Respiratory Therapy 101: Just Keep Breathing

I flopped down behind the table in the RT office, coffee in hand, barely in time for shift report. My stethoscope hung around my neck, the bell caught down my shirt collar, my shirt rumpled from the nightly rush up the stairs.  I tend to start my shifts looking like a street person urban outdoorsman, but it gets better as the coffee sinks in and the night grinds on.

I sucked down some coffee and listened as Old Therapist began.  He presented to me the usual host of characters: we had an asthmatic trucker, a couple of chronic lungers, and the other assorted medical flotsam who had washed up on the shores of Our Lady. Among the detritus was Mr. Bignose, one of my favorites and a frequent flier from one of the local nursing homes.I like Mr. Bignose. He’s an old codger who’s lived here for his entire life, working in the mills as a young man and watching them decline in his older years. His children had all moved away and his wife was dead. He was all alone in the world, a broken and bitter old man, but likable in his curmudgeonly ways.

After the end of report, I left the RT office and began my rounds. Mr. Bignose was first on my list.

I walked into his room and found him reclined in bed, staring at Everybody Loves Raymond on the television and periodically grunting. He looked at me, and looked back at the TV. He spoke, his droopy eyes and floppy ears making him look like a morose basset hound in some cheesy Disney animation.

“I hate this show,” he grunted at me. “Everybody on it is stupid. Just like at the home.” I smiled.

“Nice to see you, too. It’s time for your breathing treatment.” He sat up and leaned forward so I could auscultate. I didn’t need the stethoscope to hear the wheezing and the maytag sounds, but I made a show of listening all the same. I squirted a bullet of DuoNeb into his nebulizer and handed it to him. Raymond continued his stupid antics on the TV behind us.  Bignose and I watched Raymond destroy his life together while he sucked down his nebulizer. It sputtered out after ten minutes or so, and I took the nebulizer from him and put it away.

“So, how are you feeling?” I asked. He stared at me.

“I feel like shit,” he said.  “I hate the way those things taste. And they make my heart shake.” He slowly reached out and grabbed a piece of candy from the bag by his bedside. He popped it in his mouth and chewed, coughing once and swallowing.

“That’s a common side effect of the Albuterol in those treatments. It makes my heart race too. How have you been doing since last time I saw you? How’s Swampy Meadows?” I grabbed a piece of candy and secreted it in one my my labcoats many pockets for later. Bignose sighed.

“I hate it. Everybody there is stupid.” You never have to guess about Bignoses true feelings on a subject. We made small-talk for a while, I left him, and the shift marched unremarkably on.

I returned to Our lady the following night and took shift report again. This time it was different.

“Mr. Bignose is worsening. His pneumonia’s spread out to both lungs and he’s on a 55% Venturi mask; we don’t want to go any higher because we’ll knock out his hypoxic drive, but at some point you’re going to have to push him up because his sat’s barely 90 on that mask.” Not an optimistic report.

When I went in to see Bignose, he was staring at a spot about two feet to the right of the always-on TV, looking sicklier than usual. I asked how he was feeling and he moaned, a long, low gurgling noise that made me itch. This was worse than usual. 24 hours had practically killed the man.

His condition worsened as the night wore on. I spent a lot of time with him and his nurse, bumping up his O2 and giving him treatments, working with his cough and trying to keep him breathing. Despite all of our efforts, his respirations weakened. His final blood gas was proof enough that we had failed. We wheeled him to the ICU and intubated him. The pulmonologist did not express a great deal of optimism.

Bignose was unlikely to live through the day. I went home in the morning expecting to see nothing but an empty ICU bed on my return.

:::

A week passed.

When I returned to Our Lady, Bignose was gone. I asked Perky Therapist what had happened to him. She bobbed her head to the side and flashed her horrid smile. “Oh, he went back to Swampy Meadows just a couple of hours ago.” I lit up! He had lived! He’d beaten the odds before, and I was glad that he had survived another slash by the reapers blade.

“He’ll be back. There’s always next time to catch up,” I said as I settled in to once again take shift report. Russian Therapist sidled in and I asked him, “Where’s Shadow Hog?”

“Shadow Hog is sick. You’re all alone tonight.” With those words, change of shift began and more or less ended.

After Russian Therapist and Perky Therapist left, I sat and organized the treatment cards, clipping a floor pager to each pile. Suddenly the ER beeper at my hip went off. I examined the screen.

CODE BLUE ETA 5 MIN NEED U ASAP

Great, I thought. Always just after the day people leave. I grabbed my stethoscope and an airway kit and stomped down to the emergency department. “What do we have?” I asked them, sliding up to the head of the bed amidst the preparations.

“It’s a 77 year old male, found down at a home. EMS hasn’t been able to give us much more than that.” I checked all of my equipment: suction, ambu-bag, laryngoscope, tubes, tape. I was ready for anything. The hallway to the ambulance bay flickered red as the ambulance backed in, lights still flashing. The door burst open and Fat Medic crashed in assisted by Shady Medic, dragging a stretcher with an unresponsive form on it, pounding his chest and yelling a report at us through the din of the ER.

I couldn’t help but notice a prominent schnozz sticking up behind the airway. It was Mr. Bignose. I felt a jolt.

Shady Medic handed me the bag and I automatically began to squeeze. I looked closer. Shady had used an LMA for this patients airway. I asked him about it.

“Yeah, couldn’t pass a tube and I got sick of trying.” He shrugged.  “It beats no airway.” I nodded my agreement and forced another breath in. Bignose was somewhat difficult to bag, but his chest was rising and I could hear faint breath sounds. I kept breathing for him as the code went on around me. We went at it for a full twenty minutes to no avail.

My favorite patient was dead.

:::

A couple of days later, I got wind of his autopsy results through the pipeline. After all the pneumonias, after the ICU admissions and the ventilators and the milieu of other maladies, he had choked to death on a ham and cheese sandwich. Death by Oscar Mayer.

What a world.