Respiratory Therapy 101: Just Keep Breathing

This is an experimental post. I’ve got a collection of songs that for one reason or another sort of evoke work-related memories for me, and so I’m going to intersperse lyrics from these songs with stories and see how it works out. Tell me if you like this sort of format or not, I’m curious to see what everyone thinks: is it silly drama, or interesting reading? Let me know.

::: 

I walked through the sliding glass doors of Our Lady of Immaculate Grace, my gear-bag slung over one shoulder and my glasses fogging up in the sudden burst of A/C. I glanced to my right as I walked past the ER waiting room on my way to the RT office, peering through the fog and seeing the silhouettes of the mildly ill and the local pretenders through my glasses. As always, none of them actually seemed sick; probably they’re all just here for drugs, I thought.. Usually I am not this judgmental, but working here long enough has taught me that probably four of five patients who don’t come in via ambulance at Our Lady are here for drugs or pregnancy tests, or sometimes both.

Fourteen people died today

What a mistake they looked to the sky and tried to drink the rain

Eye-lids open wide to the poison inside

 
I thought back to my days in RT school, before reality had set in. Sure, I’d gone into it knowing that not everything would be as glamorous as they made it sound, but I had been unprepared for the onslaught of human suffering that was my job at Our Lady. When I entered the RT program at the local tech school after high school, I had unrealistic expectations. I thought I could save people, that patients would like me because I’d help them breathe. I thought that people would only come to the hospital if they were sick, that people would care about their family members. I thought that even in illness, the tender and caring side of humanity would shine through as people dropped their petty differences and pulled together for the benefit of the sickly. I had never expected the horrors that awaited me: apathetic families, families that overcompensated for years of their apathy by demanding that we raise the dead. Patients who had given up on themselves. People who tried to game the system. Academically, I knew that it existed, but somehow I was convinced that most of my patients would be good people who had had bad luck. And while a lot of my patients were just unlucky, a lot more of them seemed to be people whose own stupidity had finally caught up with them—and something deep within my brain made it hard for me to want to save them.

I saw ten old men today

Each said they were happy just to live another day

I just smiled and thought of all the bills I have to pay

I dropped my gear bag in the office and wandered into the ICU to get a cup of coffee before taking report from the day shift. I nodded and talked with my fellow nocturnes as we waited for the coffeemaker to finish. I looked around at us all, slaves to the coffee light, resplendent in our insomniac glory.

Full cup in hand, I trudged back to the RT office, eyeballing the ICU to see how many ventilators I’d have that night. Only two. Not a bad load at all.

Shift report was the usual, economically-depressed-cityscape blend of unfortunate elderly patients circling the drain and unintelligent young patients who were too depressed to care for themselves. For a little variety, we had some postoperative patients thrown in: a couple of young back surgeries and a cancer patient. Cancer Patient had been thought to have a minor sort of tumor, but when the surgeon cut her open he saw an enormous inoperable mass inside of her. It looked like she’d be dead in a week. I sighed and left the office to begin my rounds, beginning with an old man who had been admitted for his dozenth pneumonia. He chattered away at me while his nebulizer sputtered along, ignoring my requests breathe deeply and talking to me around the aerosol mask about everything that ailed him instead. I felt my pager vibrate as he discoursed about his life and times; it was an interesting history but I didn’t have time at the moment. I unsheathed the electronic leash and looked at the screen.

Cancer Lady in rm. 421 having trouble need ABGs ASAP please t/y

I smiled at the patient as I turned off his nebulizer. He continued his chatter as I hastily auscultated him despite my requests for deep breaths. Despite his ceaseless talking he had apparently absorbed some of the nebulizer as his lungs sounded looser than before. I pocketed my scope and took my leave, running up the back stairs to room 421 where our postoperative cancer patient lay in a bed.

She was connected to a stunning array of IV fluids and hanging meds, and despite what seemed to be a heroic effort she was not looking well. Her complexion was gray and pallid, and her breathing was shallow and fast. Her lungs rattled unpleasantly and her gathered family were clearly very upset about things. I introduced myself and got down to business. I snapped some large gloves on, put a pad of gauze at the ready, and hung a strip of tape from the bedrail. I grabbed the patients wrist and palpated for a pulse.

Where was her pulse, anyway? 

And I’m stuck with all the sentimental incidental costs and cavalcades

I remember all the times she cried and I just sent her to her grave

Despite what she gave

After a few panicky moments in which I thought that she was just a stealthy cadaver who’d snuck up from the morgue, I found her pulse weakly beating beneath her wrist-skin. I wiped an alcohol swab on her and re-felt the pulse, stabbing my blood-gas harpoon into the deep and fleshy waters beneath her wrist. The patient clenched her wrist and groaned; I must have grazed a nerve. I breathed deeply and apologized for the sting. Focusing on the needle, I pushed it just a bit deeper and to the left, ignoring the stares from her family as she groaned and clenched her fist. “Just a moment more, ma’am. I know it hurts. I’m so sorry.”

A spurt of blood flashed into the syringe and I held the needle perfectly still. While I waited for it to fill I gave her a quick look. Sat monitor read 90 on a 55% venturi mask. Her respiratory rate was in the high twenties. The syringe was full and I pulled it out of her wrist, quickly covering her wound with the gauze.

“Focus on your breathing, ma’am. Try to slow it down a little bit if you can. Just hang on while I get these results.” The nurse held my gauze over her artery while I bolted from the room, agitating the blood as I booked it to the lab.

