Respiratory Therapy 101: Just Keep Breathing

Another article in my series on the Rules of the House of God is coming up, but in the meantime, why not enjoy some  other blogs?

Freadom over in the RT Cave has written a good Q-and-A about rescue bronchodilators, those wonderfully abused but mostly harmless drugs.  He’s hinting at a crucial point, which is that physicians tell patients that Albuterol will prevent them from developing an asthma exacerbation because they’re too lazy to write prescriptions for real control meds like Flovent, Advair or even Singulair. Go on over and read the Q/A, it’s interesting.

Meanwhile, GruntDoc has been making lawyers crap their pants in the ER. There are very few things that make seasoned ER personnel nervous, but the phrase “I’m a lawyer” is enough to give just about anybody pause. However, the tables turn when the lawyer is on the table, as we can see here.

Moving out of medicine and into Politics, we can see that there’s an initiative coming up to repeal the income tax in Massachusetts. Having previously lived, worked, paid taxes and driven (”Spirit of America”apparently refers to passing on the right with extended middle digits–and that’s just the cops) in Massachusetts I am intrigued by this. The state doesn’t exactly have a reputation for this sort of tax-repealing small-government movement, at least not since we threw all the tea into the harbor, but maybe some of the libertarians from New Hampshire have been creeping across the state line.

Further updates as events warrant.

I know it’s been posted before–in fact, I am stealing it to re-post from the bored attorney over at Addicted to Medblogs. It’s just too amusing to me not to post this and share the madness with the rest of you.

From a combination of boredom and lack of other shows on TV, I am watching one of those silly TRAUMA: Life in the ER shows on the discovery health channel. I just saw a physician with whom I have personally worked and interacted during my RT training at a big medical center. She was the medical overseer of the entire RT program. The other students and I had to give presentations to her as part of our clinical education.

Let me tell you, that throws you for a loop. That’s about the last person I’d expect to see on TV.

Sometimes I put on those silly ER shows in the background while I am puttering around the house doing things. I don’t mean the fictional shows like “ER” where the doctors do everything and the nurses want nothing more than to bed them and steal their fortune; I mean the “real” shows where some dude with a camera follows around an ER doctor and sees what they do for a day.

Just now on one of these shows, a third-year ER resident was discussing a baby who was delivered at 28 weeks by a cocaine-using mother who checked out AMA and hit the streets for three weeks before deciding to come back in and try to take the baby. She enrolled in rehab in an effort to take the baby back and get custody of it at some point.

The doctor said this:

“Sometimes you do something and it really does affect someone’s life. Maybe this will be a good thing. I think she’ll go to rehab and get clean and make a new life for herself all for this baby. Sometimes these babies really change lives.” She then stared at this baby for a long moment and smiled wistfully.

I found myself wondering: how could somebody go through three years of medical residency in an ER and still have that kind of hope? How does she not see the more obvious and more likely trajectory, where the mother tried to get custody and then relapses and then goes back and then gets the baby and relapses and loses the baby and so on ad infinitum? I don’t have that kind of hope. I doubt that the mother’s life is going to amount to much more than despair and regret, and I suspect that the kid will probably go through our foster system…maybe there’s some hope there, but maybe not.

Anyway, it got me to wondering: how do these people maintain this kind of hope? Am I just a gloomy person, or are many people actually that deluded? I know that what I do can change lives, but I’d say for every one life I change for the better or actually “save” there are 99 lives that I’ve done little more than prolong or keep alive to allow people to continue making the same mistakes. Is this just me? Am I wrong to be doom-and-gloom, or are the hopeful the deluded ones? I really can’t tell sometimes.

I hope I’m wrong.

Wow! According to some amazing new research, government programs for the needy place an undue burden on emergency services. Who would have possibly guessed it?

