Respiratory Therapy 101: Just Keep Breathing

I’ve stumbled across some more interesting medical blogs that are much wittier than this one will ever be, and in an effort to siphon some talent from them I’m adding them to the blogroll here.

Of note, Ambulance Driver from A Day In the Life Of An Ambulance Driver has chronicled his attempts to reel in that nefarious criminal mastermind whose deeds we all have heard of: Sumdood. I have seen the many works of Sumdood in the occasional stabbings, shootings or beatings that rolled through the ER doors on some of my float shifts at Big Hospital, and Ambulance Driver almost caught him. Someday, AD…someday.

I have also linked to Emergiblog and madness: tales of an emergency room nurse. Anybody out there who’s never read any of these three bloggers (or any of the other myriad ones in my tiny blogroll) should go do it now, because they’re brilliant.

This is a question that was posed to Google, that somehow wound up leading somebody to this website. I think it’s a fair question. Most people have probably never even heard of a respiratory therapist because we are typically lost in the sea of white coats. Even some of the nurses I have worked with don’t understand what we do; a few have mistakenly believed that RRT is synonymous with CNA. Their misperceptions have been corrected.

Respiratory therapists as a group spend a lot of time with people whose breathing is dangerously abnormal. This is an important thing to do because if people are not breathing then they will probably not be doing very much else.

The first thing RTs typically do to patients is to assess them. Reading through their charts, looking at lab values such as pulmonary function studies and blood gases, and actually listening to and examining the patient are all important. You can learn a lot from breath sounds, lab values, general appearance and other clinical signs. Assessment is important because if you don’t know or understand what is wrong with your patient, then you cannot possibly hope to fix them.

After assessment, RTs treat. Some hospitals (typically larger hospitals) have Therapist-Driven protocols, which allow RTs to independently assign treatments to patients who are placed on the RT service. Smaller or less “with it” hospitals still have physicians writing orders that RTs are to carry out. On the medical floors, there are a lot of treatment modalities. We do everything from nebulizer treatments to chest physiotherapy to breathing exercises with our patients. We draw arterial blood samples to analyze how well a patients breathing is working. Sometimes we do bedside pulmonary function studies, or assist with metered-dose inhalers.

In emergency rooms and at in-house emergencies like cardiac arrests (the infamous “code blue!”) we respond and assist with everything from the early stages of CPR to the intubation and ventilation of patients whose breathing has ceased. In intensive care units, we run ventilators that keep people breathing while they are unconscious or too sick to breathe on their own. We use CPAP and BiPAP to assist peoples breathing in less-invasive ways. In some places, we insert chest tubes and arterial lines. It is a job that can be dull and routine one moment and then code-red screaming panic the next.

My advice to anyone considering being an RT? Find someone near you who is an RT, and ask to shadow them for a day. You’ll need to sign some privacy papers and some release forms and stuff, but then you’ll get a chance to observe the everyday life of an RT in action.

That being said, it might be more fun to try and shadow at a larger hospital. Most of my days at Our Lady of Immaculate Grace are spent sipping coffee and hoping that the hospital doesn’t go under before the day ends, but that’s life for you in an underfunded rural hospital. Don’t get me wrong, though: life as an RT is great, and the job can be the most rewarding thing you’ll ever get a chance to do. If you’re interested, try it out. I like my job, and so do most other RTs out there.

For more information, check out the AARC’s website. It’s a good resource for learning more!

I made a post but WordPress accidentally ate it. So I’ll have to try again later because I’m out of time to write right now.

In the interim, I’m going to add Lucid TV to my blogroll. Today’s comic is especially funny, but their stuff is always high-caliber entertainment. Enjoy!

I guess that the people of Holland have been running out of ideas for game shows to a greater extent than I had thought possible. I was reading through the BBC News this morning (for that distinctively English take on things) and I came across this article about a new game show in Holland entitled “De Groot Donor Show,” which seems to mean “The Great Donor Show.”

