Respiratory Therapy 101: Just Keep Breathing

Warning: I’m meaner than usual in this post and I don’t know why. I suspect it’s just me being tired.

Have any of you ever seen those “Wallace and Gromit” animations? You know, the ones with the inventor guy and his dog who have wacky misadventures? One of my favorites was always The Wrong Trousers:

To sum up the title, Wallace ends up stuck in the wrong trousers through the machinations of an evil penguin. I had a patient today who wound up in a very similar pickle, except you must replace the wrong trousers with the wrong tracheostomy and the evil penguin with a bills-by-the-procedure cardiothoracic surgeon.

Yesterday, I was upset because a patient who needed a tracheostomy was instead being weaned from his ventilator. I wished very much that my patient would get a trache. My wish was granted today, except that in my wishing I apparently forgot to specify which patient I wished to receive the trache.

You see, the patient who received the trache is a morbidly obese lady who (among her plethora of medical problems) suffered from obstructive sleep apnea as the result of hyperchinosis* and exceedineckitis**. While she was in the ICU recovering from her cardiothoracic procedure, somebody mentioned to her that while she was already in the hospital, and since she was having some degree of respiratory distress, she could elect to undergo a tracheostomy in an effort to lighten her work of breathing AND cure her sleep apnea! Like so many of the promises we make, it sounded too good to be true.

Instead of consulting an ENT or a pulmonologist to do a bedside percutaneous tracheostomy, the cardiothoracic surgeon took the patient to the operating room and performed the trache himself. This is not illegal, or even unethical: he is after all a qualified surgeon. It is however wildly irresponsible, since cardiothoracic surgeons do not often trache patients and this was a non-emergent procedure and also since the ENT docs are a phone call away at Sunny Flats.

While the cardiothoracic surgeon did a good job on the mechanical aspects of the trache, he did a very bad job selecting which trache to give the patient. Ideally, for a patient with this sort of body habitus, you would use a sizable trache, maybe one of the long-necked traches in a size 8. But the cardiothoracic surgeon opted instead to place a tiny little number six tracheostomy tube into this patients ocean of neckmeat. For a visual, that is like using this

to open up the neck of this:

Of course, this decision came back to haunt the surgeon. The weight of the ventilator tubing alone caused some significant torque on the tracheostomy, and the patient’s motions and occasional coughing are enough to move the trache around and cause what we RTs sometimes call “a goddamn positional problem.” The patient would be breathing fine one moment, with excellent returned volumes and really great waveforms and stuff, and then she would shift a micron in one direction and her airway would occlude. When (if) she gets off the ventilator, her neck will likely roll over the trache while she sleeps and she will either continue to suffer from sleep apnea or she will die. I would love to tell you that this got resolved in some satisfactory manner, but nothing was ever done about the tracheostomy situation.

Sometimes, you just can’t win.

* Too many chins, of course.

**Too much neck. I haven’t slept enough. Leave my sense of humor alone.

First: this is the best pirate joke ever.

Today was the second to last day of my orientation. I was in our surgical intensive care unit. Despite its outward appearances of calm and mellowness, the SICU does manage to keep you busy. I was assigned to half of the unit with a preceptor, and we kept busy all day. Apart from one ten-minute break in the morning and a twenty-minute lunch while awaiting the arrival of a new patient, I was on my feet all day long today.  A fair amount of it was busywork or me running around to fill out paperwork I forgot to fill out because I didn’t get my morning coffee. On an interesting note, one of my (now extubated) patients’ bedside pad had the legend “I AM SCARED TO DEATH OF BIRDS” written on it. Mental leftovers from anesthesia, perhaps?

In addition to the usual surgical mess, I found a perfect example of a situation in which people in medicine act without thinking. The case isn’t neccesarily “hopeless,” but it certainly does provide an example of some strange decision making.  Among my patients today was an eighty-year-old individual. This patient was long-since status post a left-lower lobectomy for metastatic cancer. The cancer has since spread to his bones.  A few days ago, the patient stopped responding to the outside world and began staring at the ceiling. The patient’s eyes are not responsive to snapping, they do not track movement, and the patient does not respond when stimulated. EEGs reveal that he goes in and out of a seizure state, responsive at first to ECT but ultimately drifting back into seizure. The patient’s head CTs have revealed nothing of any interest…yet.

The patient was intubated for airway protection several days ago. Today, I was ordered to attempt to wean and extubate him. Now, on the one hand I know that just because he is catatonic and chock full of cancer is no reason to abandon all hope. On the other hand, I have to ask myself: what are we hoping to achieve? This patient is very, very old. He is full of cancer. He is completely catatonic: to give you an example of his catatonia, when I pass a suction catheter into his lungs he doesn’t even cough or gag. From a respiratory standpoint, the decision to “wean and extubate” him is totally futile: in a catatonic state, he is incapable of protecting his own airway. The intensivist knows this, my fellow therapist knows this, and yet….I was ordered to attempt to wean and extubate. Why?

