Respiratory Therapy 101: Just Keep Breathing

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.