The show works like this: there is a terminally ill 37-year-old woman, identified only by a pseudonym, who will be placed before a panel of people who need a donor kidney. She will ask them questions about their lifestyle and their personal histories, and she will converse with their family and friends. Audience members will be able to send her advice via text-messaging, and then at the end of the show she will decide who should get her kidneys when she dies. Seriously! I couldn’t make this up even if I tried.

The network that is running De Groot Donor Show has apparently come under a lot of fire for this, but they claim to only be doing it to draw attention to the shortage of organ donors in Holland. This is another compelling statement that the shows producers are making, which I have stolen from the BBC article:

“The chance for a kidney for the contestants is 33%,” said the station’s current chairman, Laurens Drillich. “This is much higher than that for people on a waiting list.”

He makes a good point. I guess if I was on a waiting list I’d take my chances with the 33% regardless of the potential for public humiliation.

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Also on the BBC today was an article that I found interesting. According to the European Respiratory Journal, the consumption of apple juice may be linked to a lower rate of asthma exacerbations. Apparently, the “phytochemicals” in apple juice have an anti-inflammatory effect that helps to reduce the incidence of acute asthma attacks. I see Apple Juice Nebulizers in my future…

I have long admired Scott Adams, creator of Dilbert and extraordinary observer of the human condition. Today on the Dilbert Blog, he gives his perspective on peer-review. Here is one thing he had to say that hit home quite hard:

“Assuming scientists are human beings, it seems to me that most peer reviewers would fall into one of these categories:

1. Asshole
2. Biased egomaniac
3. Nice person who doesn’t want to make people feel bad
4. Too busy to put any quality thought into it
5. Person with low self-esteem who doesn’t want others to succeed in his or her field
6. Coward who doesn’t want to rock the boat.”

How many people have you all worked with who fit into more than one of these categories? One of the pulmonologists I used to work under was an biased, egomaniac asshole who didn’t want to see anybody else succeed. He actually went so far in his pursuits as to dismantle our therapist-driven ventilator protocols and replace them with his own standing orders, which were some of the most medically illiterate things I had ever seen in my life. He was the type of guy who would order us to reduce tidal volume but refuse to let us up the respiratory rate (the net effect of which is to diminish minute volume), and then he would wonder why the patients CO2 levels were rising.

What’s really amazing is that he was able to get away with this because the other physicians who worked with him filled in the other categories: there was the nice guy who didn’t want to hurt any feelings and the coward who didn’t want to make waves. I asked my boss if he would talk to the biased egomaniac asshole, but he was too busy to ever do it, and so nothing ever got done. With our all-too-competent and highly motivated team being supervised by those four people, I’m amazed that we ever managed to treat patients without killing them or getting sued.

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Last night I was sitting in the blood gas lab hiding from my obnoxious co-worker, when much to my surprise there was a knock on the door. This rarely happens: other RTs will simply burst in screaming, and the nursing staff have yet to realize that this is where we go to avoid them. I opened the door and saw Nurse Lynn, who is a very small nurse. She wanted to know if I could come out on the floor and “help them with a combative patient”. Apparently the entire hospital security staff was busy with a flood of inebriated combative people in the ER, and the floor staff desperately needed some help. Because I’m a sucker, I agreed to see what I could do.Lynn led me to the room of the difficult patient in question, and before I entered I heard not only the abusive shouting and yelling of a struggle, but a horrible splattering noise, which raises an automatic red flag when you work in a medical facility. Splatters are never, ever a good noise in a hospital. There is no conceivable way for a splatter to be a good thing in a medical facility ever. The closer I got to the room, the more apprehensive I grew. I’m not trained for combat. I’m a total wuss. I may as well be made of balsa wood, and realistically all I can do in a fight is act as padding between two sparring parties. These thoughts plus an astonishingly bad odor emanating from the room made me begin to wonder what the hell I was doing.

