Uh-Oh July 31, 2007
Posted by keepbreathing in health, health and wellness, interesting, links, medicine, respiratory therapy, weird.2 comments
Freakonomics today reports that there is a new study out from the APA that was designed to test whether there was any connection between anger and lung function. Apparently there is a correlation:
“The data pool consisted of 4,629 healthy adults between 18 and 30, living in Minneapolis, Birmingham, Chicago, and Oakland. Subjects were asked to blow into a machine to determine lung function, then answer a 50-item questionnaire agreeing or disagreeing with statements like “I am easily angered.” The results showed that, after adjusting for age, socioeconomic status, smoking and asthma, higher hostility scores were consistently associated with lower lung function for black men, black women and white women. The association was not present, however, in white men.”
Of course it should be mentioned that correlation is not the same as causation. There could be other factors at play in this connection, although it’s almost the opposite of what I would expect. I’d think that all of the yelling and deep breathing typically associated with angry people would act as a sort of perpetual lung-expansion exercise, similar to incentive spirometry…incentive screechometry, almost.
:::*(angry cartoon image stolen from Tom’s Cartoons) :::
On an unrelated note, I found the following photo on a Reuters article about the Chinese military. I’m no gun expert (I’d love to learn) but it seems to me that holding targets like that requires either an enormous amount of faith in the shooter, a death wish, or a lot of institutional stupidity. It’s entirely possible that it is some combination of all three.
The Road to hell is paved with residents July 31, 2007
Posted by keepbreathing in Career Advice, Doctors, Medical Blogs, asinine, links, medicine, nurses.2 comments
As a substitute for original content this morning, I give you a story from nurse blogger Raecatherine. She tells us the story of how even the most well-intentioned residents can sometimes wind up laying enough well-intended bricks to pave a roadway straight to hell. It’s definitely an interesting and instructional read in how not to give orders and make transfers, so go forth and check it out!
I like robots too, but… July 30, 2007
Posted by keepbreathing in hospital, medicine, technology.6 comments
I like robots. I think they’re cool and I think they will be much more widely used within the next fifty years or so in many small, unforeseen ways. And some robots could be really useful in the hospital, although I have my doubts about them being used as described in this article:
“The bare bones of the toddler robots already exist, in the form of a robot designed in Grupen’s lab called uBot-5. A few of these uBots are now being developed for use in assisted-living centers in research designed to see how the robots interact with the frail elderly. Each uBot-5 is about three feet tall, with a big head, very long arms (long enough to touch the ground, should the arms be needed for balance) and two oversize wheels. It has big eyes, rubber balls at the ends of its arms and a video screen for a face. (Breazeal’s version will have sleek torsos, expressive faces and realistic hands.) In one slide that Grupen uses in his PowerPoint presentations, the uBot-5 robot is holding a stethoscope to the chest of a woman lying on the ground after a simulated fall. The uBot is designed to connect by video hookup to a health care practitioner, but still, the image of a robot providing even this level of emergency medical care is, to say the least, disconcerting.”
I’m all for medical robots. Indeed, robotic equipment is used all the time in surgery, at least in some places. And I think that a robot designed to lift obese patients or assist with turns and manual labor would be a boon to medicine. But I don’t know about assessment-assistant robots like the one described. I guess it could go either way, but I’d be much more inclined to trust my own senses (bad and misleading as they sometimes are) before trusting an assessment robot.
On another note, I can only imagine the pandemonium that a robotic medical assistant could cause in, say, a dementia unit, or with a paranoid delusional patient. Maybe they’d like it, but maybe they wouldn’t…
What say you, loyal readers? What are your thoughts on medical robots?
My First Terminal Wean July 28, 2007
Posted by keepbreathing in Doctors, death, ethics, health, health and wellness, hospital, mechanical ventilation, medical ethics, respiratory therapy, terminal wean.8 comments
I’ll never forget that first terminal wean.
It was the dead of winter here in the Great North Woods. The grimness of the middle winter had sent many patients our way. The psyche patients were depressed and cabin-fevered, the oldies were slipping and breaking bones on the ice, and the lungers were feeling the sting of the sharp winter air.
