Respiratory Therapy 101: Just Keep Breathing

I was driving around yesterday afternoon in a mostly fruitless effort to locate a state park that sounded like a lot of fun. It was supposed to be countless miles of unspoiled wilderness, which in my head I had envisioned as old-growth forest and furry woodland critters of the sort I am used to.

The first sign that all was not going to be quite as I had envisioned was when the road turned and suddenly I was on a dirt causeway haphazardly constructed across an enormous bog full of standing water and  and gnarled old trees. That was only mildly disturbing. I slowed the car as another curve in the road approached and saw an enormous tree branch sprawled across the road like some sort of lengthy black roadblock. Something wasn’t right, but what?

My puzzlement turned to horror when the tree branch suddenly shot off across the road and slithered into the bog. I had almost run over a ten-foot coral snake. Now he was mad, and he was slithering in the direction of the trailhead, which had a crooked wooden sign bearing the legend SWAMP TRAIL. I began to feel uneasy: no wonder people here looked at me like I had five heads when I told them I was going to go for a leisurely hike on my day off. I tried to shake off my creeping malaise as I parked the car, shouldered my bag and headed for the SWAMP TRAIL.

The trail wasn’t all bad at first: nice wide paths, old trees and grass, much like I had envisioned. But it rapidly turned sour on me as I headed further into the swamp. Enormous clouds of mosquitos swarmed around me and my hiking partner, and we swatted like madmen and rapidly applied enormous layers of OFF in an effort to ward off the swarming clouds of insect death. The repellant worked, and like fools we continued into the bog.

The swamp trail rapidly became less and less friendly. The trail narrowed to a single-file lane bordered by the kind of tall grass that stinging insects and biting creatures like to hide in. The spiders began to get bigger and closer to the edge of the trail: at one point I walked into an enormous web. Fortunately for me my tactic of running and shrieking like a schoolgirl was able to keep the spider at bay, but it gave me a bit of a start.

We turned back when the trail became even more hostile and something made a large noise nearby. I don’t know what it was that made the noise, but the noise itself was enough to make both of us retreat to the shelter of my trusty car.

On the trip home, we stopped at a different and much less famous state park which was much more beautiful. We hiked two short trails, one of which let out onto the a river and the other which let out on a platform above a swamp, where we could watch the turtles and fish and birds in relative safety above gator-leaping height.

After all of those adventures yesterday, I’m not sure exactly what to do today. The outdoors so far has been met with mixed success: my trip to a state park far away a few weeks ago was good except for an encounter with a roving bear, and this weeks adventures were more or less okay, although I have learned to avoid anything with the word SWAMP in the title. I have also learned that unlike the wildlife in my homelands up North, which tends to the furry and cute variety, the wilderness here in the swampier and marshier parts of the United States tends towards the hostile and angry and scary looking variety. Next time I go hiking I’m bringing a shotgun.

I was standing around the ICU in a daze this morning. It was barely past 8, and the coffee had yet to fully hit my bloodstream and give me the extra zip to do my rounds in anything but a slackery manner. It gradually dawned on me that there were many other people standing around with me. Like me, many of them had clipboards and appeared somewhat glassy-eyed. A droning noise in the background gradually resolved into somebody’s voice.

“…so later on we’re going to take him to CT scan and see what’s going on with his brain.” A tiny blonde nurse was telling the tale of one of her patients, a cranial bleed who was looking unwell. A supervisory person in a labcoat nodded attentively.

“Does respiratory know about the transport? He’s on a vent.” The mention of my department woke me up a bit more.

“I guess I do now, yeah.” The crowd nodded at me and then moved on to another room, leaving me leaning back on a counter with my clipboard held out before me. A transport, I thought. Those are always fun. I made a mental note to look for a transport vent (we use the Pneuton) and then stretched out and began my rounds.

The day flew by. All of my patients were a little crazy, and all of them were a little busy: q4 treatments and chest PT, a couple of old alcoholics, a demented brain injury guy, and two of those tracheotomy patients who have a rabbit-like air of fear and anxiety about them at all times. Add to the mix some equally crazy family members, a wildly unsuccessful cardioversion, and my being spread between two units and you can get a sense of how quickly the five o’clock world approaches.

It was four forty-five and I was in the surgical ICU lending a hand to another therapist when my phone rang.

“Respiratory.”

“Hey, it’s Blonde Nurse. CT scan just called us and they’re ready for us to come down…can you go on the transport?” Aw, crap, I thought. I forgot all about that!