But I swallowed my fears and walked into the room, and the situation is this: There are two aides and an RN named Penny holding onto a 70-plus year old man, who despite his age and the fact that he was the size of a toothpick was ridiculously strong. There was a hideous river of gray and brown substance all over the floor. It had spattered on the walls, the curtains, the bed. Nurse Penny is losing her footing in this river of shit, and the patient has her by the forearms and is steering her around in a veritable lake of stool. For a moment, it looks as though they are involved in some hellish ballet: he is the hero, and she is the villainess, and he is trying to push her into a vat of excrement.

Immediately I knew that this was a bad situation. The patient is confused and unstable on his feet anyway, but because he is attached to three staffers and a swinging IV, if he were to take a fall he’d probably bring down one or two of the staff with him. I donned a pair of gloves and grabbed the guy by the right arm and shoulder in an effort to stabilize him before he pushed Penny or one of the aides over. Someone went to get a “geri-chair” (illegal but still in use at my hospital–rules are for wimps and commies here) while the crazy man continued to push people around in his own shit. Fortunately for me, I was at the foot of the bed and to his right, which was the only clean area in the entire room except for a small square near the door that was miraculously spatter-free.
“Geri-Chairs” (also known colloquially as bad boy chairs) are devices of restraint. The chair is comfortable with padded leather cushions and a wooden table that folds over the legs to effectively restrain someone without using wrist restraints, harnesses or chemicals. it is also on wheels, which comes in handy to move the patients in the bad-boy chair. And aid who was dispatched to find one of these lovely devices finally returned with a security guard, a huge guy with a tiny moustache. Between me, Penny, two aides, and the security guard we were able to maneuver the guy into position to place him in the chair. All was looking well, and just before we got his ass in the seat…he jumped!

That’s right. He jumped. Somehow, he was able to put his feet up on the chair and leap to freedom, like some sort of elderly Poo-Dini. He teetered high up in the air on the back of the geri-chair, which sent it wheeling forward into my feet. Fortunately, my feet are huge and my shoes are well treaded, and the chair stopped moving at the relatively small expense of my toes. Simultaneously, all of us reached out and grabbed on to some part of the patient, because if he fell from that height and bonked his head, there’d be trouble. More to the point, there would be a great deal of paperwork.

After some excessively difficult maneuvering, we were able to get poo-dini into a basically sitting position. Security had the unenviable task of holding the crazy mans shit-covered legs down, and I had a firm grip on his shoulders. Someone pulled the table down over the guys legs, and the patient…still confused and babbling angry nonsense about strange things…was wheeled out to the nursing station.

I joined the queue at the sink, where much vigorous hand-washing and scrubbing of shoes was going on. There was an eerie quiet as we all paused, cleaning ourselves off. A sudden cry pierced the silence from the direction of the Geri-Chair: “I need a little help over here!” I turned to look, and the aide who was left in charge of the patient was staring in horror as the man put his legs on the table and began to stand, screaming war cries at us all and yelling warlike obscenities. This was growing tiresome.

There was another brief struggle, after which we were able to get the guy to stand still. He stood in the middle of a circle of staff, his backside periodically spurting out horrific fluids and his former IV site dripping blood onto the floor. After all of this, the mans PCP was unavailable and the hospitalist on-call hung up on us because it “wasn’t his patient.” We finally got the ER doc to come up and write some orders for Haldol, which he refused to order PO for some reason so we had to restrain the man again while the unfortunate Lynn tried to start an IV. After a few minutes of WWE-style mud-wrestling from hell, we managed to get an IV in him and get some Haldol into his system, which mellowed him out enough that he was content to sit in his chair and call us all a bunch of goddamn reds over and over.

