Respiratory Therapy 101: Just Keep Breathing

This is awful but I must share.

I saw a new nurse learn a vital lesson in the ER. We had just gotten a patient in from the field who had imbibed a bit too much alcohol after an evening of ingesting a bit too much barbequed meat and other greasy food. The patient had been responsive to EMS but conked out on the ER doctor about five minutes after the ambulance crew left. Because he was a high risk for airway compromise we decided to intubate him.

The new nurse in the ER, a freshly minted graduate nurse with the big friendly GN letters on her badge, was busily placing an IV and taking her time about the dressing, which is a good habit to develop although it is not particularly expedient in the short term. When we mentioned to her that we were going to intubate, she smiled and seemed sort of confused. She continued standing at the patients side, parallel to his knees.

I handed the ER doc the laryngoscope and the ET tube, and she neatly pulled aside the tongue of the patient, visualizing his cords. Looking over her shoulder, everything looked good to me, and she took the tube from me and slipped it in. It looked like a perfect intubation, and as she stepped back we both grinned.

“Well, it’s in for sure. May as well take a listen.” I grabbed the ambu-bag as the doctor leaned in to auscultate the patients lungs.

Before I could attach the bag and the CO2 monitor to the tube, there was a sudden and horrifying lurch. The patient sat bolt upright, eyes wide, lips parting in that particular and awe-inspiring way that lips part before emesis flies. The sudden upright motion startled me and I jumped back, taking the ambu-bag with me. With the polished motion of twenty years of experience the ER doc dove backwards to avoid whatever horrors were about to unfold. Through a combination of deer-in-headlights effect and youthful inexperience, the GN was left out in the open to take the brunt of whatever was to come.

The patient retched and an amazing mix of old beer and barbeque wings came flying out the end of the 7.5 ET tube. Because of the effect of constrained space on fluids under pressure, this emetic stew came flying out with pressures not normally seen in flying vomitus. The GNs expression went from placid confusion to terrified disgust as the vomit, moving in what seemed to be slow motion, spattered her from head to toe, covering her new scrubs and dripping into the little holes in her brand-new Crocs. The patient finished emitting his sickening volley and fell back onto the stretcher with a whumpf, back into whatever alcoholic reverie he was in.

I removed the ET tube and began suctioning the patients oral cavity before bagging him with the mask again. The ER doctor picked herself up off the floor, and the GN stood shaking in a mix of humiliation and disgust.

“What happened?” she asked.

“I’m so sorry, but everyone has to learn someday.” I said. “You must never stand in front of an open ET tube…lest ye face the Wrath of Glob.”

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I did feel bad for the poor girl. She’ll be okay. She took a shower in the OR, sent her scrubs off to be burned, and then was allowed to go home and recover for a while. She learned a valuable lesson and I got a story to tell.

Moving on, a shout-out to kwrenb over at kwrenb’s COPD News of the Day. Kwrenb writes a blog for COPD patients that focuses on COPD and pulmonary-health related news articles and insight. It is well worth a read for curious practitioners or for people suffering from COPD, and it can be found by clicking here. I’ll also be adding her to the permanent blogroll on the right-hand side of the page. Share and enjoy!

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One final note:

Still not as smart as Ambulance Driver. Damn.

As part of my ongoing effort to be responsive to reader input in the form of comments and search-engine hits, I’m going to blather a bit about EMS and CPAP. Anyone who needs acronym definitions, I’ll put them at the bottom of the post. Sorry to “talk shop” so much lately, but I’ll resume the stories at some point soon.
Our Lady of Immaculate Grace is a fairly rural hospital as you may have picked up. We serve a large rural area in conjunction with a couple of smaller community hospitals and one hospital that is larger than us and handles the major trauma. Because of the rural nature of this area, we tend to get a lot of patients who have a prolonged transport time: that is to say, by the time the patient is reached either by rural volunteer EMS or by Backwoods Ambulance, there has been an extensive amount of time chewed out of the “Golden Hour.”

In some cases (such as the all-too-common ETOH-induced “FDGB” cases) the Golden Hour isn’t much of a concern, because the basic medical needs can be met satisfactorily by a paramedic in the field. But in some cases, specifically a lot of respiratory cases, the Paramedics have limited options: intubate or give oxygen. This leaves out a crucial middle step that we often use in house, which is non-invasive positive pressure therapy such as CPAP or BiPAP.

