Respiratory Therapy 101: Just Keep Breathing

The first time I saw this patient was a few days ago. He was totally hangdog in appearance, the sort of guy who you felt had probably been down on his luck for a really long time. His eyes drooped, his shoulders slumped, his sickly gray pallor suggested a state of near-death. The poor guy just looked sick. He stared out at me from behind his oxygen mask as I tried and tried again to get a blood gas on him, but despite my best efforts and his patience it took three RTs to get a gas on him.

To add insult to injury, his gas was terrible and he needed to go on BiPAP. He stared at me with the same doleful look in his eyes as I tightened the straps around his head. He complained and protested that it was too tight, he was too uncomfortable. I tried my best to make it less awkward for him but there is only so much one can do when it comes to BiPAP…and it seemed that even if I fixed the BiPAP totally there would still be a lot of complaining to come. So I simply did my job reasonably well and left.

The patient was in with a bad heart. He had some kind of cardiomyopathy, with an EF of less than 30% even after previous surgery. He had a pacer to keep the heart going and he had suffered cardiac tamponade, further weakening his already damaged heart. On high-dose levophed, his blood pressure wouldn’t go above 90 systolic. On top of all that, his lungs were hurting too; he had a massive ventilation/perfusion issue going on.

Today I saw the patient again. He seemed fine in the morning, but by afternoon he was sick of being on BiPAP and he wanted a break. I felt bad for him and so I removed his BiPAP and placed him on a venturi mask. His nurse came in after I left and put him on the bedpan, which was the beginning of the end for this poor gentleman.

You see, when he tried to Go, he bore down and created a vasovagal response. His heart rate dropped like a rock and he passed out, and then he went into cardiac arrest. His poor nurse found him on the bedpan, cold and gray, and she called a code.

We worked the man for forty minutes and we got him back–barely. We put him on the ventilator and his nurse was managing an astonishing array of cardiac drips to try and convince his heart to work. The intensivist went and talked to the family, who decided…a bit late…to make him a chemical code only.

Fast forward half an hour. Something has gone wrong with his pilot balloon. He is leaking air like the Michelin man in a thumbtack factory. The new intensivist comes in and decides to change the patients tube out with a tube exchanger. Some of you can see where this is going. We slid the tube changer in and pulled out the old tube. We rode a new tube over the changer and then inflated the cuff and pulled out the changer, at which point his nurse…already emotionally invested and stressed to the max…burst into tears and pointed at the monitor as his arterial line pressure waveform flattened out and stopped. His heart tracing went from slow sinus to nothing but pacer spikes.

We went through the motions, dumped some epi into his IV, but he was dead. Cold and gray and totally dead.

:::

As my fellow RT and I were talking later, we realized that it’s entirely possible that our tube changing may have caused the vaso-vagal response that ultimately killed this man. He wasn’t long for this earth anyway, but I have to wonder what would have happened if we’d simply let him live with the air leak.

In some sort of cosmic way, this seems a fitting end for my poor hangdog patient. Rest in peace, my sad old friend.