The only reason I can think of is that people in the ICU have an intense desire to feel like they are doing things even when they are not. There’s not much else we can do for the man at this point: his catatonia is not responding to any treatments, his cancer is more or less beyond any hope of treatment, and the rest of his body waits in limbo. Since there is nothing that can be done that will actually be productive, why not pretend to be productive? And what better way to do that than to wean and extubate? On the face of it, that sounds very productive indeed, but if you actually stop and think about what you’re doing–removing the airway from an unresponsive patient–all you are doing is making it worse.

The real kicker is that something productive could actually be done: if we wanted to liberate the patient from the ventilator, we could perform a percutaneous (bedside) tracheostomy and let him breathe on his own with a less restrictive artificial airway.  That would be productive, intelligent, and above all good for the patient. But we won’t do that: what we’ll do instead is sprint towards that ever-present windmill, lance waving in the wind, always hoping that this time we’ll finally get that damn giant.

It’s a funny world.

Mielikki has written what may be the most deliciously punny take on talk-like-a-pirate day ever. It’s entitled…“C-P-Aaargh.”

It gets better from there. Just go read it.

:::

In the ER today we had a patient who ingested something like 130 pills of various sorts. He had recently been discharged from a local psyche facility, where they had prescribed him an enormous amount of medicine and no supervision. In the spirit of evidence-based medicine, I’m going to go ahead and say that the evidence suggests that the processes at the psyche hospital are probably not up to snuff.

In other ER news, I met my nemesis at the hospital today. No, it isn’t the ever-worrisome Sumdood: he is far too much nemesis in one package for me to handle. Instead, my nemesis seems to be a physician who I will be nicknaming “Doctor Dork.”

Doctor Dork is about five-ten. He sports a pair of totally dorky glasses*, wears black jeans instead of scrubs, and has a shrill and whiny voice more typically associated with basement-dwelling nerds than with charming emergency physicians. Even all of this is tolerable: however, his total presentation…his mannerisms, his lack of interpersonal skills, and his generally unpleasant demeanor make him possibly the most dorky person in the entire world.

Doctor Dork also has the gift of being able to make a controlled, normal situation into a scene of total chaos. During an intubation today, he was sequentially yelling at the RT, the nurse, and me to do things that we had either already done or were actively doing. He turned a controlled, easy intubation into a nightmare scenario for all of us simply by being a total douchebag. I have decided that he will now be my nemesis: anybody so annoying and utterly incapable of being calm and rational should not be in emergency medicine, and the urge to subtly drive him to the edge of a stroke is very difficult for me to resist. The question is, how can I drive him to stroke without endangering patients? The argument could be made that patient safety would improve with the removal of this physician: this is a man who routinely writes orders for insane things, like arterial blood sticks for problems like lower extremity pain.

I’m open to suggestions here. Drop me a line and let me know.

I was amazed to meet another RT today who is familiar with a rather obscure patient evaluation tool that I learned in respiratory school. I had been assigned to the Emergency Room with Tall Therapist, and despite the tri-county coverage area and the local populace’s wild antics, the ER was strangely still. We were discussing some of our older cases, in a totally serious and not at all cruel or mocking way, when the subject of a certain patient archetype came up.

We all know this type of patient. They’re typically aging rebel boys with a crazy “anti-establishment” lifestyle. They grow out of discontented twentysomethings and disillusioned Republicans or Hippies; they become withered, rapidly aged men with a great many tattoos and adentitious mouths. They are known for their cockroach-like ability to survive astonishing systemic insults and major trauma.

Their survivability can be calculated with this obscure tool that I learned in Respiratory School. It is called

“The Tattoo to Tooth Ratio.”

Despite the relative obscurity of the TTR, I was astonished to discover that not only did Tall Therapist know of this ratio: she may well have invented it. Indeed, while I would like to take credit for the invention or rediscovery of this technique, Tall Therapist has been practicing much longer than have I and is therefore much more likely to deserve credit for her discovery.

What is this “Tattoo-to-tooth ratio,” you ask? Simply put, the ratio can be calculated by dividing the number of tattoos present on the patient by the number of teeth remaining in the patients skull. For example, a patient with 24 tattoos and 2 teeth would be said to have the astonishing ratio of 12. A general rule of thumb is that if the tattoo-to-tooth ratio is greater than or equal to one, your patient is indestructible. The higher the TTR score, the lower the likelihood of a terminal outcome. A patient with a TTR of just two could be run over by a truck after being shot twice in the back outside of the bar in which they drank six fifths of whiskey, and shortly after admission to the emergency department they would be demanding cigarettes and sexual favors from any nearby persons.

A corollary to the tattoo-to-tooth ratio is the social contribution scale. generally speaking, the higher the TTR, the lower the number of points awarded on the social contribution scale. Hence the well-known fact that likelihood of survivability is inversely proportional to social worth.