The advantages to non-invasive positive pressure ventilation (NIPPV) or related modalities like CPAP and BiPAP is that they can effectively treat the patients pulmonary malfunctions without the risks of endotracheal intubation. For many older patients with certain permutations of COPD, endotracheal intubation can be the beginning of the end. Being intubated itself is risky because of the amount of sedation required to intubate someone, plus the possibilities of airway or oral damage. It’s rare but it happens. Another risk of being intubated is the potential for infection, and while Ventilator-Associated Pneumonia is on the decline because of a number of new initiatives, it still happens. Finally, many patients who wind up intubated in the field or in the ER become these sort of chronically-ventilated trainwrecks who are difficult or impossible to wean off the ventilator without an extremely aggressive pulmonary staff, something that a lot of hospitals have but which Our Lady and many smaller hospitals lack.

The solution to these problems has become NIPPV, specifically in the form of CPAP or BiPAP. In the ER at Our Lady, we use CPAP and BiPAP fairly consistently with patients who are in respiratory failure or who are headed in that direction with massive success. Many times I have seen patients make a 180-degree turnaround with little more than CPAP and some Lasix, or BiPAP coupled with the standard treatment for COPD exacerbations.

The problem with NIPPV, especially in rural areas like this one (I actually have to carve these blogs on sheets of granite and give the sheets to sherpas to carry into a city with the internet…e-mail involves smoke signals and morse-coded rifle shots) is that by the time the patient reaches the ER, the window of opportunity where NIPPV would have worked is shut and the patient is either dead or intubated. To solve that problem, Backwoods EMS has been trying out a new form of in-field CPAP that uses low-flow oxygen and some sort of pressure device that I don’t fully understand to generate up to 15 cmH2O of CPAP in the back of the ambulance. I can’t tell you how many patients this has saved from the ET tube.

To give one example, EMS recently brought us a CHF patient from about forty miles away, which is a long and tiresome ambulance ride. The paramedics can do a lot to treat CHF: I believe that they can give Lasix around here, and that in addition to some good CPAP is usually all it takes to treat an episode of CHF. Now, before Backwoods was given their CPAP equipment, this patient would have come to us intubated and spent a long time in ICU being “weaned” from the ventilator and developing complications. But because of their newfangled CPAP-in-the-truck equipment, this patient came in the soor breathing easily without a huge tube in their trachea. The patient stayed for a day on the stepdown unit and was discharged to home faster and more safely than if she had been intubated in the field.

In conclusion, it’s my personal opinion that all ALS trucks should be equipped with CPAP. It’s a wonderful treatment for so many things: CHF, COPD exacerbations, and mild respiratory failure jump immediately into my mind. The fact is that CPAP can do all that plus keep patients off the tube, and sometimes that’s enough to save a life in itself.

Acronyms:

ETOH: med-speak for “Alcohol.”

FDGB: fall down go boom

CPAP: Continuous Positive Airway Pressure

BiPAP: Bilevel positive Airway Pressure

COPD: Chronic Obstructive Pulmonary Disease, such as emphysema or chronic bronchitis

Somebody came across this page searching for “pool limp cpr.”

While I hope that people would have the common sense to call 911 if they found someone limp at poolside and didn’t know CPR, experience has taught me that there are thousands of people who would search google for instructions for an hour before calling an ambulance.

What a world.

The title is misleading: the advent and primary experimentation with liquid ventilation was far before my time as an RT. Nevertheless, I find myself nostalgic for it.

Liquid ventilation is the pouring of a special liquid into the lungs. The liquid can either fill the lungs totally (total liquid ventilation) or partially (partial liquid ventilation.) The liquid used is a special perflourocarbon that facilitates the transport of oxygen and carbon dioxide, but beyond that my knowledge of the specific chemistry is pretty bad.

How it worked was like this: you’d get a patient with an acute lung injury (ALI) such as an enormous pneumonia, a DROF trauma (my teacher always said “suspect lung contusions if their chest spells FORD backwards) or some other sort of pulmonary insult. Typically the lung is injured somehow and becomes divided into functional lung units and nonfunctional lung units, giving rise to a condition that can mimic a big pneumonia and which impairs gas exchange. After a certain point ALI becomes Adult Respiratory Distress Syndrome, or ARDS, which is helpfully defined by Steven A. Conrad MD/PhD on eMedicine:

“Background: Adult respiratory distress syndrome (ARDS) is a diffuse pulmonary parenchymal injury associated with noncardiogenic pulmonary edema and resulting in severe respiratory distress and hypoxemic respiratory failure. The pathologic hallmark is diffuse alveolar damage (DAD), but lung tissue rarely is available for a pathologic diagnosis. Therefore, diagnosis is made on clinical grounds, according to the following criteria set forth by the American-European Consensus Conference:

• Acute onset
• Bilateral infiltrates
• Pulmonary artery wedge pressure less than 19 mm Hg (or no clinical signs of congestive heart failure)

• PaO₂/FIO₂ ratio less than 200 (ARDS) or less than 300 (acute lung injury [ALI]): ALI is a milder clinical expression of the injury of ARDS that may or may not progress to ARDS.” 

