Respiratory Therapy 101: Just Keep Breathing

I’m lazy tonight but I feel entitled to be lazy. I worked like a dog today and yesterday, and today we had an airway disaster involving a pulmonologist, two anesthesiologists, three and a half RTs, and who knows how many other people. Ultimately we had to nasally intubate with a 7.0 ETT and a bronchoscope.

So because I am feeling lazy, let me post a link to some funny articles. From the depths of the Online Nursing Degree Dictionary, I present to you: 10 Terrible Patients You’ll Find In Every Hospital and How to Deal With Them!

I swear to you that I have cared for every one of these patients. There’s The Paranoid, The Complainer, and most dreaded to RTs on tight schedules everywhere, The Talker. My god, the talkers…they can take an eight-minute neb and turn it into a 45-minute ordeal, and by the end your ears are bleeding and your throat is sore and you feel like you just need to lay down somewhere, but you can’t because now you’re an hour behind on your rounds and they still insist on talking even as you run screaming from the room…where was I?

Also of interest to me was the other interesting article, 10 Ways a Ron Paul Presidency Would Affect Healthcare. Go forth and read, and maybe I will have some original content another day.

I am excited for the new computer system at work. You see, we’re implementing a whole new billing and charting system in the RT department. I suspect that over time it will improve the consistency of our documentation, the adequacy of our care (arguable), and our charge capture. But the big reason I’m excited boils down to one thing: flowsheets.

You see, in most hospitals I have worked in us RT’s get our own flowsheets in the ICU. We document ventilator settings, respiratory and mechanical measurements, and treatments or interventions on them, and typically we leave them attached to a clipboard attached to the ventilator in the patient’s room. We do this for a number of reasons: a physician or nurse who wants to see what we’re doing can easily access the flowsheet, and we don’t have to chase papers when we’re doing our rounds.

But at Sunny Flats, we share our flowsheets with nursing. The ICU nurses have a trifold flowsheet that documents everything they do, and fully 1/3 of their trifold is dedicated to us RTs. The problem is that those flowsheets are in high demand. In addition to all the charting that the RN has to do on it, physicians are using them, risk managers and utilization reviewers are looking at them, the HUC needs them to enter orders and do mystical chart things, and pretty much everyone but the janitor needs the sheet for some reason.

What does this mean? It means that I spend probably a good two hours every day tracking down or waiting for flowsheets, which I then use for about two minutes of good solid documentation. This seems inefficient, at best.

But with the advent of our Computers On Wheels (COWs, complete with names like “Bessie” or “Moo-lan” or “Moo-nshine” or any other cow pun you can imagine) and our new mediserve charting system, documentation will be a cinch. I’ll simply wheel my computer up to the ventilator, click the patient’s name on my worklist, and fill out our vent form. If I do a treatment or any interventions I simply enter them under the appropriate spot in the system. In the event of a patient on isolation for infectious organisms, I’ll do a variation on what we do now, which is to write everything in Sharpie on a paper towel and tape it to the door of the room, to be transcribed once I am in a clean zone again.

This whole new computer system will streamline our processes and make life easier…once the implementation is finished. The implementation will be fun because many of my fellow RTs fear computers like dogs fear vacuums, and also because people tend to fear and resist change. But I suspect that things will get better once the griping dies down.

I, for one, am looking forward to it. Minor changes like this can make enormous differences in quality of care. I’ll keep you posted.

Extrapolate.

I love Calvin and Hobbes.

A nurse and I were talking about a patient today. The patient is a young woman who was recently paralyzed. She has only just begun to understand that it’s not “paralyzed for now,” it’s “paralyzed for the rest of your life.” The horror and the enormity of being permanently paralyzed from the neck down has sunk in. She is quite understandably devastated.

“In fact,” I said to the nurse with whom I was conversing, “just the other day we were talking and she asked me to pull the plug and let her die. It was really sad. I really think she wishes she had died in the accident. She kept mouthing ‘pull the plug, pull the plug’ until I left.”

“Awww…that’s terrible. But doesn’t she have that right? I mean, if she’s competent and she can voice her wishes, don’t we have to honor them?”

“I think she does, absolutely. If she’s competent and she can tell us to stop*, I don’t know why we should keep going. I don’t know if I would want to live like that.”