“I’m kind of busy. Have you seen my partner in crime lately?” The angry obese woman I was treating shifted her eyes and glared at me for using a nasty word like “crime.”

“I just asked him but I guess he’s expecting a floor transfer soon. I need somebody, I can’t take him by myself!” The nurse sounded agitated, and having long ago learned never to agitate a nurse if it can be avoided (note to AJC: Irwin is a noteworthy exception as he is permanently agitated.) I agreed to head over and transport with her.

I managed to get the Pneuton assembled and ready and be in the room within five minutes of being called. By an astonishing chance, that put me there way ahead of the patient transporters, who were apparently climbing a mountain in Bangladesh judging by the time it took them to come. We hooked the patient up, I grabbed the ambu-bag and off we went, clattering and clunking through the halls. As is the fate of any RT on a transport, I was smashed into many walls and doors because of the awkwardness of bagging while walking beside a too-wide bed in a too-narrow hall. They really should just let us “code surf” all the time…

…Anyway, we arrived at Radiology in short order. The patient seemed to be holding up just fine, but when Blonde Nurse went in to tell Radiology that we had arrived they looked at her as if she was from mars. As I stood in the hall and bagged, I could hear the sounds of Blonde Nurse tearing into one of the CT technicians as they argued about who called whom and who was not waiting in line. Something seemed amiss. I looked at the patient, and he seemed to be in pain. His face was beet-colored. His eyes watered. His respirations were increasing. Blonde Nurse came back and spoke to me.

“I don’t really like the way that he looks, dude.”

“You know, Blonde Nurse, I don’t really like the look of him either.” We decided that our emergency beat whatever it was that radiology was doing, and so we burst into an empty room and set up the transport vent and some suction. Blonde Nurse checked the patients monitor, and screamed. “Fuck! He’s infarcting!” I glanced at the screen and saw the telltale signs of myocardial doom. I began to bag a little deeper and faster. Blonde Nurse made a command decision. “The hell with the CT scan, we’re going back upstairs!” I nodded in agreement with her. “A CT’s no good to a dead man. Let’s roll.” We pushed out of radiology and began hustling back up the hall to the ICUs, much to the confusion of the already confused rad techs.

It was in the elevator that things began to go wrong. The patient, who was drooling a lot, managed to cause his ET tube tape to slip. With one sudden motion, the tube came out by a few centimeters and I heard a cough. Oh shit. I lunged for the tube and crammed it back into the patients throat, holding on to it for dear life and refusing to let go. The patient began looking much more purple in color. I bagged faster. He still had chest rise and the bag felt about the same as before, and I looked skyward and begged for assistance as we flew down the hall and burst into the unit in a flurry. Within seconds a gaggle of nurses and others had descended upon us. In the midst of emergenct EKGs and medication administrations, I found myself trying to retape an ET tube that was already slick from gallons of mucous.

Much to my gratitude, an RN/RT stepped in and assisted me at this point. From here, things improved: the patient stabilized, the tube stayed in, and everybody lived more or less happily ever after…

…except for the poor patient, who is to be terminally extubated in a few days. “Excitingly Futile” might describe this day better than anything else.

Please welcome to the blogroll Postcards from Kiddieland, the tales of Dr. Bee, pediatrics resident. Dr. Bee is rotating through the PICU, which is a fascinating place to be indeed! Best of luck to Bee, and remember that no matter what the attendings might say, Albuterol really does not cure Croup.

My Tubes&Lines class was intriguing. It was basically a review of the reasons to intubate and the methods of doing so, followed by a few minutes of intubating a plastic airway dummy. I did fine with the Macintosh (curved) blades, but the distaste for Miller (straight) blades that I learned in RT school is still with me. It just seems so much easier to flick the blade into the vallecula than to flip the epiglottis out of the way; any thoughts on this from medics or anesthesia types?

As far as the Lines part of the class, it was hilarious. The teacher held up an Arrow A-Line Cath Set and said

“You’ll just have to watch people do this to learn about it. It’s sort of like putting in an IV but weirder. You’ll have to suture it, but don’t ever suture somebody elses line because you’ll regret it.”

And then we were done. This is medical education at it’s highest level, folks: the philosophy is apparently derived from that oft-used axiom of “See One, Do One, Teach One.” I think I like that better anyway. Sometimes learning things in the classroom can actually be counterproductive, because real-world medicine and textbook medicine are so dissimilar. Not that I’m saying classroom education is worthless, because it certainly does have a lot of value to it. Indeed, without classroom learning nothing that happens clinically makes sense. I guess what I am getting at is that it seems that classroom should learning should more closely approximate the real world sometimes.

