A little knowledge is a dangerous thing March 29, 2008
Posted by keepbreathing in Career Advice, my life, stupid people, weird.5 comments
I’d just like to take a moment to remind my readers that this blog is intended mainly to be a source of entertainment, not a source of education or reliable medical information. I am a certified and licensed respiratory therapist, but I am not a physician and I do not know you or your circumstances. I would be happy to provide information within my scope of practice, but you’re better off checking with a physician or other healthcare provider face-to-face than you are getting information from a blog written by a stranger on teh intarwebz.
I bring this up because I got an email some time ago from a fellow RT. It seems that a colleague of hers who was in possession of a little knowledge made an interesting string of decisions. My fellow RT explains:
I have been subscribing to your blog for a while now and I just have to tell you thank you for the shit you have stirred up in my Neonatal ICU. I am a Respiratory Therapist of 8 years…I have a patient who was a 25 weeker and is now 7 months old. He has been in the unit since birth and required at least CPAP of +10 . He has severe tracheomalacia .Well he REQUIRED it until 20 or so days ago when Nurse KnowItAll convinced the physician that he “really didn’t need it at all”He was switched to a trach mask on Feb 6 and continued to struggle to breathe until a few days ago. You see we do primary nursing, so these nurses seem to think that they know ALL aspects of the patient’s care, including the Respiratory part.We called in the big dog, the Pulmonology Medical Director who recommended CPAP for this patient. Nurse KnowItAll blew her top and very loudly made her case for no CPAP known. Needless to say, he did not go on CPAP that shift.The next day the Big Dog came through again and voiced his dismay as to “why they ask for my consults and then don’t listen to me”……..the patient went on CPAP much to my joy. I had been saying all along that the baby needs help breathing.The next day Nurse KnowItAll was back on shift and royally pissed. She even brought forth some “information” that CPAP is not FDA approved for infants at home. She was trying to convince folks that he could not go home on the LTV 1200 that we had him on, because it was CPAP.Where do you come in? I know you are wondering that very thing.Well the next day Nurse KnowItAll was not there but Nurse SweetandNice was and she pointed out the medical article that Nurse KnowItAll had printed off to prove that my tiny patient was not benefiting from CPAP because he had an uncuffed trach.I immediately recognized the title!Respiratory Therapy 101-Just Keep Breathing. It was your blog from June 6 2007 entitled CPAP and uncuffed tracheostomies:just say “no”.
I laughed my ass off. This was her medical research that showed that my patient could not use CPAP. Clearly she missed the all important word FENESTRATED in your argument against CPAP for your elderly patient.Soooo we have now called a patient care conference for next week, and I plan to tell them that her research is just a blog (No offense really, I love your blogs)If nothing else thanks for the laugh and for giving me the opportunity to tell Nurse KnowItAll that she really is a dumbass!!!!
Rule Number Four: The Patient is the One with the Disease March 28, 2008
Posted by keepbreathing in Career Advice, The Rules, health, hospital, medicine, respiratory therapy.Tags: disease, hypochondria, medicine, rules, rules of the house of god
2 comments
It’s time for installment number four in my long-neglected series on The Rules of the House of God. Today’s rule: The Patient is the One with the Disease.
At first, rule four seems obvious. Many of you are saying, “Of course the patient is the one with the disease. That’s why they’re the patient, you jackass.” But if one looks at the rule in the context of the book it becomes more meaningful. It confronts some of the demons that young, idealistic people in medicine often have to face: the hypochondria that comes from seeing endless streams of sick people, the paranoia that comes with the hypochondria, and the specter of mortality.
Hypochondria
Hypochondria is an easy thing to develop. It is especially easy to develop when one spends a lot of time with sick people. It is not uncommon to face patients day in and day out who present with minor complaints and wind up becoming critically ill or dying. People present with a chest cold and wind up dead a week later; the headache becomes a brain tumor or viral meningitis; toe pain turns out to be terminal bone cancer.
When I first got into Respiratory Therapy, I was very young and very idealistic. I wanted to help people and I wanted to feel like I was saving lives and making a difference. I assumed that fixing people’s breathing would be easy and that it would be appreciated. I was completely unprepared for the magnitude of the suffering that my patients were experiencing. I simply had no idea how sick people could get, and what really got me was that these people were exactly like me, and too often there was nothing I could do to alleviate their suffering. I felt powerless and frightened.