There was a slight pause as the nurse and I pondered. What would it be like to have such a fate, conscious and aware but completely immobile forever? How do you deal with that, with the horror of never being able to do anything for yourself?

I was brought back to the moment as the nurse took a deep breath and spoke.

“I guess she’d probably have a hard time signing the consent to withdraw form, wouldn’t she?”

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I thought it was funny. But then I may be crazy.

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*Of course, it can be argued that anybody who is expressing suicidal ideation is incompetent by definition. This is a tricky argument and one I won’t get into for now.

I picked something up from somebody at work and now I’m sick. It began in my sinuses and now it’s decided to move in and get cozy in my bronchial tubes. Lovely. I’ve been hacking and coughing and blowing snot out for the last few days, and though I thought it had peaked a few days ago it’s just not going away.

But you’ll note that unlike the million or so bored inhabitants of Scumble County with nothing better to do, I’m staying at home and sucking down some cough drops instead of going to the ER and demanding antibiotics and treatments and pain meds for “this awful cough.” Not that I’m at all bitter about wimps   people who present to the ER for no good reason  people who are differently-tolerant of mild illness  wimps, mind you. I have nothing but the utmost respect for people who  have nothing better to do than abuse the ER    couldn’t find Walgreens with a map and a troop of boy scouts  wish to continue their excellent self-care and so present to the ER to make sure they’re okay.

I don’t know how this went from “pity me I have a cold” to “I dislike many of my patients and wish to use my public forum to complain about them,” but I’m going to blame NyQuil and we’ll leave it at that.

This is part three in the ongoing series of articles about the Rules of the House of God. Parts one and two can be found by clicking the links on this page.

Rule Three is short and sweet:

At a cardiac arrest, the first procedure is to check your own pulse.

Although House of God was written to expose some of the darker aspects of modern medicine, it can contain some startlingly good advice. Some of it is spread out through the book subtly; some of it, like rule three, is short and to the point. It’s a simple rule, a slightly tongue-in-cheek rule, but one that I honestly believe they should be teaching in BLS and ACLS courses. And it doesn’t just apply to cardiac arrests: it applies to emergent situations of all kinds.

Why does it apply to every emergency situation ever? Simple: in an emergency, people get shot full of adrenaline from those lovely little glands atop the kidneys. Adrenaline triggers the fight or flight response. But in this modern world, we’re trained subtly over many years to hold back our responses, so while people’s bodies rev up their brains shut down. The upshot of all this: you, perhaps slightly more seasoned with emergencies, walk into an emergency and find a room full of people standing around, eyes wide and hearts pounding, doing absolutely nothing more than staring at a dead guy. Sometimes there’s a couple of more seasoned people doing CPR, and sometimes they even remember to bring the code cart, but more often than not you’ve got a crowd of gawkers and nobody useful.

This could be averted  if people simply remembered those words of wisdom: in a cardiac arrest (emergency), the first procedure is to take your own pulse. The act of physically moving your fingers over your radial artery and counting the beats brings you back into the moment. It forces you to be aware of your own body, and in a sort of primitive biofeedback way it calms you down. Now, slightly calmer and slightly more aware, you can begin to think.

Let me give you an example. Just the other day at Sunny Flats, I was on the Code Team when a Code 99 was announced on one of the medical floors. I grabbed an airway box and set out with the rest of the code team and their various accouterments: the critical-care pharmacist and his PDA, the ICU nurses with their defibrillator and drug cart, and the charge nurse to monitor and record.

When we got to the room a couple of minutes later, this was the scene: there was a young guy laying flat on his back with a grossly distended abdomen. The charge RT’s had already arrived and were attempting to intubate the patient. The patient’s nurse was standing by and had just finished a round of CPR. The floor charge nurse was recording. These people had taken their own pulses, stepped back and thought for a moment. This was a smooth-running code. A couple of less-experienced people flitted about in a tizzy, but the more experienced folks kept them in control. There was no shouting, minimal chaos, and all things considered it went fairly well.

Compare this to some of the codes I’ve been to, where there’s screaming and shouting and chaos, and the difference is obvious. When everybody is calm and in control of their own functions, emergencies run as smoothly as they can. Of course, sometimes this is not very smooth anyway, but that’s the nature of the beast. Simply remembering to check your own pulse first can ground you in the moment and help you remember not to panic.