But it was for none of these reasons that the weaning patient was brought to us. No, he was brought to us for other reasons. He had come in to have elective throat surgery in an effort to correct his sleep apnea without losing any of his much-treasured body fat. But something went wrong. When he came back to the ICU from the OR, we were all horrified by the mangled mess that was his airway. Where his throat used to be was an enormous, gaping stoma. An anesthesia tube jutted out at an awkward angle, held in place by sutures covered in sterile gauze. Somebody had slipped. Things were not looking well for this mans throat.
Over the course of a week, he was brought to and from the OR countless times. He was infected, debrided, closed up, reopened. They got his throat to close but he couldn’t breathe on his own. He remained intubated for days and days; the ENT people and the pulmonary people and the maxillofacial people tinkered with this mans body, but to no avail. His long downward spiral had begun.
Eventually they were able to close his throat, but he had suffered a couple of minor MIs and a stroke. He was septic. His heart was giving out slowly, and it was looking unlikely that he would make it. The ICU physicians called a meeting with the family and the hospital ethics committee to discuss the course of action. It was decided that the best course of action was to end his life before it was taken from him.
And that duty fell to me. I was working with a therapist named Jeff, a guy who lived far away but made the drive to Our Lady for reasons not clear to anybody. Whenever questioned about it, he’d simply say “I used to be a trucker” and change the subject. Jeff and I were told by the day shift that the family was at the bedside, and that at 8:00 the physicians would write the order and discontinue supportive measures. Jeff turned to me.
“Have you ever done this before?”
“No.” Jeff looked at me from behind his hermit’s beard.
“It’s time you learned.” I didn’t object, and so the decision was made that I would do the primary work of extubating the man.
8:00 rolled around. The ICU doc of the evening strolled in with a cup of coffee and spoke with the family, making sure that they understood that there was no turning back now. The chat went on for fifteen, twenty minutes. I sat nervously in the fishbowl behind the nurses desk, watching with interest and wondering about what I’d have to do. Finally, the time came. The family left. The doc came up to me and showed me the order:
“Discontinue: (1) mechanical ventilation, (2) ET tube, (3) all pressors, (4) parenteral feeding. Do not resuscitate. Comfort measures only.”
I called Jeff and he came in with me. The man lay supine on the bed, the tube sticking out between his cracked lips. The ICU nurse moved about the room, removing lines and turning off drips and preparing the patient. Jeff coached me.
“Just make one smooth move. He won’t even feel it. Deflate the cuff, pull the tube back, and turn off the vent.” He passed me a 20-cc syringe, and I drew the air out of the cuff. The ventilator beeped in alarm as the breath it tried to deliver slipped around the cuff.
“Cough for me, sir.” I said it more out of habit than out of any hope that he would cough. I pulled the ET tube out, carefully laying it on the Chux pad that the nurse had thoughtfully put beneath his chin, cautious not to dribble tube slime all over the fresh sheets and the patients chest. Nobody wants to hug grampa goodbye and get a chest full of mucous. The ventilator screamed in protest, and I reached over to flip it off. A question burned in my mind.
“How long before…?”
“Depends. Sometimes they go for hours. Sometimes they go for minutes. C’mon, let’s get this vent out before the family comes back.” We made sure the RN didn’t need anything else from us and then skedaddled out of the ICU, abandoning the vent in the dirty room until we could get it cleaned up later on.
I went back and sat in the fishbowl, watching the patients monitor. The nurse let the family back in, and within ten minutes of the discontinuation his heart slowed down and stopped. It was over: he was dead.
:::
For all the fuss they made in RT school about this sort of thing, and about the ethics of these situations, it was remarkably easy to do. I thought about it a lot over the next few days, turning over the situation in my head again and again, thinking about the man and his family. It took me a while to sort everything out in my head, but ultimately I came to realize that it wasn’t my decision. I didn’t decide to take him off life support, and I didn’t decide to send him to that botched surgery. Indeed, the only decision I made was to carry out an order that I could have easily asked someone else to do. Further, the man’s life was likely to end in a horrific code, and this way his family got to say goodbye.
Sometimes, death isn’t so bad. On that note, check out this hilarious video about coping with death. I’m not sick, it really is funny. Seriously, check it out!