Paranoia
Eventually it began to wear me down and I started to get paranoid. I’d have a stomach cramp and immediately wonder if my appendix was about to burst. I’d get a headache and flash back to a patient with viral meningitis whose new home was heavy on lush hardwood and conveniently located beneath six feet of sod. It began to affect my attitude and my performance: since these patients were doomed anyway, why were we bothering? What’s the point? I got depressed. The job wasn’t what I signed on for; by virtue of a sheltered rural upbringing and simple naivety I was unprepared to face sickness and suffering.
And then one day it hit me: no matter how bad I feel I’m not the sick one. I can stick a needle into some guy and not feel a thing*. As the rule says: The Patient is the One with the Disease. Realizing that helped me get over my shock and my frustrations enough that I can function relatively well as an RT and as a human being…although I do still have a tendency to question the reasons for much of what we do.
The Specter of Mortality
To me the rule is definitely about hypochondria and the process of learning to deal with suffering, but it is also about mortality. In the book, Shem embodies mortality in a patient known only as The Yellow Man. The Yellow Man is a patient who develops hepatitis under a suspicious set of circumstances. One of the resident physicians working alongside the narrator misses this diagnosis. Because of this, the patient worsens, becoming progressively more and more sickly. The mental and physical health of the resident begin to suffer; he feels overwhelming guilt about the part he played in The Yellow Man’s illness. Eventually the Yellow Man dies, and the resident commits suicide by flinging himself from the roof of the hospital**.
Reading into the story a little bit, it becomes apparent that the resident felt deeply guilty for what happened to the Yellow Man. In his efforts to help, he hurt; and instead of learning from his mistake and moving on, he became consumed by guilt and responsibility. Ultimately, he took on the disease of the Yellow Man; not in a literal sense but in the sense that he was unable to function normally as long as the Yellow Man remained ill. The resident embodies the rule: he fails to learn that the patient is the one with the disease, and as a result he is unable to function. He is so stricken with grief and guilt from his mistakes that when the patient dies he commits suicide. The lesson is vital: if you forget that The Patient is the One with the Disease, bad things will happen. Always.
Conclusion
And so we can see that the rule isn’t a callous statement about physical pain or a degrading statement about the health of sick people. It’s a warning, a reminder that if you forget which side of the bedrails you’re on you’ll be unable to function. It is vital to remember that the patients are the sick ones. It doesn’t mean that we can’t feel bad for them; quite the contrary. It’s a reminder that if you carry the sympathy too far, if you take things personally and dwell on them, you’ll die a little bit inside every day.
Be careful out there. Don’t forget which side of the rails you’re on.
*except one time when a guy kicked me in the head while I was getting an ABG. I felt that one.
**It’s not a “warm fuzzies” sort of book.
Bad Things to See March 27, 2008
Posted by keepbreathing in airway management, respiratory therapy.2 comments
When you’re looking down a laryngoscope, and you pop the epiglottis out of the way and you see the vocal cords, you feel good. “Look, here I am!” says the trachea. “I’m right here! Put a big plastic tube in me!” That is a happy feeling, and when the big plastic tube goes through the cords you feel good. No matter what else may be happening, the airway is secure, and that’s important.
But it is not always so nice. For example, you might insert the tip of the laryngoscope right into the vallecula and lift the epiglottis gingerly out of the way, only to see a giant puddle of green liquid rushing up the laryngoscope at you. If you’re extra special lucky, you’ll see the puddle of green liquid go swirling down between the vocal cords as you desperately suck pure bile out of your patients throat with a yankauer.
But despite it all you might see the tube go in. The tip will go through the vocal cords, and then the cuff, and then the markings as you advance the tube to the appropriate depth. This will make you very happy. But then you may see a thing which makes you sad, which is vomit shooting from the ET tube; this will be followed by an intensivist pulling the tube out because “there’s no way there’s that much vomit in the lungs.”
You win some, you lose some.
Huh March 26, 2008
Posted by keepbreathing in Uncategorized.1 comment so far
Out of perhaps a dozen old stab wounds, at least one gunshot wound to the head, several months in rehab, and a lifetime of IV drug abuse, the final push for one of my patients was…
…a fall from bed leading to a subarachnoid bleed.