Once a patient is in ARDS, they become difficult to ventilate properly. Often we resort to high levels of Positive End Expiratory Pressure (PEEP) or to inverse-ratio ventilation or even HFCWO ventilation, which as I understand it is a mystery in action. ARDSnet has a ventilation protocol which suggests high-rate low-volume ventilation to prevent alveolar trauma from the constant pressure of opening and closing.  These strategies often work well enough, but often times they don’t. So some guy thought up liquid ventilation.

Basically, you take this liquid (Perflubron was a popular one) and pour it into the ET tube. You can either fill the patient up with liquid (total ventilation) or fill them about halfway up (partial ventilation.)  A special ventilator attachment is placed in to circulate the fluid, scrub the CO2 and add in enough O2 to ventilate and oxygenate the patient, similar to an ECMO machine except in the lungs and not the bloodstream.

This had a lot of advantages in ARDS-style situations: for one, you avoided the constant pressure placed on the alveoli by the repeated blasts of high pressure needed to achieve opening pressure. You can avoid the circulatory problems created by high levels of PEEP, and for all that you get decent gas exchange in the functional lung units and a reduction of additional insults to the traumatized areas of the lung.

Plus, it was really cool: you got to pour liquid into peoples lungs, and it didn’t count as trying to drown them. Is it just me, or does everyone secretly want to get to do that?

It always amazes me that we let some people go home with certain drugs. In the area where I practice, we get a lot of patients who are frankly just stupid, and many of them wind up discharged home on heavy painkillers or antipsychotics, which they are allowed to use with minimal supervision. Now, maybe I’m reading this wrong: maybe it’s not just poor decision making to let these people take home their drugs. Maybe it is actually part of a larger plot to get rid of all the stupid people and make it look like an accident. I guess I’ll never know, but either way I have some good anecdotal evidence that these people should not be taking narcotics home.

Just a few weeks ago, we got a case in the ICU that perfectly illustrated this point. The patient was a 35-year-old female from a tiny little township to the west of the town that Our Lady of Perpetual Grace resides in. She had been brought in by Backwoods EMS after a long run that included the ambulance getting stuck in the mud and needing a tow after the patient vomited all over the back of the rig while being intubated.

The call had originated when the patients boyfriend called 911 in a panic after she passed out in front of him for “absolutely no reason whatsoever.” Her only prior medical history was chronic back pain, no seizure disorders or neuro problems. Why would she just pass out all of a sudden for no reason? The ER staff were perplexed until her recent medical records were obtained and it was revealed that she had recently been placed on the Fentanyl patch. Hmm…

Armed with this evidence we searched her body, a horrific task. No patches were found. The police came in with the boyfriend, and between their tactful questioning and the ERs skillful medical team we were able to ascertain the truth. As it turns out, earlier in the day the happy couple had been having a bit of an argument.

What had happened was this. The patient had produced her box of Fentanyl patches and was about to affix one to her skin when her boyfriend had an excellent idea: why didn’t they scrape the fentanyl off the patches and freebase it? Then they could both get high, she could say she lost the script and get a refill. The patient said no, she wasn’t sharing and her back hurt anyway, and the argument escalated almost to physical violence. Things were thrown, threats were made, and the patient–being of a higher intellectual caliber than most–decided that in order to prevent her boyfriend from freebasing all of the fentanyl, she would eat it.

Yes. She would eat it.

So, she opened the box (shouting obscenties all the while no doubt) and devoured all of her fentanyl patches. I believe that the patches come three to a box, and each patch is good for 72 hours. Do the math on that and the patient has eaten nine days worth of fentanyl in a little less than a minute. I can’t imagine doing this: fentanyl can’t taste very good, and the platic patches must be a bitch to chew. But I guess desperate times call for desperate measures…

Anyway, the patient passed out and almost died. I’m not sure why she was breathing at all when the EMTs arrived: she should have been long dead and gone with that much fentanyl on-board.