I got two feet right in front of me

so my head don’t hit the ground

As I walked to the blood gas lab, I saw a flock of nurses walking rapidly in the other direction carrying equipment. They entered the room of the old man I had been nebulizing just before the blood gas came across my pagers. Shit, I thought. That’s rarely a good sign. As I popped the ABG syringe into the analyzer, my pager vibrated again, telling me that the old man was having some increased distress and requesting my presence. I pondered this new development as the ABG machine dinged at me. I examined the results from cancer-lady.

pH 7.15 PaO2 55 PaCO2 85 HCO3 30.2 K+ 6.3 LAC 4.7(approximately, my memory’s a bit touchy)

I stared at the screen. The pager vibrated again, insisting that I attend to my distressed old man. I blinked. The ABG results did not change miraculously as I had hoped they would. Aw, double shit. I tore off the blood-gas slip and jogged lightly down the hall. A nurse from the old mans room flagged me down. “We need you,” she said. I poked my head in and looked at the old man. I could hear him wheezing from the door, and his SCMs stood out from his neck like he was some weird body-builder. I tore off two albuterol bullets from a five-pack and handed them to the nurse. “Give him these one after the other. I’ll be right back. I need to go upstairs.” She sneered at me. “Don’t you have another therapist you can get to do that?” I laughed. This was a bit of a sore spot of mine; Our Lady’s staffing policies left me alone at night more often than not. “Here? I’m alone tonight. I’ll be back. Don’t kill him.” Before she could say anything I turned on my heels and ran upstairs, just in time to hear the code pager in my labcoat begin beeping. I listened overhead to see where the code was. It was Cancer Lady.

caustic eyes and ears all falling on this perfect situation

bitter lips and sneers all throwing shiny daggers in my shoulder blades

I ran into room 421 and picked my way through the assorted onlookers to the head of the bed. The patient had ceased breathing and was lying apneic on the bed, eyes staring at the ceiling. I grabbed the ambu-bag off the oxygen meter, tilted her head back and began to ventilate her. Cancer Lady’s nurse, an old salt, grabbed the mask for me: always nice to have some help.

A moment later, the ER doctor arrived. “What happened?”

“She’s a postoperative patient of Thoracic Surgeon. She was having some respiratory distress, and we got ABGs, and then a moment later she just stopped breathing.”

ER Doc looked at the heart monitor and demanded a round of epinephrine. I handed him the ET tube and a laryngoscope and read the ABG results to him.

“Those sound bad.” He remarked to me as he slid the tube through the lady’s cords.

“They are,” I replied. I began to sweat as I tried to tape the patient’s ET tube to her face, a task made all the more difficult by the force of someones chest compressions. Just as I had finished my tape job, my pager went off again, startling me and making me rip the tape. I lost my cool for a moment. “Damn it! This is totally futile! She’s just going to die and I have another patient that I might just be able to help if I wasn’t here.”

I noticed that the room was suddenly quiet. My skin began to crawl and I felt my heart begin to pound. Everybody who wasn’t doing CPR was looking at something.  I looked up. The family was staring at me, a mix of contempt and shock on their faces.

I didn’t know whether to apologize or whether to look away. Ultimately I chose the latter and retaped the tube as the code went on around me.

And I’m stuck with all the sentimental incidental costs and cavalcades

I remember all the times she cried and I just sent her to her grave

Despite what she gave

We worked on the patient for another fifteen minutes or so before the doctor spoke with the family and called it. They collapsed on one another in grief, and like a coward I snuck past them. I wanted to apologize for my indiscretion. It’s not that I didn’t care about Cancer Lady; it’s that I could only take so much. But they were crying and I had work to do. My pager vibrated again and I sighed, running downstairs to the old man’s room. He looked worse. Someone had placed an NRB on him but it wasn’t making any difference. The nurse came up behind me. “He’s a DNI, but Pulmonary ordered him on BiPAP. Your settings.” I nodded and left to get the BiPAP.

Even on 15/8 of BiPAP the old man was looking bad. His gray skin was not pinking up and his mental status was declining. I drew some blood gases on him and they were not good; despite the BiPAP his PO2 was dropping and his CO2 was rising. He needed a tube. Old Man’s nurse and I got the supervisor to call the family.

The family came in, followed shortly by the pulmonologist and the priest. There was a long conference from which I took my leave to go and take care of some of my backlog. An hour later, I got paged with an order: take the BiPAP off and put him on some low-flow oxygen. Nursing would give him some morphine and we’d see what happened. I took the BiPAP off the patient and gently put him on some low-flow O2, finally leaving him behind to die among his family.

I got two feet right in front of me

so my head don’t hit the ground

The sun rose over Our Lady. I stood in a stairwell and watched its ascent in the clear morning sky. Brilliant rays of red and orange poured into the stairwell, shining through the peaks of the pine trees behind the hospital. I pondered the events of the night before. Two of my patients were dead. I felt like a total asshole. The night had been a wash.

Day shift arrived and I gave them the rundown. My shift was finally over. I walked out of the sliding glass doors and into the blasting late-July heat. Outside of the hospital, cancer lady’s family was gathered around a rundown old car, smoking cigarettes and talking among themselves. They hadn’t seen me yet.This was my last chance for redemption: I could swallow my pride and go talk to them, apologize for what I said…or I could go home and admit defeat.

I got two feet right in front of me

so my head don’t hit the ground

I walked to my car and drove home. Sleep came too easily.

Sometimes things don’t work out how you’d like them to.

:::

The lyrics, by the way, are from the song “2 Feet” by Rocktopus, a Maine-based band that’s changed their name to As Fast As.