They Never Learn July 27, 2007
Posted by keepbreathing in Medical Blogs, asinine, interesting, links.5 comments
I get a disturbing number of hits to this blog (this post especially) from people who google things like “Eat Fentanyl Patch” or “Get High Eat Fentanyl.” My advice to all of those people is to get a hobby. A hobby that doesn’t involve eating narcotics and making my hospital waste taxpayer dollars treating your worthless ass. Perhaps you could build model ships or learn to read them thar books. Seriously, people: the body is a temple, but your behavior has reduced your place of worship to a filthy stinking hovel. Get some help.
On a different note, the long-discussed collaborative blogging effort between police blogger Matt, Ambulance Driver and Babs RN is up. It’s long but it is very well written. It’s the same story of the same night, written from the different points of view. It’s interesting to see things from the wheel of a cruiser, the back of a box, and the bay of the ER and to watch them unfold, and it’s a story that anyone who’s worked in medicine for a while has seen unfold before. Click Matt first, then AD, and then Babs. It’s worth your time…would that I could write so well so frequently.
Linky Time! July 26, 2007
Posted by keepbreathing in Medical Blogs, links, news, nursing homes, patient safety, respiratory therapy, weird.2 comments
As a substitute for anything approaching actual content, I give you a series of links that will surely provide you with some interesting reading.
First, Change of Shift is up at MonkeyGirl’s blog. There are some awesome articles there this week, and the theme is crayons and their colors, which automatically appeals to the crayola enthusiast in us all.
In other linky news, a respiratory therapist named Wayne Albert Bleyle who used to work in California has been sentenced to forty-five years in prison for molesting large numbers of patients in a convalescent ward in San Fransisco. Not only did he molest them, he photographed himself doing it and put it on his computer, which was a big contributor to his getting caught. I think I can speak for RT’s everywhere when I say that I hope that Mr. Bleyle chokes to death on some shitty prison food and then rots in hell. Intriguingly, he is named Wayne, which according to Freakonomics (link goes to their blog) is an aberrantly common name among criminals. It does pop up a lot on crime websites.
For today’s final link, I give you Oscar the Death Cat (link changed), who curls up on nursing home patient’s beds just before they die. The RT in me immediately began wondering about causation and allergies and so on, but apparently he’s just the messenger. I could use a cat like Oscar in my work. It would really help me to prioritize my treatment regimens, plus he’s just adorable with his little collar and bell! He’s supposedly very accurate, having called 25 deaths to date. The nursing home staff have begun to use him as a diagnostic, going as far as to call families in when Oscar makes his predictions. I’d try it at work with my housecat, but his major skills seem to be stalking flies and throwing up in fascinating spiral patterns on the tile floor.
I think that the nursing homes around here should invest in some cats. They could use one or two to do patient rounds. It beats their current system of making an aide poke the patients with a broom handle from the doorway of the room and then calling 911 if they don’t say “ouch…”
On CNN! July 25, 2007
Posted by keepbreathing in Medical Blogs, links.4 comments
My fifteen seconds of internet fame has arrived. I’ve been linked to by CNN. At the bottom of their page that I linked to in my last post, they have re-linked back to me. Sure, I’ll get like five visitors from CNN and most of them will just click through, but I just had to share about my fifteen seconds of internet fame. I’m expecting to be replaced by a dog on a skateboard any minute now, so I just have to gloat while it lasts.
Katrina Doc Not Prosecuted July 24, 2007
Posted by keepbreathing in Coming to an ER near you, Doctors, Katrina, criminal negligence, death, ethics, hospital, medical, medical ethics, medicine, patient safety, respiratory therapy.8 comments
I was on CNN when I heard that Dr. Anna Pou, the doctor who helped euthanize some patients in the aftermath of Katrina, is not going to be prosecuted. A grand jury dropped the charges against her, allowing her and the nurses accused alongside her (who were immune to prosecution by way of cooperating with prosecutors) go free with no trial.
