Respiratory Therapy 101: Just Keep Breathing

Interesting stuff out there tonight. From”Not Totally Rad” we have a flouroscopic series showing a sword-swallower in action. It’s fascinating to watch: I had a hard time with the first ten seconds or so but then it seems to clear up some.

And over at the RT cave, Rick Frea has an intriguing ethical problem that is encountered all too often by those of us in the breathing business.

“One of my patients thinks I am trying to kill her and my other guy does nothing but shit and moan. That’s why I’m back here eating donuts.”

Sort of sums it all up, really.

Win some:

Three year old girl presents with multiple facial lacerations. She is screaming, terrified, frightened of the pain and of the strange people in white and blue who are doing things to her. With a little smooth talk from a pedi nurse and a little bit of modern chemistry, she calms down enough that the doc can suture her face back together. Once the stitches come out she’ll be fine.

27 year old woman presents with sudden onset shortness of breath. She’s an asthmatic who hasn’t had any problems in a few years. With some steroids and some aggressive treatment, she’s relieved of her symptoms and out the door again in four hours.

Lose Some:

A man comes to the ER early in the morning because he is uncomfortable and he feels like he cannot catch his breath. He is triaged into a room in the back and given a treatment. While waiting on a lab result he suddenly has an episode of bradycardia and begins to complain of chest pain, at which point he is whisked to the Oh Shit Room. His respirations become noticeably labored and he is intubated. He then proceeds to code. After coding on and off for three hours, he is pronounced dead. He was a classic “walkie-talkie.”

A nursing home resident is brought to the ER by ambulance. The nursing home’s stellar staff observed a total lack of movement and respiration on the part of the patient and called 911, whereupon the paramedics observed that she was in fact mostly dead. However she had a pulse, so she was trucked with lights and sirens to the ER. Just as the medics rolled in the door she went asystole. After a few rounds of CPR the doctor asked if anybody had any objections. When nobody spoke up, he nodded and left the room. As he was walking out somebody asked him, “So you don’t want to keep going?”

The doc shrugged his shoulders and looked around.

“Nah.”

—

If you have no interest in participating in your own care, please do us all a favor and stay the hell home.

That is all.

A question for my fellow RTs.

I had a patient on A/C, low volume/high rate sort of strategy. His ABGs were holding steady with a respiratory acidosis, pH around 7.3 and PaCO2 in the high 50’s no matter what we did to him. His peak pressures were rising consistently so we switched him to PCV just to see what happened.

With a high inspiratory pressure set, he was drawing smaller tidal volumes and therefore had a lower minute volume than he had had on volume control. I could not increase the respiratory rate, and the inspiratory pressure was at the maximum that I was comfortable with. I wasn’t sure this would work because of the lower minute volume, but I figured that I’d leave the patient on for half an hour and see what he did.

Despite the lower minute ventilation, my patient’s PaCO2 dropped like a rock and his acidosis corrected. It was exactly the opposite of what I had expected.

I feel like I’m missing something here. Am I just having a brain block, or is this actually kind of weird?

One thing I’ve mostly avoided in the years of my career has been contact with disgusting body fluids. I’ve narrowly escaped rivers of liquid stool, lakes of spilled urine, pools of tacky blood and fountains of vomit. I’ve narrowly dodged the gale-force flatus of a 400-pound man who was facedown on the floor. Whether through pure luck, a sixth sense, or simple good timing, I’ve been able to avoid being hit with anything disgusting for several years straight.

Today, my streak came to an end. I was assisting one of the ICU nurses with a turn, something I am more than happy to do simply because working in intensive care is a team effort. We were turning a patient who has recently been bestowed with a tracheotomy. The turn went from mellow to slightly more frantic when the patient suddenly became distressed. The heart rate went up, the respirations increased to a frantic pace, the blood pressure skyrocketed. Without even exchanging a word the nurse and I quickened our pace, stuffed the old blankets beneath the patients back and flipped them over the hump.

At that moment several things happened. As the patient rolled over the hump the ventilator tubing disconnected from the trache. The disconnect caused the trache to pull. The pulling of the trache caused the patient to cough madly. Time slowed down to a crawl. I watched from a distance as a giant wad of tan phlegm came flying out of the patients throat. I turned my head and braced for impact.

And then it hit me. It was rather like a very unpleasant rain shower. The patient had scored a direct hit. I winced in disgust. I could feel the clammy muck spattered about my face. I left the room to the sound of the nurse laughing (in a sympathetic way) and found my way to the closest sink, in which I dunked my head.