Now, before I get a thousand snippy comments from people who are angry that I am suggesting that the poor should be denied emergency services, let me clarify this. The reason that so many of these destitute bums* wind up coming to the ER is that they lack any other options. As I understand it, Medicare and Medicaid don’t typically pay well enough for private physicians to be willing to accept patients whose only means of payment is through those programs. This means that an enormous percentage of these people have no primary care physicians to do things like monitor chronic illness or manage minor ailments, and as such these people wind up presenting to the emergency room with bullshit complaints. People who aren’t in the field don’t seem to get this: our Fearless President recently stated that he thought it would be okay for people to just go to the ER rather than see a private doctor.

Now, even if we reformed Medicare/Medicaid and made it possible for the destitute* to go and see primary docs, we’d still have a fair number of problems in the ER. We’d still get the dumb-asses who come in pretending to hurt just to get drugs, the people for whom the question “what number from one to ten is your pain” is an invitation to suddenly drop their 200-dollar cell phone and pretend to writhe about in agony, screaming “it must be a twelve!” The only ways to get rid of these people are to either shoot them (generally considered unethical) provide them with terrible service so they don’t come back (frowned on by paper-pushers) or to perform large numbers of punitive diagnostics such as spinal taps and blood gases with 14g needles (also unethical.) I’m a believer that enough documented abuses of the ER should be grounds for refusal to treat; plenty of people get snotty and whiny about this, but they’re not the ones dealing with whiny liars all day.

But even if we got rid of the financial burdens and the lying whiners, we’d still be stuck with a big problem in the ER: overdiagnosis. By this I mean the overuse of expensive diagnostic exams for no real reason other than the ER doc feels like it or the ER doc fears a lawsuit if he doesn’t get this diagnostic. I was the victim of many useless diagnostics in a recent ER shift in which I performed 16 blood gases and four arterial lab draws with BGs in twelve hours. Of the 20 blood-gases I ran that day, maybe three of them were indicated: one on an unresponsive intubated patient, one on a decreased LOC, and one on a diabetic in DKA. The other 17 blood gases were drawn and analyzed mainly because one of our ER doctors orders them on everybody who comes in for no relevant reason. Now, a blood gas analysis costs somewhere around 200 dollars, so if you add it up I billed for 3,400 dollars in useless diagnostics over twelve hours. This is a problem in other departments, too: an enormous percentage of our patients get things like CT scans simply because people are out of ideas and want to feel like they are doing something. After all, even an unindicated useless exam is more something than nothing. Incidentally this is a clear violation of Rule 13, which I will be essaying about at a later date.

Anyway, the point I am driving at is this: the emergency medicine system is badly broken. No longer is it a system in which people having genuine emergencies are seen and treated by physicians who only use evidence-based medicine to solve simple and complex medical cases. It has become a catchall, a safety net in which the dregs of society are caught and given treatment based on either (a) the preferences of aging physicians who don’t believe in evidence or (b) the fear of lawsuits from irate patients. Genuine emergencies still come in frequently, but they are sadly overlooked and forced to queue with the patients who are in the ER just because they have nowhere else to go. Only if we can solve the problems of government healthcare, whiny liars, and overzealous physicians will the emergency room be returned to its proper place in the hospital: a place for patients in crisis to go and be treated.

Any ideas?

Not too long ago I told you the tale of a rather intriguing and ironic tattoo that I saw at work. Recently another tat has trumped the previous one.

The patient is a man who was walking down the highway at night after snorting cocaine. He was walking in the dark on the side of a busy freeway when he was struck from behind by a fast-moving large truck. His left arm was almost severed, he suffered from a flail chest (the “sucking chest wound”) and he was mangled beyond recognition. Sometime during the collision his skull was shattered in a couple of places.

The patient looked like a rough sort of guy. His muscles were toned, his body was covered in tattoos and (deliberately) pierced in many places with metal objects. His tattoo-to-tooth ratio prior to the accident would have been good; after the accident not so much, but he’ll be able to chew if he ever wakes up.

In order to get him to the OR it became necessary to shave his head. I was present during the head-shaving, and much to my surprise as the nurse shaved his head a new tattoo became visible.

Wrapped around the back of his skull, opposite the portion of his skull that was struck by the truck, was the word CRUSHPROOF.

The irony is delicious.