I think the people who rushed to judge these medical professionals have too much time on their hands and too little contact with reality. “Mercy Killing” is not something I would normally advocate, but the circumstances surrounding the incident were far from normal:
Patients, staff and their families rode out Katrina. But four days after the hurricane hit, despair was setting in. The hospital was surrounded by floodwater. There was no power or water, and the heat was stifling. Food was running low, and nurses were forced to fan patients by hand.
And in those circumstances, people expect what out of us? Without power or water, there is almost nothing that I can do to sustain somebody’s life. If it was 90 degrees and 95% humidity outside, and Our Lady was surrounded by floodwaters and we had no electricity or running water, I don’t think I would be able to do much for my patients. And after a certain point, when your patients are getting weaker and weaker and the medicine is running out, what do you do? How do you react when there’s no help on the way and no sign of relief from the hellish onslaught? Do you prolong their life and hope for the best, or do you help them to slip into dreams and hope for forgiveness?
Sometimes the kindest thing you can do for someone is to let them go. And I know that “helping them go” is different from “letting them go” in a number of very important and highly relevant ways. But considering the circumstances…what would you do? Without any pretenses or delusions of grandeur, what would you honestly do? What can you do?
Leave me a comment or send me an e-mail (anonymoustherapist at gmail dot com) with your thoughts. I’d love to see what people think about this.
Subscribe! July 24, 2007
Posted by keepbreathing in Medical Blogs, technology.1 comment so far
First, thanks to everyone for the insightful comments and feedback on yesterday’s post. I enjoy getting feedback. It’s nice to know that there are people reading this stuff out there.
To continue now in the spirit of stroking my own ego, I would like to announce that I have signed up for FeedBurner, and anyone who is so inclined can click on the link at right for an e-mail subscription to this blog. If that’s not your thing, I added a little widget so you can subscribe via feed-reader to this blog. I like Google Reader, but then I’m something of a G-phile, which will be to my advantage when Google takes over the world.
More medically oriented posts soon. Just a break for technogeekiness today.
It worked. What now? July 23, 2007
Posted by keepbreathing in code blue, death, health, health and wellness, hospital, life, medicine, respiratory therapy, work.14 comments
Some of my favorite things in life are totally absurd. Some philosophers would tell you that everything in life is actually absurd, but this is an RT blog and not a philosophy blog, so that will have to wait.
Anyway, back to my favorites. I like things that don’t make sense, things that reveal that despite all appearances life is actually a lot less meaningful and a lot more absurd than any of us would like to admit.
Sometimes things like that happen in the medical world.
It was two o’clock in the morning, that disorienting time of night when everything begins to feel like a dream. Sometimes at that hour I feel like I’m moving underwater, and the easiest thing to do is just to sit and space out until something happens. And that is exactly what I was doing when the overhead speakers popped into life, jump-starting my adrenal glands. Code Blue, Fourth Floor, Code Blue, Fourth Floor. I leaped into action, jumping up from my seat and grabbing my stethoscope as I began pounding down the hall, running for the stairwell.
My legs burned as I hit the top of the stairwell and bolted into the hallway. All the way at the end of the hall, the white light above a patients room was blinking, signifying the need for codish people like myself. I jogged lightly to the end of the hall and found a giant ISOLATION sign staring me in the face. An aide handed me a yellow gown and I tossed it on over my lab jacket, throwing on a pair of gloves and shoving my way to the head of the bed. As per usual on the floors, nobody was doing anything: one nurse was straddling the patient and pumping his chest, and another was dreamily holding an ambu-bag in the vicinity of the patients head. At least she got the right end, I thought.
I grabbed the bag and tilted back the patients head. Suddenly I was staring into a lake of brown liquid that was pouring out of this decrepit old mans mouth. I noticed the bald head, the bony protuberances all over his body, the adult diaper. This guy had to be ninety years old, and instead of dying in peace we’d keep his body suspended for a few days until he grew immune to our drugs and died anyway out of spite. I hate it when this happens.
“Suction!” I snapped. “I need some suction!” A floor nurse handed me a yankauer, which I plopped into the pool of liquid with no result. “Turn on the suction! Why is the suction not on?” Someone was kind enough to turn on the sucker for me, and I evacuated a good quantity of the Mystery Liquid before slapping the mask onto the patients face and squeezing some air into him. He was hard to ventilate. No surprise there. ER Doc and the ICU team arrived in the elevator, pushing their own code cart that experience had taught them to bring. The exhausted floor nurse who had been doing compressions stepped down and was replaced by the prankish ICU orientee.
