Respiratory Therapy 101: Just Keep Breathing

As promised, something funny to compensate for the bitterness. From Basic Instructions, I give you one of my favorite images of all time (click to enlarge):

It’s perfect, isn’t it?

(Image stolen from Basic Instructions without a hint of a scrap of permission. Copyright belongs to the comedic genius Scott Meyer.)

The word of the day today is Polybabydadia, a word which I have stolen without a hint of permission from the ever inventive Panda Bear MD. The rest of this post unexpectedly deteriorated into a bitter tirade, but you should be used to that by now.

Polybabydadia as I see it is the condition of having too many children by too many baby daddies. Its many manifestations are the scourge of our pedi ER, and a terrifying glimpse into the future; after all, the kinds of people who are grunting out five and six kids by as many fathers are not the kind of people who should probably be entrusted with the life of a tiny human being. And as much as I’d love to believe that all the children will be OK and grow up surrounded by love and rainbows and candy ponies, I know that the few of them who manage to make it past age 2 without being suffocated under a pile of jackets at a party will probably just continue the cycle ad infinitum. Every now and then a kid breaks through and changes their life for the better, but the sad truth is that most of these children are just screwed. It’s very depressing to look into the innocent eyes of a child and realize that the irresponsible, empty-headed, soulless pile of carbon who gave birth to them is going to screw their life up forever with neglect and unwillingness to take responsibility for what they have brought into the world.

The only cure that I know of for polybabydadia is mandated sterility, although a lot of people get pretty offended when I say that.  Perhaps we could ward off some of the epidemic by giving out Depo shots and claiming that it’s morphine. It could work; many of the victims of polybabydadia seem to have a habit of chemically enhancing reality to escape from the soulless husks that they have become. Moving the blame to the daddies, we could offer discounts on beer in exchange for vasectomies.

That’s it for now. I’ll make up for the bitter with some funny later.

Now for a break from the usual madness. By way of Atomic Nerds, I found this image:

I am way too amused by this. I’ll be chuckling about this all week.

We all know that I think the Joint Commission is about as useful as a screen door on a submarine. I’ve found that most people who work in actual clinical jobs share my contempt for the Joint Commission because we can see it for what it is; namely, a useless organization devoted to improving patient safety by making it impossible for any clinical person to actually do anything. After all, if we can’t do anything, we can’t possibly harm the patient!

Nurse K over at Crass Pollination shares my contempt. JCAHO has mandated that her code meds must be locked in individual drawers in a med machine down the hall secured by an eight-digit PIN and fingerprint access. That is like making a police officer keep his mace, club, gun, and ammo locked in a safe in the trunk of his car. In a word, it is bullshit.

Go on over and sympathize with Nurse K. The joint commission has struck again. Will they never stop?

I’d like to give a big shout-out and a big thanks to Doc Russia, who has composed this elegant piece entitled The Lie Of Multiculturalism. I normally shy away from anything political, but this is too good not to share.

The ER physicians at my hospital are addicted to ABG’s. Our blood gas reports seem to have a crack-like effect on them; they take on hit of the ABG report and suddenly they can’t stop ordering them. It’s not just ABGs, it’s everything: CAT scans, lab tests, and more.

Not all of the ER physicians are like this. A large number of the ER staff only order ABGs if they’re indicated. But we have a large group of serial offenders who will order ABGs on every single patient that comes in: patients with hangovers, patients with GYN complaints, patients with orthopaedic malfunctions and the like.

Most recently one of our serial offenders has begun ordering ABGs on psyche patients. Recently I was asked to stick a needle into the artery of a paranoid schizophrenic who was having some sort of psychotic delusional episode; the patient had been brought in by police after acting in threatening and bizarre ways. Since the patient has a known psyche disorder and their chief complaint is purely psychiatric, why would the doc order an ABG? This doctor has also asked me to get gases on patients who were having homicidal ideation, nervous breakdowns, and a patient who was hallucinating that the Beatles were trying to kill her.

My question is, why? On a patient with abdominal pain or chest discomfort you can sort of justify asking for a blood gas; but on a patient whose only complaint is psychiatric, why would he ask me to stick a big giant needle into their arteries? Why, when a patient is already feeling threatened, would you ask me to go perform painful tests on them? What exactly is he hoping to achieve here?

This same group of serial offenders has developed a habit of ordering full-body CAT scans on everybody. While a CAT scan is very useful, it is not automatically indicated for everybody. Just because somebody says their head or their gut hurts doesn’t automatically mean we should make them ride the donut. The serial offenders will also check off every lab box on the standard order sheet, all the way from the BUN and BNP to the Urine and Stool specimens. Shit, for all the actual “thinking” they do, I could do their job: they walk into the room, interrogate the patient for all of five seconds, and then check every single box on the order sheet.

At that point, the question in my mind is: why even have an ER doctor? Any monkey can check off all the boxes, wait for the results, and then call the hospitalist to admit. The serial offenders don’t even do procedures most of the time; they’ll simply make the paramedics or the intensivists do the procedures for them. I often ask myself why we’re paying them to check boxes and delegate; I could do that just as effectively for a fifth of their salary. And I’d probably have a lot less of an ego about it too.

I should add that not all of our ER doctors are like that. Probably 60 or 70 percent of them are really quite good. The good ones that we have triage and sort their patients, order only what’s indicated, try to expedite the emergency medicine process. They don’t order tests that aren’t indicated, they don’t admit every single patient just because they can, and they do make an effort to perform high-quality medicine. But that bad 30-40% really make the ER a frustrating place to work.

In summary, the few physicians we have who are using inappropriate diagnostics way too much are driving costs and wait times up for the rest of us. They are increasing workloads on their staff, increasing expenses for the hospital, and decreasing efficiency and safety out of the force of their habit and quite possibly out of pure laziness. The few bad apples who inappropriately apply diagnostics are ruining it for the rest of us. How very frustrating.

30 years old with terminal cancer of a non-removable deeply essential organ. No family. No friends. No wife. No children. Just a man alone with his tumors, wasting quietly away in the ICU where we can do absolutely nothing beyond meaninglessly prolonging his suffering.

That, my friends, just plain sucks.

Hypnosis would not be my first choice for anesthesia, but I guess it works for some folks.

There’s been an eerie lack of excitement at the hospital lately. We’ve not had a single code, bad Critical Assessment Team call, or trauma in a few days. We’ve still got all of our longer-term patients, but as for new stuff…well, not so much all of a sudden. As usual, the optimist in me says “Hooray! A few days without bad things!” but the pessimist is thinking “Something huge is brewing.”

We’ll see, I suppose.

“Heck no we weren’t using him for medical experiments. His basic problem was that he was a late term HIV patient in an ICU. That’s like being a thirty million Tesla magnet in an iron filing museum.”