Respiratory Therapy 101: Just Keep Breathing

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.