have a lot of patients who are just in the ICU transiently: septic people, surgical mishaps, recovering heart surgeries, trauma patients, and so on. These people will recover and leave. But we also have a lot of chronic elderly patients who are going to linger in the ICU for several months and then die. We can animate a slab of carbon for quite some time, but just because we can doesn’t mean we should. I can’t speak for everybody, but when I die, I don’t want the last two months of my life to be spent in an ICU. That’s no way to go.

In conclusion: I like the idea of Kendal at Hanover. I think that we in the healthcare industry should follow their lead: we should lay out the fact that everybody dies and then offer people control over the end of their own lives. Pretending that medicine will keep everybody alive forever is only going to make it worse. Mortality is a fact. We can either hide from it or face it head-on, but we will never escape it.

People often ask a lot of general questions about respiratory therapy. I often get asked what I like about the job, what I hate about the job, or what drove me into it. At the hospital, patients (who tend to classify everybody into the category of doctor or nurse) often fail to understand exactly who I am and what I do. I like to explain it like this:

“I’m a respiratory therapist. I help people breathe.” If this is not enough, I tell them:

“Breathing is important. If you aren’t breathing, you’re not going to be doing anything else either.” That usually gets the point across. The veiled implication that if I go away, they might not breathe is often enough to make people cooperate a little more with their therapy.

Breathing is one of those absolutely essential functions that we often take for granted until we can no longer do it. Having been unable to breathe before I can state that it is the single most terrifying feeling in the entire world when you move your chest and no air goes in or out.

But the truth is that breathing goes further beyond other body functions in that we can voluntarily control it. Most body functions are essential, but it’s very difficult to control your glomerular filtration rate or the speed of your digestion. But breathing! It’s a simple matter of brain power to inhale deeply, hold your breath for a moment, and let it go.

The ability to control your breathing (to an extent) gives you a lot of power over yourself. Next time you’re stressed out, stop yourself and take in a very deep breath. Fill your lungs until they feel like they’re going to explode. Close your eyes, hold it for a moment, and slowly let it out through pursed lips. Repeat this exercise a few times, making sure to breathe deeply and slowly. I can’t make you any promises, but I bet you feel a little more relaxed. I’d gamble that your pulse is down, your blood pressure is gradually normalizing, your head is spinning a little less. In a minute or less you’ve calmed yourself down; I know that I can go from a frenzied maniac to a less frenzied maniac with this simple exercise. I use it a lot at work. It keeps me from going completely cross-eyed.

Anger management uses these same principles to tame those raging tempers. As I understand it, one of the steps to anger management is to stop, breathe, and repeat to a count of ten. Anywhere from thirty seconds to a minute have passed by the time you finish, and the forced respirations may have helped calm your body’s natural responses to anger. And for all the effort of a few simple breaths, you’ve dodged that second felony assault conviction.

For all that breathing is also one of the most immediately important body functions. When one stops breathing, especially if one does so in any place other than the safety of the ICU, it is an actual real life-or-death emergency. The cessation of breathing very quickly leads to the cessation of all other activities. After a few years in the ICU a lot of things no longer make my heart pound, but one of the things that will make me sweat and get the adrenaline moving is a respiratory arrest.

Luckily for us, most breathing problems are pretty easily repaired. The insertion of the magic tube means we can breathe for you. Impending arrests can be warded off by vigilant practitioners. Chronic conditions like COPD and CHF can be managed as well as the patients will allow them to be managed with “control” medicines and vigilance.

The bottom line is this: breathing is important. From the first screams of life to the last sigh before oblivion, breathing defines our life. When we can do it well we ignore it; when it fails we plead for it to come back. Being a respiratory therapist is more than passing nebulizers and finding exciting new ways to procure phlegm; it is assisting people with the most obviously vital function in the body.

So next time you take in a deep breath, the next time you fill your lungs with fresh air, take a moment and reflect on it. Be thankful. And as you go about your business, just remember to keep on breathing…and everything else will work itself out.

Content coming tomorrow. Until then: the Respiratory Therapy Cave has an awesome article up about ventilators and the end of life decisions that often come with them. Head on over and take a look.

The lack of content here is due in part to a recent panic at the hospital caused by a highly visible conflict between upper management and RT management that has escalated into a full-blown administrative war. It’s been distracting to me. That plus we’ve had a lack of interesting patients recently.

So to substitute for my own laziness, go on over to Movin’ Meat and read the tale of some ER staff who truly went above and beyond to help out a homeless guy. It’s inspiring, and it reminds me that sometimes people take an extra step and do what needs to be done no matter how horrific it is.

As promised, something funny to compensate for the bitterness. From Basic Instructions, I give you one of my favorite images of all time (click to enlarge):

It’s perfect, isn’t it?

(Image stolen from Basic Instructions without a hint of a scrap of permission. Copyright belongs to the comedic genius Scott Meyer.)

The word of the day today is Polybabydadia, a word which I have stolen without a hint of permission from the ever inventive Panda Bear MD. The rest of this post unexpectedly deteriorated into a bitter tirade, but you should be used to that by now.

Polybabydadia as I see it is the condition of having too many children by too many baby daddies. Its many manifestations are the scourge of our pedi ER, and a terrifying glimpse into the future; after all, the kinds of people who are grunting out five and six kids by as many fathers are not the kind of people who should probably be entrusted with the life of a tiny human being. And as much as I’d love to believe that all the children will be OK and grow up surrounded by love and rainbows and candy ponies, I know that the few of them who manage to make it past age 2 without being suffocated under a pile of jackets at a party will probably just continue the cycle ad infinitum. Every now and then a kid breaks through and changes their life for the better, but the sad truth is that most of these children are just screwed. It’s very depressing to look into the innocent eyes of a child and realize that the irresponsible, empty-headed, soulless pile of carbon who gave birth to them is going to screw their life up forever with neglect and unwillingness to take responsibility for what they have brought into the world.

The only cure that I know of for polybabydadia is mandated sterility, although a lot of people get pretty offended when I say that.  Perhaps we could ward off some of the epidemic by giving out Depo shots and claiming that it’s morphine. It could work; many of the victims of polybabydadia seem to have a habit of chemically enhancing reality to escape from the soulless husks that they have become. Moving the blame to the daddies, we could offer discounts on beer in exchange for vasectomies.

That’s it for now. I’ll make up for the bitter with some funny later.

Now for a break from the usual madness. By way of Atomic Nerds, I found this image:

I am way too amused by this. I’ll be chuckling about this all week.

We all know that I think the Joint Commission is about as useful as a screen door on a submarine. I’ve found that most people who work in actual clinical jobs share my contempt for the Joint Commission because we can see it for what it is; namely, a useless organization devoted to improving patient safety by making it impossible for any clinical person to actually do anything. After all, if we can’t do anything, we can’t possibly harm the patient!

Nurse K over at Crass Pollination shares my contempt. JCAHO has mandated that her code meds must be locked in individual drawers in a med machine down the hall secured by an eight-digit PIN and fingerprint access. That is like making a police officer keep his mace, club, gun, and ammo locked in a safe in the trunk of his car. In a word, it is bullshit.

Go on over and sympathize with Nurse K. The joint commission has struck again. Will they never stop?