Today is a well-earned day off here in the RT household. I plan to spend most of the day doing crap that I’ve put off for far too long, but the morning so far has been one of staring out the window and drinking coffee. Later today I am going to go talk to the local university about their BHA program. It sounds boring, but I’ve never claimed to lead an exciting lifestyle.

Tomorrow is technically a day off for me, but I plan to go to work anyway. I can hear you all now: Have you lost your mind, good sir? That is a fair question and one which I often ask myself, but I have not lost my mind yet. What good reason could I possibly have for going to work on my day off?

The answer is Tubes and Lines.

You see, when I left Our Lady of Immaculate Grace, I left because of years of built-up frustration. Our Lady treated RTs like nothing more than nebulizer jockeys. I had been volunteering on a hospital committee for a little more than a year in an effort to bring the RT and nursing departments out of the early 1900’s and into the modern world. But the committee’s hard work and advice were ignored by managers who feared change and physicians who liked power, so I said “the hell with it” and left for Sunny Flats.

Sunny Flats is a different sort of place. They let their staff work to their fullest potential. From the RT perspective, this means having the freedom to run ventilators the way you know they should be run and being able to use your clinical judgment to determine what your patient needs and get it done. We haven’t cut the physician out of the picture…they can always override our protocol…but most of them are more than happy to let us run the show, and with that we have improved patient survivability and lowered our rates of ventilator-associated pneumonias.

So anyway, I am going in to work to take the Tubes and Lines class. This class will allow me to have more of the therapeutic discretion that I crave: after taking the class and scoring a certain number of supervised attempts, I will become an Intubator and an Inserter. I will be allowed to intubate patients should they require intubation, and I will be allowed to use my clinical discretion to insert arterial lines into people who will be needing a fair number of blood gases. This is very exciting to me. At Our Lady, I couldn’t even move the ETT without physician orders; I couldn’t draw blood without written orders, couldn’t change O2 settings even by a margin without and order. Here at Sunny Flats, I get to do…everything. And it is a refreshing change. That is why I am going in on my day off: I finally have a chance to be a real respiratory therapist instead of a Floor Whore, and dammit, I’m going to go for it.

Have a happy Wednesday, everybody!

First: I saw the best patient ever today. She was a young lady who needed a blood gas, and not only was she cheerful and cooperative, she was absolutely charming even with a needle stuck in her artery. I was totally impressed with her as a patient and left her room smiling and feeling satisfied, an unusual occurrence. Another patient of mine had a very curious family member who was considering a career in RT, and I spoke with him for a while and hopefully was able to sway him in the direction that’s best for him. Those are two really positive, awesome things that happened today that offset the sad case of Mr. Crusty.

Mr. Crusty was encrusted in weeks worth of filth. His disgustingly large omentum was covered in fungus and dried liquids, and his toenails appeared to require the services of a professional arborist. He was, in short, totally incapable of caring for himself in any meaningful way. This had not prevented him from living alone in his own filth, where he had apparently slipped on something abominable and landed on his head on a floor covered in effluvium.

Mr. Crusty was officially a DNR patient, until the physician called his family (Crusty Junior, a few towns over) and asked them if they were OK with Crusty Senior’s DNR status. Crusty Junior was in direct violation of Geraghty’s Law of Grieving (thanks PJ), which states that there is an inverse relationship between the volume and duration of grief and the amount of love and care demonstrated for relatives in the past. Needless to say, we intubated Crusty Senior and dragged his mostly-dead, filth-encrusted butt up to the ICU.

This is a perfect example of the Hopeless Case of the Week.

What we did was to take an 80-some year old man, who stated that he did not want life prolonging measures, and perform some of the most aggressive procedures we have on him to placate his yokel family. We spent a great deal of time, money and resources to “save” the life of a man who (a) has stated that he does not want to be saved in the presence of his physician, and who (b) has absolutely no quality of life outside of the hospital. We violated his wishes to make his family happy. Not only is this a really bad use of critical care resources, it’s a violation of the implied contract between patients and caregivers, and that disheartens me.  Why did we do this? What did we achieve? If nothing else we can ask these questions and maybe think a little bit about what it is that we sometimes do to people.

Mr. Crusty is this week’s best candidate for the Hopeless Case of the Week so far.

