Respiratory Therapy 101: Just Keep Breathing

First and foremost: over at the Respiratory Therapy Cave there is an overview of 2007, the year of the RT weblogs! Go ahead over and check it out.

Now on to the content of the day.

I was babysitting another RT’s ICU yesterday while she was in CT scan with a patient. I was planted behind a desk, keeping my ears open for vent alarms or the telltale sounds of the crash cart, when the doors to the ICU swung open and a harried-looking CCU nurse burst through the doors. He was dragging behind him a stretcher, attached to which were another stressed-looking nurse and a miniature teenage transporter. I stood up and looked at the patient as they maneuvered the stretcher into the room.

The patient was a middle-aged man, flat on his back with an enormous cardiac scar on his chest. His head was cocked to one side, and his eyes were wide open and focused at a point in the middle distance. I watched him as he went by and became concerned when I noticed that he didn’t seem to be breathing.

I jumped as my co-worker returned behind me. “He’s got the whole ‘Come-To-Jesus’ look going on, don’t he?” she said to me. “Is he even breathing?”

“I’m not really sure. He could be.” I followed the stretcher into a room, my co-worker just behind me. While the nurses made the bed ready and prepared to slide the patient over, I walked up and stood next to the stretcher. I placed my hand on his chest and looked at him for a moment. He was breathing; I could feel some excursion with my hands. But it was shallow and not sufficient. Better get the airway box, I thought.

The nurse had other plans.  He came up behind me and leaned in close to the patient. With a colossal breath in, he bellowed:

“HEY! HEY! YOU GOTTA WAKE UP NOW, MISTER! WAKE UP!”

With a jerk and a jump the patient lifted out of the bed and snapped out of his trance. His wide-open eyes found the nurse, and he screamed back:

“WHY?”

A snappy comeback, and one that made me a little more confident that this patient would be alive for a little while yet.

I’ve been nominated over at MedGadget under the “Best New Medical Weblog (established in 2007)” category! This is quite exciting, as when I began this blog I never expected to even find an audience. In light of the fact that I have indeed found an audience I’d just like to say “thanks” to everybody who reads this thing. It’s a lot of fun to get the odd e-mail from a reader and to see the comments that get left here, so I’ll try to keep the good stuff coming and hopefully you all will stick around.

I’ll be back to more regular blogging in a few days once I am back from my Christmas break. Hope everyone had a jolly holiday!

I’ll be on a little holiday-related break for the next few days, but expect the resumption of the normal madness around the end of the month. Once I get back to work I’m sure I’ll have tons of holiday-related stories to tell you all!

Meanwhile I’m off to visit the family. Merry Christmas everyone!

Dilbert pulls through again. I often want to ask people what Alice asks the PHB in this strip but I usually manage to bite my tongue.

Dilbert is reproduced here without any permission at all.

Go and read this over at ImpactED nurse. Go on, go and read it and then come back.

What bothers me about this isn’t that he drove nails into his head to drive away evil spirits. Indeed,much of the literature recommends driving nails into the head to cure Evil Spirititis. Making new openings to allow the spirits to escape or trying to spike them with a nail makes sense under the circumstances. No, it isn’t the patient’s logic that bothers me. What bothers me is his lack of pattern recognition. It seems to me that after the first two or three nail-skull interfaces failed to resolve the Evil Spirititis, he would try an alternative therapy like exorcism or hard drugs. It’s a classic case of poor pattern recognition, and maybe it’s how they know he is crazy. After all, the definition of insanity is doing the same thing over and over and expecting different results.

Sorry for the lack of content here lately. I’ve had a few days off and some family is in town for a visit, and last time I worked all of my patients were boring or crazy. I had one crazy woman who was out of it and believed me to be trying to kill her. For some reason a lot of delusional people think I am trying to kill them.

I had a delusional patient a few days ago who was involved in an MVA in November. He was busy smoking drugs when he crashed his car into some sort of obstacle and ejected himself onto the roadway, spattering his brains against the inside of his skull. But the brain-spattering wasn’t enough to kill him outright, just enough to make him a little loopy. When I saw him at the end of last week, he demanded that I stop trying to shoot him and then tried to strangle me, an attempt which was hindered by his wrist restraints. When he realized that strangling me was not an option, he settled for kicking violently at me and screaming. Now, his history with me was long and complex. He had been on the vent for a couple of weeks and given me endless amounts of trouble by being “difficult to wean.” He was a COPDer on top of his many problems and his respiratory status was suboptimal. A further complication was his psychosis; trying to treat a combative and insane patient is not easy for anyone, especially for mask-and-needle wielding RTs.

I left his room to a symphony of shouted profanity and threats. I covered my ears and closed my eyes, trying to make my patient-generated headache leave. As I uncovered my ears I overheard the trauma doc discussing when to bring the psychotic man to the OR to give him a PEG tube. My head continued to pound as the patient continued screaming his delusions. An idea formed in my head.  I sidled up to the doc and insinuated myself into his discussion with the nurse.

“What’s going on? You’re going to take him and PEG him?”

“Yeah. He needs the feeding tube and I figure he’s too marginal to do him bedside, so I’m going to bring him to the OR and do it there.”

“You know, this guy was a pain to wean. It took us almost two weeks to get him off the vent and he’s just now recovering enough to be feisty. If you take him to the OR and reintubate him, he’s going to wind up right back where we started and we’ll be behind another two weeks. Why don’t you trache him while you’re in there anyway? It would save us all a lot of time and effort.”

“You think that’s a good idea?”