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I’d like to say that this is an uncommon thing, but not a week after this patient came in–while she was in the ICU, in fact–we got another similar case. A couple of kids had been able to get their hands on some patches, and one kid came in all narced out after licking the back of half of a patch. This raised the question of where the other half was and who was licking it, but I’m sure we’ll find out soon enough.

To wrap this up: I think it’s safe to make a few conclusions. Number one: stupid people should never be given narcotics. I don’t know what they would get for their “chronic pain” or whatever, but I suspect that a lot of chronic pain is overblown and used as an excuse to get drugs and attention. Number two, if stupid people are given narcotics, they will abuse them and generate work for an already taxed system. And finally, number three, people will eat anything…even plastic narcotic patches…in the midst of a heated altercation.

Mielikki has some similar musings over at First Do No Harm.

I don’t know what it is about Nursing Homes. Maybe it’s their difficulties in staffing appropriately, maybe it’s the fact that Nursing Home directors are the cream of the crap, or maybe it’s an ancient mummy-related curse. Whatever the reasons, all of the nursing homes that Our Lady takes patients from are total pits that no human being should ever be placed in. Ever.

Last night, Backwoods EMS brought us a patient from the local home known as The Manor. The patient was an unresponsive 85-year-old female. As usual, the nursing home staff claimed that the patient had been “fine” an hour ago but that she had just been found in her current state by an aide.

The patient was a large and sort of doughy lady. She had that old-lady frizzle-top of gray hair and the ubiquitous skin flaps that seem to develop on more rotund people with age. She was conked out on the stretcher, eyes half open, drool spilling from her mouth into the O2 mask. Her arms lay limply at her sides and she had that six-foot gaze at nothing, a good sign that the lights are on but nobody is home.

I stood near the head of the bed as the patient was transferred from the paramedic’s stretcher to the ER bed. The ER nursing staff buzzed around, pouring fluids into IVs and rubbing the lady’s sternum vigorously to no avail. The ER doc shone a flashlight into the patient’s eyes and thought for a moment.

Her breathing was alarmingly slow. Not quite agonal, but very bradypneic. The ER doc ordered the usual battery of CT scans and blood draws. Because her breathing was concerning, he asked me to obtain a blood gas. I eagerly complied: ABGs are one of my favorites.

As I ran the blood gas upstairs in the lab, I pondered this case. What could be causing this lady’s problems? She could be stroking out, or she could be overmedicated. Maybe we had missed a narc patch somewhere on her skin. Maybe it was respiratory failure. I looked at the screen of the blood gas machine, and the answer was right there. In with her pH of 7.31 and her PaCO2 of 60* there was a blood sugar value of…14. This is a severe aberrance from the normative value of 100.

I picked up the phone and called the ER to report in. An easy enough problem to solve, or so it would seem. The ER nurse on the case thanked me and hung up, and I ambled downstairs to see what would happen next.

The ER doc ordered some glucose for the patient and then began to review her records. Much to our alarm, this patient did not have diabetes. Why, then, was her blood glucose so lethally low?

This question was answered shortly when Backwoods EMS brought us another patient from the same nursing home, an old diabetic man whose blood glucose was up in the 400’s and who was having some shortness of breath and tachypnea.

It turned out that this old man was in a room next to the room of this old lady, and he was an insulin-dependent diabetic. On closer examination of their respective charts, it appears that whoever was doling out the meds at this nursing home had given the old lady the massive dose of insulin meant for the old man. I’m not sure if the rest of their meds were inverted or not; I got paged and I had to leave the ER before I could find out.

This did not end well. The old lady didn’t fully recover and got admitted to the ICU, where she actually wound up dying a few hours later. An inquest will determine whether the accidental administration to her of insulin meant for another patient of another gender in another room was what killed her. The old man wound up admitted to the medical floor.

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So, in summary: one woman is dead and one man is ill because a nursing home gave the wrong med to the wrong patient, who had a totally different name, gender, and room assignment from the patient who was supposed to get the med. This is criminal negligence, not to mention the astonishing and soulless apathy and carelessness needed to make a mistake like this. Heads need to roll. Hospital admin has been contacted; angry phone calls have been made to the nursing home.

Amazing.

*(Edited! Miss Fuzzy [below in the comments] caught an error on my part. These numbers indicate an acute decompensation, not a partially compensated decompensation as I had previously written. I blame sleepiness for that particular error and I thank MF for pointing it out.)