It was a late night for the immigrant. He had been working hard all day, trying to make a living for his mother and his girlfriend. He was busy thinking about them, wondering what they were doing and anticipating his long evening with them at home. He was driving along in his battered but trusty old American car, listening to the radio en Espanol and thinking about later on. He approached a stop sign and slowed his vehicle to a complete stop, checking both ways and then pulling into the intersection. There were lights in the distance but they were far off.

It was too late of a night for the teenagers. They had told their parents an elaborate story about seeing a movie, and then snuck out to go to a party with some other teenagers who were up to the usual defiant teenage shenanigans at someones house. But they had lost track of time, and they were worried that their story would unravel if they got home late. The teenager at the wheel hit the gas. There was an intersection ahead, but the roads were always dead at this time of night in this backwater southern town. Four girls in a tiny car zoomed through the hot southern night, hoping to make it home and get away with everything. With a high rate of speed, they sped towards the intersection, and ultimately towards their destiny.

Five lives crossed paths in that dead intersection.

With a horrible crunching noise, five bodies contorted. One teenager was thrown from the car and hit her head on the ground. Her life was over before she knew what happened. The driver through the window, gouging an eye out on sharp glass and smashing some bones. The force of the impact flung the other girls from the car and into the ground.

The crash twisted the immigrants body violently and flung him out of his ancient car. His life in America was about to change. Today, he was my patient.

He has CSF coming from his ears and air leaking into his skull. His brain is contused. One scapula and several ribs are shattered; one clavicle is cleaved into two pieces, separated by several inches of skin and lung. His left leg is fractured. His aorta is torn and dissecting. His lung is collapsed. He is full of tubes and hoses. His blood count is dropping, his aortic tear is widening, and he is circling the drain faster and faster. He did everything he was supposed to do, but I guess his number was up.

One innocent life destroyed by another. One young person killed in an instant. Three permanently wounded survivors and one likely to die. The driver will probably never be the same again.

Sometimes, life’s just not fair. Usually it doesn’t get to me like this, but this one was bad. The immigrant is my age. I drive that road. It could have been me.

I’ll be back to my old self tomorrow. With any luck I’ll be funny again instead of depressing.

A few moments from last week that stuck with me. Sometimes a snapshot in time just sticks with you, and for me the best way to get it out is by sharing the joy with others.

The first snapshot is a moment in time involving the trache-needing catatonic guy that I had in the unit. He was (is?) on heavy duty precautions because of his sepsis, and I was standing in the doorway of the room downing my protective gear when I saw his wife standing near the head of the bed. She was a short lady and he was in a big bed, so when she stood she was at his ear level. I watched her for a moment as she stroked his thin hair and whispered in his ears, talking endlessly to him about nothing at all and desperately trying not to think too much about the moment that she was in. Throughout it all the patient’s eyes stared off at nothing at all, his brain a puddle of mush beneath his skull. Denial is the saddest phase.

The second snapshot was a long moment as I was walking by a room. I did not have the patient in question, but looking into the room I could see a middle-aged man supine on the bed, ET tube and chest tubes stuck into his body. A woman of about his age was draped across his body, arms thrown awkwardly across him in a loving embrace. I watched for a moment as she held him and sobbed silently into his bedsheets, and then I turned away, unsure of what to do. Part of me wanted to comfort her, and part of me…wanted nothing to do with it.

Just a couple of moments. Had to share before bed. Hope y’all have a lovely day.

As of tomorrow morning at 7 AM, I am off orientation and free to roam about as an official RT.  I have heard this stage of working here referred to as “being thrown to the wolves,” but I’m not concerned. With any luck I don’t make any enormous errors or have any unlucky moments on my first day…but if I do I’ll be sure to tell you all about it here.

It’s my day off today, which means I don’t have any intriguing stories to tell you. So instead of coming up with my own original content, I will hijack the content of another blogger.

Panda Bear MD has written an interesting piece about the way things are perceived and operated in the Emergency Room. Often, we wind up flinging lots of resources and time at totally hopeless cases instead of focusing on the less glamorous but more salvageable patients. Dr. Bear uses the example of a young man shot in the heart versus a young woman bleeding out through her tonsils. What typically happens is that everybody on earth goes to see the hopeless young man die in a fantastic way while ignoring the more salvageable young girl who has an unexciting, unglamorous condition. Not only does this happen in the ER, it happens in the ICU environment also. The sad truth is that we often focus so much on the hopeless cases simply because we get to use cool toys on them, while the less exciting cases become rote and boring, so we ignore them until they become hopeless, at which point we can once again use our cool toys. It’s an endless cycle, and it amazes me that so few people notice or care.

The cardiothoracic surgeon I wrote about the other day is on The Onion.