“Absolutely! I think we need to do more early traches here actually*. Why not begin with this guy?”

The trauma doc nodded and I excused myself. My work here was done. A day later the psychotic man was trached. Why, you ask, would I ask trauma to trache the psychotic man?

First and foremost, his respiratory status was marginal. If he had been intubated he would have stayed intubated and run up an enormous bill over the next several weeks which we would see very little of. He would have been more likely to get ventilator-associated pneumonia, sepsis, a worsening of his psychosis or some other ICU complication. With a trache he could be weaned from the vent sooner and then sent out to a chronic-care floor.

Second but equally as important: when you’re trached, nobody can hear you scream. And after days and days of being abused by this man, I didn’t care if he never spoke again. In this case a trache was a perfect panacea: it would sidestep a medical complication, it would facilitate the patient’s eventual transfer to another facility (placement comes first,) it would probably reduce his ICU length of stay and it would greatly reduce the amount of time I had to spend listening to the worthless garbage coming from his mouth. Respiratory Therapy: it’s all about problem solving.

* I really do advocate for early tracheotomy. Many studies I’ve read have indicated that after seven days of intubation, tracheotomy is indicated and can greatly reduce lengths of stay and medical complications. It facilitates ventilator weaning, facilitates airway management, and ultimately can lead to better outcomes. All kidding aside I really think we should be traching more people.

Wow. I have been beaten in every aspect by The Happy Hospitalist’s Frequent Flyer Club. It is a total, comprehensive guide to all of the chronic patients that we have to deal with. I am impressed!

Hat tip to Shadowfax at Movin’ Meat who originally posted this awesome link.

As you may recall I had some rage issues with a nurse in the PACU a little while ago. Today, much to my delight, I met that same nurse in the PACU when I had to wheel over a “wake-up vent.”

When I saw her, I made eye contact and then simply turned and ignored her. This made her decide to agitate me. She nudged the anesthesiologist, a mellow bearded man sitting next to her documenting, and spoke to him.

“Hey, last time this guy was here he freaked out when I extubated somebody.” She was all smirks and giggles, the unspoken message being: look at this clown! Thinks he’s all that and he can’t even take an extubation. The anesthesiologist looked up at her.

“Oh really?” He gave me a quizzical glance. I remained silent,dialing some settings into the vent.

“Yeah, he got all angry at me when I did it.” At this point I spoke up.

“That’s because we do it the right way, and you do it the wrong way. And you know that’s fine. I’m not here to pick a fight, and if you guys want do it the wrong way then that’s fine. But over in the ICU we like to do it right.” The nurse scoffed at me and the anesthesiologist looked over at her.

“How did you do it?”

“Just like you guys do. I just popped the balloon off and pulled the tube out.” The anesthesiologist cocked an eyebrow.

“Um, that’s the wrong way. You can’t do that.”

“What? Why not?”  She gave the doctor a wide-eyed stare, incredulous at being corrected by the person she was hoping would back her up. Sensing an opportunity I chipped in at this point.

“Because if you don’t take the air out of the balloon first, then you could theoretically cause vocal cord paralysis or damage the cords. There could be swelling and even airway compromise. You could really screw somebody up that way. Ripping the pilot balloon off is no guarantee that the air will leave the cuff, which is why we prefer to deflate it first. It’s a small risk but to prevent it only takes a few seconds.” The anesthesiologist nodded and went back to his paperwork with a final word of advice to my nemesis “Yeah. You should really be deflating the balloons.” I resisted the urge to jump across the table and scream“In yo’ FACE!” at the nurse, and instead settled for giving her a shit-eating grin and sauntering out of the unit, vindicated.

Round two:

RT 1

PACU RN 0

I have always loved the online cartoon Red Meat. Today’s strip seems to sum up my job in a nutshell.

I often wonder if I am actually very crazy and simply unaware of it. If I am crazy, I think I have some kind of Crazy Power Disorder, where beneath my mild-mannered exterior is a raging megalomaniacal egotist who is just waiting for a chance to get loose. I often begin to wonder if I am crazy like this after making judgments on the lives of people who I have never met. For example, one of my patients today.

The patient is a 43-year old man who is in the hospital for a coronary artery bypass graft. He is an unemployed morbidly obese drug-using government-check-cashing drain on society who has recently decided to further his pursuit of scumdom by developing a meth habit. For reasons unclear to me, somebody thought it would be a good use of time and resources to enable this mans lifestyle by fixing the problems he gave himself, and so it was that he underwent a coronary artery bypass grafting today.

When I got report on this man and realized I’d seen him before, and when I realized that he was still abusing drugs and refusing to care for himself, my immediate reaction was rage. Why do we do this? Why do we enable this mans defective lifestyle? There are those who argue that maybe this will be the impetus for him to turn over a new leaf but I simply can not believe that. If he is like every single person I have ever met, he will not turn over a new leaf; he will try for a day or two and then go back to what he was already doing. We’re not going to cure his ills: we are going to enable him to continue his selfish, destructive lifestyle. We are the codependents to his alcoholic, the enablers to his addict. We are making it worse by fixing him. I find myself thinking, If I were in charge we’d just let him die, because otherwise he will never learn. And that is a scary thought to be thinking: it occurs to me that I am disregarding the life of another human being simply because I find him to be a repulsive pile of scum. And then, after that emotional burst, I remember logic, and realize that he was disregarding his life long before I was.

After all of this, I sit down and I find myself wondering: am I crazy? Have I gone off the rails, or am I just being honest with myself and not being sucked into the delusions of some of the aspects of modern medicine?

Any opinions? Am I crazy?