I returned to the scene of the crime. The floor, walls, and bed of that particularly unfortunate gentleman’s room were still covered in horrific substances. To combat the stench I placed a dab Vicks Vap-O-Rub under each of my nostrils. The aides and nurses concerned will probably have to burn their shoes; they were pushed around in that horrible poo in manner reminiscent of the Ice Capades from hell. It was like a Disney production that was managed by a guy on a bad acid trip. The next morning, when day shift finally arrived, their morning-people senses were activated and they had an acute sense of something being wrong. I don’t know what tipped them off, but I suspect it was the lingering odor in the hallway and the continuing verbal abuse pouring forth from the patient.

“How was the night shift for you? And what is that smell in the hallway?” they asked me. “It smells like somebody died really bad.”

I tried to think of the best way to respond. The best I could muster up:

“I got a front-row seat at the shit capades.”

Evidently, the reason that Poo-Dini had gone so crazy was that his mild dementia had been exacerbated. Because he was being colonoscopy-prepped for a procedure the following day, he had been given the better part of one of those enormous jugs of Go-Lytely, which had totally failed to maintain his ‘lytes properly and had driven him mad. C’est la vie.

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Just a short aside: I was inspired by a post over at Legal Antics in which the author asks people to tell people about her blog. The author, NBlack, says:

“If you like what you read here at Legal Antics, I implore you, dear readers, to let your friends know about my fledging blog. It would be absolutely fabulous if you’d share the hilarity of this fine blog with 5 friends. Do it now, por favor! Email this post to your friends, share it on Facebook or MySpace, book mark it on delicious–the possibilities are endless. I don’t care how you do it, I just respectfully request that you do it! It would be most appreciated.”

I will respectfully oblige. Legal Antics is hysterical even for us non-lawyers, and I’d recommend that people go and check it out. Also, I’ll repeat the request on behalf of RT 101: any readers out there who enjoy the madness here at RT 101, please feel free to spread the word. My internet-ego needs attention, and anyone who’s willing to give me a mention on any networking page will forever be in my heart. I’ll even promise to be nice to you if I ever see you in RT-land.

Stories will resume later.

I remember doing my student respiratory therapy work way back when I was but a wee lad. I was assigned to one of the larger hospitals in the area, which was very exciting for me since most of my contact experience to that point had been in smaller suburban hospitals. The Big Hospital had a lot to offer students: interesting cases from all over the state, brand new technology, staff people who were smart and willing to teach, and a spectacular cafeteria made every day at The Big Hospital well worth the hour-plus commute.

The amazing cafeteria at The Big Hospital had a rather nice coffee bar set away in one corner of the cafe. They had a wide selection of urns full of flavorful blends to choose from, and they also offered a variety of creamers and sugar products to mix in if you so desired. For a 12-ounce cup, the price was unbeatable at a dollar fifty a pop. Since I was following respiratory therapists around, and since my classmates and I were all trendy college students, the drinking of coffee was nothing short of a daily ritual. At morning report everybody had a cup, and during the day people would sit and sip in the cavernous respiratory supply room that was located between the five ICUs.

The Supply Room was a perfect place to go and hide. Nurses and other persons of a Non-RT nature did not know the access code, and the supervisors seldom would wander through. If they did wander through, there were rows of shelves to hide in and columns of ventilators to busily pretend to be inspecting. All of this made it a perfect place to go hide for fifteen minutes while drinking a cup of coffee. Of course, between the electronic leashes assigned to all the therapists and the hectic pace of ICU living, people often had to abandon their coffees mid-break. All of this seemed normal to me, and I did not see any problems with the system whatsoever. Until one fateful day…

One of my three patients was being taken to some other part of the hospital for some sort of procedure. Normally I would have loved to go on a transport across the facility, but the Float RT didn’t want a student on the transport and my other patients were sufficiently interesting for me to want to stay in the ICU. What the Float RT did want, however, was some help in readying this intubated and ventilated patient for the ride. As I watched the nurses and the techs pull sheets and straighten lines, Float RT looked at me and gave me a command.