And really, that’s all you need to know about how to handle emergencies. Don’t panic. Check your own pulse.

(This is an unusually theological post. I’m no seminarian but I’m pretty sure that I’m right about this. Read on.)

One of the most important lessons to learn in the practice of modern medicine is that no matter how hard we try, we can’t possibly save everybody. Indeed, over a long enough timeframe we can’t save anybody. But I think that this lesson, that we can’t save them all, could be applied just as well to some other professions. Like pastoring.
In one of the ICUs we currently have a rather young patient. The lad in question was out performing minor felonies with his friends when he was involved in some sort of major traumatic incident involving most of his body, but especially his head. His friends, the ever-considerate minor felons that they were, put his lifeless body in the trunk and dumped him in front of the ER.

After a major workup it has been determined that he is just this side of brain-dead. He’s not technically “brain dead” because he still breathes, but he is in a deep vegetative state and he will probably never wake up. Even if he did, it would be irrelevant; the higher sections of his brain were crushed in the incident.

Despite all of this, and because of a lot of ambiguous wording by lawyerphobic physicians and the normal processes of denial, the lad’s family seems to believe that not only will he awaken, he will be his old normal self. But their expectations and wishes don’t meet reality, so they brought a pastor with them when they came to visit.

I happened to be in the doorway of the room next to the lad when the pastor was holding a prayer service. My attention wandered, but I got bits and pieces. Until one particular tidbit of the pastor’s prayer caught my ear:

“Lord, let your healing powers FLOW through this boy. May his healing and his full recovery be an example of just how perfect you are! Let this boy’s healing speak to your power! Christ, we know you can fix this boy and we know you will fix him and glorify your name through him!”

Now. I’m not especially pious in the traditional sense, and I’ve never attended seminary or any sort of religious training. But I know bad religion when I hear it. False hope mixed with bad theology and a truckload of desperation makes for some might bad religion, and while there’s a lot of good to be found in religion it can be badly misapplied. From a medical and a theological standpoint, this pastor was practicing bad bad religion.

Let’s analyze the medical aspect first and the theological aspect second. If I offend you and/or you feel a need to refute me in the comments, please do so respectfully or you will face the wrath of the delete comment key.

Medically speaking: miracles happen every now and then. I’ve seen people recover from illness who I’d written off for dead months before. I’ve seen people come back from the very brink of death. I know that sometimes my negative prognostications are wrong, and that sometimes hope is needed for patients and their families. But I also know that this lad’s brain is gone. Not only is it damaged beyond any repair, it’s growing mold. Nothing is going to bring him back, and anybody who tells the family otherwise is a liar. As I have said before: dangling the carrot of false hope is a terrible idea because it makes the inevitable whack with the stick of reality that much more painful. False hope is abominable, and medically speaking the pastor’s prayer was full of nothing else.

Theologically speaking the pastor’s prayer was filled with bad religion. First and foremost: the point of Christianity is not to live this life forever. The point of Christianity is to make the best of what you have and then go see Jesus. The entire religion is based around human error and human mortality. Everybody is expected to make mistakes, and everybody is expected to die. And with the grace of God, in death you are to have new life. That’s the entire religion in a nutshell. And yet this pastor seems to be willing to overlook this most fundamental aspect of her religion when she begs and pleads with God to change his mind and bring him back to a world that her own religion tells her is evil. But instead of telling the family this, instead of reminding them that all that is born was born to die, instead of giving them hope of the afterlife while they are staring into the maw of the inevitable, she tells them it will be okay. She tells them that Jesus is going to wave his magic Jesus Wand and the boy will pop out of bed, cured of both his brain injuries and his felonious nature.

Not only is this astonishingly bad theology for a pastor, this is the worst kind of lie that can be told. Ultimately, when this boy dies and Jesus never waves his Magic Jesus Wand and the boy isn’t cured, the family will be both saddened by his death and disillusioned by the perceived failure of their prayers.  The pastor’s prayer is destined to fail on every single possible level, unless you count the few moments of false hope delivered right after the prayer as a success. I’d entertain the argument that making the family feel better in the moment is a worthy cause, but I don’t buy it. Ultimately this is going to make it worse for them. Promising that God is going to do anything is bad form for a human being of any religion; but the circumstances here make this an especially grotesque parody of what the religion is supposed to be about. Christianity is about hope for the next life, not an indefinite extension of this one. And I think that that truth is too often lost in the politics and the badness these days.