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In other nursing-home related madness, GruntDoc has a post about a new practice in his areas of MARs being sent along without the time of dosage on them. What the hell, nursing homes? What is your problem?

I thought I had seen some disgusting things in my day. After all, I work in an environment where I am surrounded by sickly people, many of whom will attempt to coat me in their horrible bodily fluids. Sometimes I must work with people whose hygiene skills are…who am I kidding? They have no hygiene skills. I mean, some of my patients are growing yeast in their disgusting doughy folds. Some of them haven’t bathed since the Nixon administration. Others sit in vile pools of their own filth, wallowing in their horrific excrement, marinading in a hellish sauce of doom or sometimes skating around in it.

But even considering all of those horrible things, it would seem that Dragon Laugh (link warning: horrible, disgusting, and yet strangely amusing story under the link) has managed to top everything I have ever experienced. She even made me come up with a new “disgusting” tag just for this post. An excerpt from the original post:
“So, here’s the scene: You’re sitting at your desk with an oaf of a woman damn-near plastered to your side, and she stinks. You lean away a little bit, trying to be casual about your search for fresh air. She leans in, towering her sweaty bulk over your shoulder and head. The more you casually lean away, the more she comfortably leans in, until you’re as sideways in your chair as you can get without falling, and save for her feet being planted on the floor she’s in your lap…

Imagine someone following around a dog bloated from a steady diet of beans and boiled eggs, scooping up the inevitable foul explosion, and eating it. Daily. That is what her breath smells like. Further, it’s no little waft that drifts by your nose on occasion; this woman is a full-fledged mouth-breather, and due either to her weight or some anatomical oddity, she’s also a hard breather.  “

These are fairly mild excerpts that I found funny for whatever reason. The story goes on, and it is amazing what the woman in the story does: letting off warlike cries in the public restroom, leaving fluids and discharges on surfaces, and experiencing a total failure to comply with the basic laws of cleanliness. I feel for Dragon Laugh…the only word I can even come up with is “horrible.” I’ll link to the original one more time so you can go experience it for yourself. It is amazing.

Original content later.

I found a fun little blog-rating toy on UroStream just now. Apparently, I’m NC-17 because of my frequent use of words like Death, Assholes, and Hell. Who knew?

Mingle² - Online Dating
The same site that offers this tool also has a handy-dandy cadaver-value calculator, a coffee addiction test and a test to rate your likelihood of surviving a zombie attack, which is something I worry about every time we get another undead nursing home patient.

There was a code blue tonight. I made the mistake of being first on-scene except the floor nurse, who…as many (many, not all, nurse readers!) floor nurses do in codes…was too busy staring at the dead guy to remember to do things like get the code cart or initiate CPR. Since I was the first non-floor-nurse responder on the scene, I had to open this guys airway.

It wasn’t what I expected. I tilted his head back in the classic sniffing position/head-tilt-chin-lift position and pried open his mouth. Often, the mouths of code patients are filled with stuff: blood, vomit, dirt, and sometimes more bizarre things. I’ve even pulled tube feeding out of airways, which usually indicates some sort of problem somewhere. But this one surprised me.

I opened the patients mouth and in it was a vast pool of thick, strawberry-colored and strawberry-smelling goo. I looked around. There were no cans or bottles of any sort laying around, and the patient didn’t have any obvious signs of having eaten any food lately. I grabbed a yankauer and began to suction. What the hell was it? Vomit is rarely so sweet.

It turns out that the patient was scheduled for a barium study at some point in the near future, and that he had been given a large can of strawberry-flavored barium to drink. Since barium, even strawberry barium, is nasty…the patient threw up. Sadly, he did it while lying down, and then it got stuck in his throat and he choked and died. And then I got it all over my gloves and my equipment. Yuck.

On the bright side, never before has a death smelled so sweet. It was actually sort of pleasant.

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On an unrelated note, MedicMarch from Movin’ Meat has a hilarious story about paint thinner and stupid people. Go ahead and check it out: I laughed out loud, and I never ever laugh out loud. Nice story, Medic!

A shout-out to Vitum from Vitum Medicinus, the newest addition to the RT 101 blogroll! His recent comparison of the relative merits of medical school and incarceration is hysterical, and the rest of his blog is pretty funny as well.

I’ll have some more fun and enlightening RT stories soon, but right now I haven’t slept in way too long and if I don’t get some shuteye soon I’ll pass out. Thanks to everyone for their interesting comments on Terminal Wean; I’m glad you can see where I’m coming from with that story.

More later. Sleep now.