Go figure.
Complementary and Alternative Medicine March 23, 2008
Posted by keepbreathing in health and wellness, humor, links.4 comments
Ah, Complementary and Alternative Medicine! Such a controversial topic, full of intrigue and shady evidence and passionate arguments from many different people. Speaking personally, I don’t have an issue with CAM; indeed, I know and am related to many people who swear by things like acupuncture and herbal remedies. When I was but a wee lad, my mother pumped me chock full of herbal remedies in a loving but possibly misguided* effort to avoid putting “chemicals” into my body.
The problem that I have with CAM is when people use it exclusively, claiming that real medicine is misguided or somehow deficient in ways that CAM is not. I have family members who, when they experience physiological malfunctions, will eschew a trained physician in favor of an herbalist.
Now, in some cases I can see their argument for deficiency in modern medicine. In theory, medicine is “evidence based” but in practice many physicians and practitioners are really “litigation based” or “I learned it that way 20 years ago based.” This does lead to deficiencies in care. However! The fact is that most medicine is based on some body of solid research, where most CAM is based on flowery prose with a minimum of solid research. I’d make the argument that CAM is marketed by people who have an economic incentive, but so is real medicine, so that argument is not a good one to use.
So given the fact that modern medicine is backed by evidence and CAM is not, why do so many people continue to prefer using CAM only? To find the answer, I have turned to that ancient illuminator of the truth: comedy! The humorous and surprisingly accurate website Stuff White People Like gives us an excellent answer to the problem of CAM:
Because of a rather shady history, white people do not trust the pharmaceutical industry. Using pretty sound logic, they believe that the drug companies have no motivation to find real cures for things like AIDS since the real profit are in drugs like Viagra and Xanax.
Using their powers of deduction, white people have determined that herbal remedies are unilaterally better than anything produced by a drug company.
Since white people can’t really blame any race for their problems, they need to blame corporations. In this case, the reason that they are sick or fat or without energy is because the drug companies are in a conspiracy to keep them addicted to placebos. This helps them shed accountability, and it lets them feel like they are helping the environment by rejecting the polluting, greedy, awful drug companies and taking natural, organic medicine from the earth.
But perhaps it goes deeper. Hundreds of years ago, another group of people believed firmly in natural medicine and it’s ability to cure disease. Then white people gave them blankets with small pox and they all died. So perhaps turning to natural medicine also helps white people feel better about killing natives.
Once again, comedy helps us see the truth.
*Pretty much everything we do boils down to chemicals in action. Trying to avoid putting “chemicals” into your body is like trying to avoid putting “air” into your lungs.
For the Children March 22, 2008
Posted by keepbreathing in humor.1 comment so far
There are two things that have really gotten out of hand lately. One is those little bracelets that come in a variety of colors that are supposed to show how much you support a cause. You know the kind I mean, the little bracelets with things like LIVE STRONG or FIGHT FOR A CURE or whatever written across them. It seems like there’s one of those for everything nowadays, and quite frankly it’s gotten a bit out of control.
The other thing that is out of hand is people begging for things “for the children.” Please, support this random cause–it’s for the children! Please cease to exercise your rights, as it may scar or offend the children! People are asking you to alter your lifestyle as a surrogate for their own shoddy parenting skills, and it gets old fast to hear people make an inane argument for something stupid and then follow it with a visceral appeal “for the children” rather than using logic or supporting facts to make a case.
And so it is with great delight that I saw MonkeyGirl’s new coffee mug. It reads,
POOP STRONG
FOR THE CHILDREN
It turns out that there is quite a variety of poop strong products out there. There are pens, shirts, bracelets, and many others. I may just have to invest in a handsome set of those poop strong pens; I could even hang the bracelet from my stethoscope, as some of the more “hip” people at the hospital have been doing lately.
More Linkage March 20, 2008
Posted by keepbreathing in Uncategorized.1 comment so far
By way of Emergency Emily, I found the blog of Aaron Buzzard, an physician with the U.S. Army who is working in an ER in Iraq. There’s some mighty interesting reading in there, so if you’re up for something nifty go on over and check it out.