This is a story that will stay with me for the rest of my life. No matter how I try to forget this little gem, it will always remain locked inside of my brains somewhere, just waiting to come out. Anybody who’s offended by the fact that people have genitals should stop reading this right now.

It was a cool day in the early fall in the Great North Woods. I was working an extra shift at Our Lady of Immaculate Grace, a day shift for a change, and the effect of the sunlight and the odd hours (for me) were combining to make my day an exercise in caffeine-driven medicine. Luckily for me, the day was turning out to be on the slow side, and so it was that I was sipping a steaming cup of coffee and admiring the gorgeous fall day through the window of an empty room when I felt the pager vibrate at my hip. I swallowed my coffee and glanced at the screen.

PLEASE CALL ER 8120

I put down my coffee and picked up the phone in the patient room. The ER phone rang once, twice, three times. Finally the secretary answered.

“Emergency.”
“Respiratory.”

“Hang on.” There was a thud as her phone hit the desk. I heard a distant who needs respiratory? Some muffled speaking responded and the secretary returned to the phone. “They need a blood gas in room one as soon as possible.”

“I’ll be right down.” I hung up the phone, chugged the remainder of my coffee and went to find the student. After all, if I can get paid to have somebody else do my work in the name of learning, why not? I wandered into the ICU and found the student checking one of our vintage 1980’s PB-7200 vents.

“Want to get a blood gas?” The student looked up and nodded. I found his preceptor and told them I was stealing him for a few minutes, and then the student and I marched through the halls, twisting around bends and descending stairs until we were in the basement ER of Our lady. On the way I explained the ER to the student.

“There’s a board behind the desk that has all the patient information on it, so you can copy their names and stuff before you have to do anything. Make sure you get a blue-card* stamp on them and check your orders.” We entered the ER through the Secret Staff Entrance and I went to examine the board. Something was off: under the DIAGNOSIS column for room 1 was the legend priapism. I turned to the secretary.

“Hey, you said room one, right?”

“Yeah. Here’s the chart.” I grabbed it from her and examined the cover sheet. The box for ABG was checked off. I figured that somebody had forgotten to write in a new diagnosis and shook off my doubts. I grabbed a blood-gas kit, beckoned to the student and went to the room. I knocked on the doorframe, pushed the curtain back…and saw what was quite possibly the last thing I was expecting to see.
A middle-aged man was reclined on the gurney. His legs hung over the foot of the gurney and he was on his back staring intently at the ceiling while a white-coated urologist peered intently into his disturbingly tented johnny. I stopped dead in my tracks and blinked once, then twice. I glanced at the student, who had his head cocked to one side and seemed perplexed by the scene before us. The urologist ceased his peeping and turned to us, eyeing the student and me over the top of his reading glasses.

“Ah, respiratory. Good. I need you to get a blood gas–” here he pointed at the unfortunate patient’s engorged member–”on this.” He rolled his stool back to let us in and gestured at the johnny-tent.

There was a long and awkward pause. Dare I say that my posture stiffened a bit? The student, on the other and, was wilting into a flaccid pile of collegiate awkwardness in the corner. I stared at the urologist, and he stared back at me. The patient stared at the ceiling and probably tried very hard not to think about what the urologist had just asked me to do. The atmosphere was a bit tense, to say the least. Finally I spoke.

“I’m sorry, you want me to do…what?”

“I want you to get a blood gas. On his…you know. On his priapism.”

“You want me to what?!” I turned bright red in embarrassment and shock. Nothing in the world could have prepared me for this. I never learned about this in RT school; our blood-gas models were plastic arms, not fake penises. I was deeply and truly shocked that someone would ask me to stick a needle into another man’s genitals. Perhaps I have not spent enough time in the city but this truly seemed unusual to me. The urologist, not sensing my confusion, simply nodded at me, saying: of course I want you to do that. Just another day in the life, right? I stammered out an objection.

“I…um…no! No, I absolutely will not do that. That is so not even in my scope of practice to be jamming this needle into that man’s penis.” The patient, already tense, turned white at the mention of this act. The urologist’s resolve seemed to harden at this point: my denials of service served only to infuriate him.