“Alright, folks, what happened here?” The ER Doc gathered a brief history from the floor nurse: 89-year-old male, sepsis, MRSA, pneumonia, CHF, renal failure, dementia, and so on. She gave the history and then briefed us on the issue at hand:
“He’s still a full code, we talked to the family today but they weren’t ready to make a decision about that yet.”
“Bummer,” said ER Doc, examining the rhythm on the heart monitor. “Alright, go ahead and give him some epinephrine to start, and then lets go ahead and get that airway taken care of*.” My co-therapist, Cindy Lou Who (CLW), prepared an ET tube and a laryngoscope for the doc as the code went on around us. Things moved at a leisurely pace: it was pretty clear that this was a code for the family. The patient wasn’t going to live. Why hurry?
A few minutes and a few cycles of drugs passed in this leisurely fashion. I pumped the bag, feeling no assist from the patient. The patient’s heart monitor still showed us no rhythm. His dead eyes stared up at the ceiling. ER Doc looked at the patient, looked at CLW and me, and then addressed the room.
“Does anybody have any other ideas? This is pretty futile.” I scanned the room. Nobody spoke, and just as ER Doc was about to call it off, Floor Nurse jumped in.
“I think we should do one more round. I would feel a lot better talking with the family if we’d just do one more round.” I glared at ER Nurse. This was just cruel, now: a literal flogging of the dead horse. ER Doc shrugged and gestured at us all to resume CPR while ICU Orientee, now off compressions and on Rx duty, prepared another round of code drugs. We pounded the old man for another ten minutes. A full round of CPR, a full round of drugs, another ten minutes of cadaver abuse.
There was a rhythm on the monitor. Sinus Brady. I looked at CLW, CLW looked at ER Doc, and ER Doc looked at the monitor with an expression of total surprise. There was silence in the room. CLW leaned over and spoke lowly to me.
“Now what?”
“I don’t know.” I squeezed the ambu-bag and watched the room. Someone reported that the patient had a pulse that corroborated with the monitor. I reached down and fingered his carotid. It was weak and thready, but there was a pulse. I looked at CLW in disbelief. “This has never worked before.”
“Get me a BP,” ER Doc ordered. Military ICU Nurse grabbed a BP cuff and liberated my stethoscope from me to listen for a pressure.
“I’ve got 88 over 60,” she reported. “What now?”
:::
What now indeed? There we stood, a crack team of lifesavers who had not actually expected this code to work. It was the precise definition of irony: a group of people who are dedicated to saving lives were standing around in disbelief and disappointment that they had succeeded with their stated goal. None of us wanted this man to live: his life consisted mostly of pain and confusion. His ICU stay would assuredly be short and brutish, and then he would run up an enormous bill and die anyway, leaving his family saddened and destitute. I assert that it would have been better for him, for us, and for his family if he had simply died quietly in his sleep.
:::
ER Doc spoke up again. “Let’s get him moved down to the ICU, start a levophed drip, call in the family…” He rattled off a bunch of orders. I handed CLW the bag and went downstairs to prepare a ventilator for the patient. He followed me down a few minutes later, attended to by the ICU staff, and we watched him overnight. His body was teetering on the edge: his BP would drop precariously, his heart wasn’t working, his kidneys couldn’t take our pharmaceutical onslaught.
I felt bad for the old man. His body lived through the night and the next couple of days, and then he died anyway. Like anybody could have seen that one coming.
Sometimes, the effort of saving a life…just isn’t worth it. That’s my outrageous assertion, and you can take it or leave it, but I think it stands: all we achieved was to make the mans body suffer and dangle the carrot of false hope before the family, only to whack them in the ass with the hard stick of reality when they leaned forward to nibble at hopes delicious orange body. It’s bizarre. But it’s what I do for a living.
*Here at Our Lady, RTs are stuck in the dark ages. We can’t intubate and we have minimal protocols. Sunny Flats, where RTs intubate and do A-Lines and run the show by protocol, will be an enormous improvement.