And so it goes in the wonderful world of respiratory care.

We recently had a young lady who came into the hospital with abdominal pain. She was explored, declared healthy, and sent to the floor. There she became septic, came back to the ICU, and promptly died from a massive infection with whatever microbe it is that causes necrotizing fasciitis.

This was very upsetting to me personally for a number of reasons. One: the patient was young, vital and alive when she came to the unit in the morning, and by nightfall she was dead. She was intubated two hours after she arrived, sent to the OR within three, and dead within eight. It was terrifyingly fast. Two: the patient was recently married with a young child. The look on the husbands face when she died was awful. Three: it seemed to be totally random. She was not a high-risk person, she didn’t have a high-risk lifestyle, and I could see no reason for this. It was just one of Nature’s random cruel streaks.

Eerily, this young lady’s room had been inhabited not too long before by another patient with necrotizing fasciitis. The patient was like her in many ways: young, vibrant, alive. They had developed necrotizing fasciitis in a wound near their genitals* and were extremely sick; I never found out if they died or got better while I was in another unit.

If another NF patient comes into this room, I’m never setting foot in there again.

I often suspect that medical numbers are sort of made up.

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I think this exact scenario happens a lot more than we’d like to admit.

It is no measure of health to be well adjusted to a profoundly sick society.

~ Krishnamurti

For once, news about healthcare that seems to be positive. I refer to an article in todays Times about Kendal at Hanover, a nursing home affiliated with Dartmouth-Hitchcock Medical Center way up in New Hampshire.

Kendal at Hanover is apparently not your usual nursing home. For one thing, they apparently focus on giving the elderly a choice in medicine that they may not even know they have: the choice to say “no.” According to the article, the staff at Kendal are very assertive in speaking with residents about the choices they face at the end of life and the implications of those choices. I quote (emphasis mine):

Slow medicine, which shares with hospice care the goal of comfort rather than cure, is increasingly available in nursing homes, but for those living at home or in assisted living, a medical scare usually prompts a call to 911, with little opportunity to choose otherwise.

At the end of her husband’s life, Ms. Gieg was spared these extreme options because she lives in Kendal at Hanover, a retirement community affiliated with Dartmouth Medical School that has become a laboratory for the slow medicine movement. At Kendal, it is possible — even routine — for residents to say “No” to hospitalization, tests, surgery, medication or nutrition.

Charley Gieg, 86 at the time, was suffering from a heart problem, an intestinal disorder and the early stages of Alzheimer’s disease when doctors suspected he also had throat cancer.

A specialist outlined what he was facing: biopsies, anesthesia, surgery, radiation or chemotherapy. Ms. Gieg doubted he had the resilience to bounce back. She worried, instead, that such treatments would accelerate his downward trajectory, ushering in a prolonged period of decline and dependence. This is what the Giegs said they feared even more than dying, what some call “death by intensive care.”

First: the right of patients to refuse treatment. This is a right that I think many patients don’t even know they have. I can’t count the number of times that people have demanded to know why they “have to do this,” only to be totally surprised when I tell them that they have a right to refuse care. The principle of patient autonomy dictates that we should not force treatment upon people who do not desire it, and while we are very good at following this principle most of the time I think we could do a lot better if healthcare providers were a little more aggressive in informing people that they have a choice.

We could also do a little better about talking to the families of those who have been incapacitated. Often, families make a choice that the patient would not want because they are not ready to let go. This is a difficult situation at best, but what the patient wants should come first; the family is an afterthought.

Second: death by intensive care. This describes probably half of what we do in the ICUs where I work. We have a lot of patients who are just in the ICU transiently: septic people, surgical mishaps, recovering heart surgeries, trauma patients, and so on. These people will recover and leave. But we also have a lot of chronic elderly patients who are going to linger in the ICU for several months and then die. We can animate a slab of carbon for quite some time, but just because we can doesn’t mean we should. I can’t speak for everybody, but when I die, I don’t want the last two months of my life to be spent in an ICU. That’s no way to go.

In conclusion: I like the idea of Kendal at Hanover. I think that we in the healthcare industry should follow their lead: we should lay out the fact that everybody dies and then offer people control over the end of their own lives. Pretending that medicine will keep everybody alive forever is only going to make it worse. Mortality is a fact. We can either hide from it or face it head-on, but we will never escape it.