“You will so! I need a blood gas on it to see how long it’s been like this. He says maybe four hours, but I need a CO2 and a lactic acid to be sure. And you’re the people who draw blood gases, right? So do it already! You just put the needle into the corpus cavernosum and you’re there. Easiest thing in the world. Simpler than wherever you usually get them.”

“That’s as may be, but no way. Absolutely not. Nyet, nein, nay, no. If you get me the blood I will run it but I am not going to do that. I’m going to go wait by the nurses station and you can bring me the blood to run.” I left the syringe on the table, turned on my heel and left. I wanted to apologize to the patient but the embarrassment would have been unbearable for both of us.

It was a brief wait before the Urologist brought out a tube of blood for us to run. The CO2 was pretty high; the lactic acid was 17, an astonishingly high number indicating that he’d had a problem going on for quite some time now. The urologist was pleased with these results, and evidently solved the problem by draining all of the blood from the penis through some sort of needle. I was curious to see exactly what was done…but not that curious.

:::

To read the tales of a real-life urologist, see Keagirl’s blog! She’s been busy with Sudoku lately but hopefully will be back soon.

*The blue-card stamper was a machine in which a plastic card with patient demographics was inserted between a sheet of paper and a gigantic stamping machine. It is a precursor to the more modern adhesive patient labels.

I think we all know that the mass media has a tendency to skew information. I try not to put too much stock into anything that the media tells us because most of the time it is either factually inaccurate or deliberately skewed. This is especially true when it comes to medicine in the media.

Reporting on medicine in the media tends towards two types: there is the “minor threat that will steal, kill and eat your children” coverage such as the recent hubbub about MRSA; and there is the “research that reached tenuous conclusions after years and years of study and review that will be boiled down to a probably inaccurate 32-second blurb.” Another common type of medical reporting is the “inspiring story about a guy who overcame something,” but this story style seems to be on the down-and-out with the recent trend away from anything positive and towards shock and raw emotion in the media. As usual, The Onion manages to capture all of this remarkably well in a perfect little piece of satire entitled Man Lives Thanks to Heart Stolen From Dead Man.

It’s just a matter of time until Good Morning America is doing this. Mark my words.

Well, it’s Monday and I am far too lazy to actually make any content today. So for your amusement, I present to you some links!

First, Julia at Snotjockeys Revisited has written an informative and fascinating piece about resistance to change. She explores some of the reasons behind the resistance to changes in the medical field, and her analysis seems spot-on to me.

Second, an anonymous medblog troll named Linda has apparently decided that MonkeyGirl is an evil evil nurse. Now, we all know that this isn’t true: indeed, MG is a footsoldier on the front lines of the endless battle with Sumdood and his pill-popping legions. Now, Linda claims not to be a member of Sumdood’s endless legion of narc-abusing pain-fakers, but someone with a reaction this visceral to what is clearly a humorous jab at some of the most frustrating and obnoxious patients we deal with is probably compensating for something.

More links as I stumble across intriguing things.

Despite my recent raving about Gomers and the frustrations that they bring to the healthcare world, I honestly feel a lot of sympathy for them. They’re feeble old people who should have been allowed to die with dignity, but who we are keeping alive for reasons I am unable to discern.  Terry over at Counting Sheep has made this point much more eloquently than I have. The last line here is exactly what I have been trying to say:

These are the lost people of our society, and they cannot speak for themselves: the crowning culmination of a life. lived. long. They come to our ORs to have feeding tubes inserted into their abdominal wall; to have their bedsores scraped and excavated; to have their broken bones repaired; to have months and sometimes years of neglect “fixed” so that they may return to exist. In a life without hope or happiness, only today, over and over again.

“Where do they all belong?”

This old, edentulous woman, this shriveled shadow of a man in the bed. Surely he once laughed, and dated; she married and bore children. She cooked; he worried about his family. She did the ironing and darned the family’s socks. He had opinions; he balanced the checkbook. She felt the hot sun on her head; the icy winter blast of wind braised his cheek. She lost her husband too soon; his children all moved away.

There is nothing we can do to save them from us.

How very true.