“You there, Student Man. Do something useful and go and get me a transport ventilator.”

Being a young and naive student, I was terribly excited at this prospect. The transport ventilators at The Big Hospital were smallish, laptop-computer sized ventilators that had a convenient carrying strap so that you didn’t have to push an unwieldy wheeled ventilator around behind a moving bed while trying not to extubate your patient, which is always a fun challenge. The transport ventilators were stored in a row underneath a shelf used to repair things, and they stuck out just a few inches from under the shelf so that they would be easy to grab. Reaching across the shelf to grab the ventilator, I noticed a few things out of place.

First, the room was eerily quiet and empty. None of the usual crowd were around, and the room was hauntingly still. A few chairs were pushed back in disarray and coffee cups were precariously perched on top of things, giving me the impression that the RTs on break had been forced to leave in a hurry for some reason.

I would have stayed and reflected on the implications of this but I was in a hurry. Continuing to look at the mess left behind by some of my hurried compatriots, I grabbed a ventilator by the shoulder strap and pulled it up, hoisting it into position like a man-purse or a messenger bag. And then I heard the noise.

The horrible, unmistakable splattering of liquid hitting a tile floor. I felt the warm sensation of something horrible leaking into my shoes, and as I looked down in terror, I saw the source of all this badness.

A river of coffee was dripping out of the ventilator. The 20,000 dollar brand-new transport ventilator that had just come in a month before. The piece of equipment that I had been sent to obtain. My studential mind reeled. Did these new ventilators have some sort of coffee-making feature in them for thirsty RTs on the run, and had I somehow activated this feature? Had the machine come to us with a terrible caffiene addiction that nobody knew about? A more likely theory came to mind as I put together the scene of disarray, the overturned stool near the shelf, and the empty overturned 20 ounce coffee cup that was conveniently positioned over the edge of the shelf and which was still dripping out its sweet brown nectar into the cooling fans of the transport ventilators below.

As I pondered this situation, the door to the supply room burst open. Day Shift Supervisor, a large bearded man who spoke at a volume usually reserved for very angry drill instructors, stomped in. “What is taking you so long? Float RT told me to come check on you and make sure you weren’t dead or something, and…oh…my…God…” He looked me up and down, taking in the coffee puddle on the floor and the drips coming from the ventilator, observing my coffee-stained lab jacket and my terrified expression. His face began to get redder and redder. Fearing for my life, I tried to squeak out a denial of responsibility, but Day Shift Supervisor turned and stalked out of the room. Later, I would learn that he called an RT meeting and screamed and hollered for a frighteningly long period of time.

Not knowing what else to do, I replaced the ventilator in the rack and got an undamaged one. I returned to the ICU and then asked to go get some scrubs to change into. I never got too much flak for the incident with the ventilator, which honestly surprised me since all available evidence would have supported the conclusion that I maliciously dumped twenty ounces of hot coffee into a ventilator’s fan.

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First and foremost, I’d like to thank the Williford blog (my thoughts) for linking back to me. The author of that blog is enrolling in RT school to embark on a new career; best of luck to him as he joins the ranks of the white-coated. Also hello to everybody from Hell On White Clogs, and I hope you all have been enjoying the blog.

Moving on, an excellent story from the hallways of Our Lady of Perpetual Grace. In an effort to reach out the The Little People, the CEO of our hospital came down for a visit with the staff to discuss some of our morale problems and explain to us why all of the money for equipment and salaries had gone to the remodeling of the admin building. The visiting of the little people by the CEO is a remarkable event because in our hospital there is a caste system: the upper caste is the administration and their squads of support people, the middle caste is filled with the janitors and the people who clean up after the orgies that administration holds in their wood-paneled leather-furnished office suites, and at the bottom is the untouchable caste, those of us who deal with the actual patients.