So there you have it: a crash-course in the venerable patient assessment tool known as the TTR. Print this webpage out and present it to your supervisor for an hour’s worth of continuing education credits. And if you do, let me know how that works out for you.

::UPDATE:: William the Coroner has written about postmortem tattoo analysis here. Go check it out.

By way of Monkeygirl, I give you the ED of the future as envisioned by Dr. WhiteCoat.

It’s the logical conclusion of all this patient safety nonsense. I mean, obviously some measures make good sense to keep patients safe from medical errors or preventable accidents, but there’s got to be a line drawn somewhere.

Another post that’s a little off-topic but relevant to my own personal life. In keeping with my decision to join in with the gun culture (and in keeping with my desperate plea for funds in the Arm the Therapist Fund) I’ve been reading through some of the backpages on “The Other Side of Kim.” Specifically, Kim offers some wonderful advice for gun-culture newbies like myself, and the entire back section of his blog (known as the “gun thing“) is well worth perusing.

Respiratory Therapy to resume as normal tomorrow. In the meantime, I leave you with this joke:

“Hey, did you ever hear the pencil joke? No? Well…it was pointless.”

See you tomorrow, readers.

Mielikki, one of my favorite nurse bloggers, has written about how some of the rules at the zoo could easily apply to the hospital. This is very true. But my favorite bit was when she mentioned us RT types:

-Oooh, look honey! The rare and exiting septic patient with a Swan-Ganz catheter! I hope we are in time to watch the nurses take the readings! Maybe they will let us help with the Wedge!
Or, how about
Damn! must be a slow day at Podunk. All we have are the garden variety COPD’ers, withdrawing drunks, and a Fentanyl patch eater. Ah well, at least the patch eater ate a DIRTY patch that she got out of her friends garbage. That makes it a little more rare. Maybe she’ll retch and we can have a picture. Oh, she has a go-lytely drip via NGT to rinse out the charcoal! Maybe this isn’t so bad after all!
Oh, look over there! A man getting a Respiratory Treatment! Quick! Let’s go see if we can get the RT to throw sputum at us by heckling him!

I was quite tickled by the image of a white-coated therapist screeching like a monkey and flinging a glove full of bright yellow pseudomonas at someone’s head. Of course, it might not stop there. (the remainder of this is recycled from the comment I left at Mielikki’s blog because I’m lazy.)

They’re lucky if all we do is throw sputum. Heck, us RTs can be downright dangrous when cornered: respiratory therapists have been known to use inline suction catheters ninja-style, like horrible phlegm-coated nunchuks. If it’s an especially dire situation, we’ll use our special radial-nerve-seeking blood gas syringes, or even point an open tube at someone in hopes of calling down the Wrath of Glob on their heathen heads. If they’re really threatening we may even lavage them.

After all, it really is a zoo out there.

Shelved in the W’s, the working notes of a hospital librarian in blog format, has compiled what may be one of the more comprehensive physician blog directories I’ve ever seen. Go check it out. I’m sure there’s plenty of interesting reading filed over there.

I don’t think I have a coffee addiction problem. Sure, I drink a couple of cups daily, but it doesn’t seem to affect me too adversely except for some hummingbird-like motion patterns. But I was at the doctors office the other day, and he told me that maybe it was time to cut down. So now I’m on one cup a day:

I know, I know. It’s a tired old joke. But I still think it’s funny.

It was another exciting day on the floors today. My objective was to learn the paperwork that we do for assessments and protocols, which I did in about an hour. After that, I still had a long day ahead. I took half of the assignment from the other therapist, and just had a mellow sort of morning.

The afternoon was more of the same, with the exception of one trache patient who decided midway through the afternoon to become very anxious and full of mucous. For whatever reason, her nurse (one of the less skilled floor nurses, evidently) ignored her for the better part of forty minutes and then called Respiratory in a panic when she began to crump.

So my charge therapist, my preceptor and I ran into the room and did some bag/suction and whatnot until the lady was better. Of course, when I showed up there were about five nurses in the room, and as soon as more than one RT was there they all broke for the hiding places on the floor like roaches running for the underside of the ‘fridge. Not one of them asked if they could help us or if they could do anything, and none of the asked about the patient or explained anything beyond the painfully obvious. This was a somewhat disheartening experience, but it’s not one I’ve had at this hospital yet so I am hoping that it is the exception rather than the rule.

:::

After work, I was feeling kind of bored so I went for a drive. There’s a very nice gun shoppe in my town that caters to the non-sketchy crowd who are looking for some good, honest second-amendment fun. The owner appears to be a former marine, and he is more than happy to assist newbies to the firearms scene in their choice of weaponry. Considering all of the advice I got after this post, and considering the particular store’s stock and the advice of some friends of mine, I think I have decided to become the owner of a lovely little Ruger. The only hurdles in my way are getting a drivers license for my new state and… 395 dollars plus change.

Donations for the “Arm the Therapist Fund” are welcome: e-mail anonymoustherapist at gmail dot com for details.