Kidneys For Sale March 20, 2008
Posted by keepbreathing in Uncategorized.5 comments
Marko over at The Munchkin Wrangler has written an interesting piece about paid organ donation. I always have been the sort to make light of organ donation. Indeed, a friend of mine and I had a long-running joke about starting a kidney smuggling ring for fun and profit. But all jesting aside, organ donation is a serious issue and one that deserves a fair bit of attention. There are thousands of people out there who need organs, and there are thousands more who die every year while waiting for organs to be donated to them by somebody out of the goodness of their heart.
The truly heartbreaking part of the system is how many potential donors are not harvested and how many potential recipients miss out because of that. I can’t tell you how many times I’ve seen perfectly good donors (brain-dead teenagers, almost-cardiac-dead adults, and so on) be buried with their organs because of a squeamish family or a family who have misconceptions about where the organs go.
A potential solution to the problem of donor shortage is to simply allow people to be paid for their organs. Now, plenty of folks get really upset when you mention the concept of paying somebody to donate an organ, but I have never once heard a coherent argument against paid organ donation.
Anyway, Marko’s got it covered. Go on over and check it out.
Time off March 18, 2008
Posted by keepbreathing in Career Advice, my life, respiratory therapists.3 comments
After a couple of epic weeks of almost nonstop work I finally have some time off. I need it badly. In this last two-week pay period I slammed 164 hours out at the hospital. That’s only four hours less than the number of hours in a week. I’m amazed that the hospital let me do that, but they’re so understaffed they can’t say no and the patient load is way up lately owing to a unique combination of illnesses and stupidity in the local area. The simple truth is that they’re desperate for staff and it’s (arguably) safer to have some very tired and fatigued staff than to have no staff at all.
As for why I would even work that much, I’m poor and even after Uncle Sam takes away most of my overtime to subsidize the lazy ignorant unemployed bastards I spent my workweek taking care of*, I’ll still come out ahead. Someone asked me if I was “desperate or just stupid” to take this much extra time, and I honestly couldn’t answer them. But none of it seems to matter at the moment…because until I have to return to work on Friday, I am off. I plan to knock back a few frosty cold beverages and spend my time reading some very non-medical books. I suspect that this little break will be enough to recharge the batteries and chase away these nagging feelings of burnout and apathy that have been chasing me around lately. I may update between now and then, but I may not.
*Not that I am at all bitter about this. You know, putting my energy and my finite time here into futile anti-Darwinistic care for people who may or may not actually deserve it for a measly paycheck, half of which is confiscated by a government who will simply use it to pretend to solve problems by flinging cash at them. Rant over…
Scenes from the Floor March 17, 2008
Posted by keepbreathing in asinine, medicine, moments, my life, nebulizers, nurses, patient safety, respiratory therapy, stupid people.10 comments
“I think that the man in 513 needs a breathing treatment,” the nurse said to me over the telephone.
“I just gave him one a couple of hours ago and he was fine. Is he in distress or do you just want him to have a treatment?” This has become a standard question when someone calls and asks me to give a treatment simply because I know that a lot of the time they are just asking for a treatment for no reason, or because it’s on their Med Administration Record sheet and they want to check off all the boxes.
“Well he is in some distress, yes. Please come see him.” I mumbled something to the affirmative and reluctantly stood up from the chair I had just sat down in. I often suspect that the RT chairs have Ass Detectors in them that are linked to our spectralink phone system to trigger a call to anyone who has just taken a seat, but I digress.
I sauntered over to 513 and looked into the room. I have learned to do a sort of in-hospital Primary Survey before entering rooms, because there are some situations that an RT just does not want to walk into. The patient in this case was sicklier than he had been a few hours ago. His skin was the grayish color of doom and he appeared cold and clammy. He had a moist washrag over his eyes and he was moaning unintelligibly. I looked up at his heart monitor and immediately saw the problem: his rate was 35 and his BP was 70/40. The nurse appeared at my side. I turned and looked at her.
“You know, I really don’t think that a breathing treatment is what he needs right now. I think what he needs right now is some atropine or something. Have you called the Critical Care Assessment Team on him?”
“No, I don’t want to bother them and I can’t find any atropine. But I think he needs a treatment. Maybe it will make his heart rate go up.”
:::
I shit you not, folks. I couldn’t make this up if I tried. I think I’ll spend my afternoon shift today filling out Risk Management forms.