So naturally, when someone from the upper caste decides to grace us with their presence, we go like the peons that we are supposed to be. In addition to the joy of meeting upper management, we also get free donuts. Moving like an elephant among a flock of ducks, the CEO waddled and huffed and puffed his way through the many halls of Our Lady, nodding at the Little People in their colorful scrubs and acknowledging in a more meaningful sense the managerial staff and those physicians who hadn’t yet threatened to kill him. After a lengthy processional, he finally reached the conference room stuffed full of anxious people awaiting their donuts and their leader. As he entered the room to the sound of applause muffling our mumbled threats, he looked for a place to sit and set his eye on one of the aging chairs that us little people are given. With a spectacular “Ooof-dah!,” the CEO flopped down in this most ancient swivel chair.

Before continuing, it is important to note that the CEO had told our managers to tell us that we didn’t have the equipment we needed because the capitol budget had been stretched to a breaking point. The previously mentioned remodeling of admin and fiduciary misconduct by the executive compensation committee had left us with little cash for needed supplies such as saline and band-aids. Among the things we had desired were new lab equipment, new beds for the patient, and new chairs for the staff that don’t threaten to damage your reproductive abilities when you sit down.

Back to the meeting. Because the swivel chair was approximately 20 years old and had survived a long and abuse-filled career, and because the CEO is a tad hefty, when he sat down a number of things happened. An unsettling creaking filled the room. The CEO began to list, and with a sudden look of fear and panic he lurched forward to try and regain his balance. At that exact moment there was an enormous SNAP and the CEO tumbled backwards, ass-over-teakettle, legs in the air and he hits the ground with an enormous THUD. In between the peals of laughter in the room and the shouts of “Man overboard!” and “Beached whale!,” my favorite supervisor in the entire world smirked, looked at the CEO, and said:

“Does this mean we can have the capitol budget for a new chair now?”

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I know that Suicide is not laughing matter. It’s a serious problem, and having seen a couple of my friends make serious efforts to kill themselves, I’m not immune to the sadness of it. But sometimes, it can be a funny thing.

The patient I am thinking of was an unfortunate forty-ish year old lady who had a terminal form of cancer. Not quick-terminal, but one of those “six years of agonizing pain as the tumors consume your flesh” cancers. After several months of excruciating pain, she had decided she wanted to die. And who could blame her? I’d probably feel the same way.

The problem was that none of the typical suicide modalities appealed to her. Firearms? Naaah. Arterial gore-spurting wrist-slashing? No, not that either. Overdose? Been there, done that, failed. After a while of thinking, she decided to drown herself. She was alone in the world: she had no family and she didn’t want to trouble her friends, so she called her Oncologist and left a message with her answering service stating that she wanted to die and was going to go kill herself. For reasons unclear to everyone in the entire world, the answering service didn’t seem alarmed by this and failed to notify anybody. Evidence suggests that they are stupid. Moving on.

She drove her car to the lake and got out. The moon was full and semi-obscured with clouds, as would befit such a gloomy scene as a suicide. For dramatic purposes and suspense, I will now cut time to the following morning.

The Oncologist walked into her office and plunked down her bags. She sat in her big easy chair and called the answering service to retreive her messages from the previous night. I imagine that the dialogue went like this:

Answering people: “Mr. Thomson needs more meds, Mrs. Jacinte needs a follow-up appointment, Mrs. S said she was sick of life and wanted to end it all and the pain would be over soon.”
Oncologist: “I’m sorry. Did you just tell me that one of my patients left you a suicide message? Did you…call anybody?”

Answering people: “Well, she said it wasn’t an emergency.”

Understandably, The Oncologist flipped out. She called 911 and had an ambulance dispatched to the home of her patient.

The EMTs arrived, gained access to the house, and found the unfortunate woman curled up in a ball on the floor, sobbing. She was soaking wet, wrapped in a towel, completely distraught.

She told them that she had tried to drown herself….

…but that she couldn’t hold her breath long enough.

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