After all, you can pray all you want to, but you can’t steer a train.
Less religious posts to resume shortly.

I just got word via a comment on the About page that there’s a new RT forum out there on the web. Respiratory Care Forum is a new place for RTs to go and have professional chatter about RT things like ET tubes and research and the hardcore clinical sciencey things that this blog tends not to focus on. Right now it’s just getting started, but I’d be willing to bet that as this catches on it will attract some interesting conversations. It has the added benefit of being a provider-only forum, so we can theoretically avoid the hassle of dealing with general public trolls.

I’m planning to register. I’d encourage any other interested RTs to do the same!

A scene from the ICU today:

“Hey, what happened? I thought that the kid in 8 was supposed to go to a long-term place.”

“He was going to but then they found out that his brain is growing mold. I guess some Aspergillous got in underneath the plate in his skull and now he’s full of some kind of fungus. Infectious Disease doesn’t know what to do because nothing will cross the blood-brain barrier. I guess we could spray fungicide on the plate…can you imagine growing fungus in your brains?”

“Well, look on the bright side. He used to just be a vegetable but with the extra mushrooms he’s got the entire produce section down.”

Here’s something that has been on my mind lately.

So. Let’s assume that there is a patient who, in all probability, is infected with HIV. Let’s say he is a happily married middle-aged man. The suspicion of HIV arises when the patient presents with some atypical infectious organisms and a history of sexually transmitted infection. The ID physician suspects HIV and asks the patient for consent to have an HIV test.

The patient refuses and asks us not to tell his wife that we want to test him for that.

Now, according to “medical ethics,” the right thing to do is to honor the patient’s autonomy and not test him. His private health information is his and his alone, and regardless of the circumstances we must honor his wishes. But how can this be ethical? His refusal to be tested doesn’t just endanger his health: it endangers the health of his entire family. Doesn’t his right to swing his fist (by refusing the HIV test) end at someone else’s nose (the potential effect on his wife and daughter’s health)? Let me add here that I’m not advocating that we force him to act on the results of the test; I’m just advocating for his family members, who I think have a right to know if he’s infected so they can take reasonable precautions against becoming infected themselves.

What really gets me about this is that we in medicine routinely fail to honor patient autonomy. Physicians will override DNR wishes, family members will refuse to recognize living wills. Patients who wish to die are deemed incompetent and kept alive against their will. When it comes to death and dying, we are only too happy to override patient autonomy. But when it comes to a lethal infectious disease that poses major public health risks, we honor patient autonomy like Jesus himself is going to smite anyone who doesn’t.

How is this ethically correct? The behavior of healthcare practitioners in general is inconsistent at best in this regard. Further, I can’t think of any good reason not to test the patient.

What if he is afraid of the results, you ask? Well, that’s a stupid question. If we didn’t tell people what was happening to them because we were afraid that they would be afraid, then we’d never tell anybody anything.

What if he doesn’t want to know? I’m sorry, but if he doesn’t want to know if he is sick then why did he present asking for treatment? If he didn’t want to know that he was sick he probably wouldn’t have sought medical attention.

What if he doesn’t want to know because he’s afraid of the social stigma? Frankly that’s not our problem to deal with.

And finally…

Patients have a right to refuse, you say. That’s true. They do have that right. However! We routinely ignore that right when people display signs of being mentally incapable of making decisions. For example, a psychotic patient who declines treatment is going to get treatment whether or not he likes it. Doesn’t the right of the patient to refuse become a gray area when it’s a public health issue? I don’t want to advocate infringing on his civil rights, but I do think that his refusal to be tested puts his immediate family in a not insignificantly risky position.

I honestly can’t think of any good argument against testing him. And it drives me insane that this man is willing to risk infecting his family with HIV just to put off his inevitable fall from grace and save a little face in the here and now. It sickens me and to be perfectly honest I find myself disgusted by this mans actions. Judgmental? You bet, but we’re all judgmental on the inside. I’m just letting it out today.Discuss.