Respiratory Therapy 101: Just Keep Breathing

It was ten fifteen in the morning when the phone rang. I answered the phone and was greeted by an ICU nurse breathlessly calling me from the operating room.

“We need you to come to the OR and take this patient down to the rad lab with us.”

“Is it one of mine?” I asked, unsure if my patient was in the OR.

“It is now,” she said as she hung up. I grabbed a ventilator and wheeled my way down the hall to the operating room, pausing to don the mandatory hat and mask on my way in. Walking into the OR, I saw a gray patient laying flat on her back on the table. She was a young woman, healthy looking apart from the dusky color. Anesthesia was hanging a fourth bag of saline while the ICU nurse was setting up two units of packed cells in the rapid infuser. I counted five lines, all flush with fluids. “BP is 85 over 60,” the ICU nurse said to the surgeon. “Levophed,” said anesthesia without thinking.

“What happened?” I asked.

“She’s the trauma from this morning. Motor vehicle, hit a piling on the underpass.”

“Jesus.” I looked the patient over again. Her abdomen was packed and draped; bilateral chest tubes collected blood slowly. Her head was uninjured, and as I looked at her face the anesthesiologist muttered “at least this one was helmeted. Less messy.”

We packed the patient up as best we could, IV lines and pumps and infusers weaving a tangled web of lines. I bagged the patient with one hand and pushed the bed with another. The surgeon pushed the rapid infuser and IVs behind me and the ICU nurses pushed drugs and watched monitors as we flew down the hallway. Within a few short minutes we had arrived in the rad lab.

“You’re going to put her on the ARDS protocol, right?” the surgeon asked. 

“Yes sir.”

“Good. Make her lungs work.” With those words, he turned and began giving orders to the ICU nurses as we moved the patient onto the table. The interventional radiologist asked what we wanted, and the surgeon told him to find the bleeding and do what he could to stop it. As I dialed in pressure settings on the vent the nurses continued their fluid resuscitation. We were up to five units of blood and three of packed cells plus the saline, and the patient’s BP was still only double-digits. Time passed as the interventions proceeded; the patient was bleeding massively from many of her organs. The surgeon asked for a blood gas, and as I drew the blood from her arterial line I observed that it was thin and transparent, the look of kool-aid. 

“Uh, she needs more blood.” I held the syringe up to the surgeon.

“Two more units. Now.” Those words set off a flurry of activity. The nurses scrambled to find blood, and I ran down the hall to the nearest ABG machine. The results were not great but not terrible, although we were unable to get a hemoglobin. The H&H came back shortly thereafter; the patient’s hemoglobin was a whopping two. “Eight more units of blood please. Right now.” The surgeons commands were answered and more blood began pumping into the patient. He sighed and put his head in his hands. From my seat I heard him say quietly, “She’s got coagulopathy…must normalize her labs. Very bad.”

By noon, the interventions were over and we moved to the CT scanner to image the patient. From there we hurried upstairs to the ICU, where a fellow RT met me and helped me set up the vent. Sometime during her procedure in the rad lab, she had begun bleeding into her ET tube, and as we hooked her up we suctioned 100cc of blood from the tube. My fellow RT let out a low whistle. “Holy shit,” he said quietly.

The chest tubes began oozing more rapidly, and another ABG showed a severe deterioration with a pH of less than seven. Bicarb was given; vent settings were adjusted. The patient became more and more difficult to ventilate. Inspiratory pressures were in the thirties. I was frustrated and angry; nothing I did would get the patient to ventilate, and a rapid series of ABGs showed the CO2 climbing while the PO2 fell. I asked for permission to raise the PEEP, but in light of our low blood pressure the surgeon declined. I changed to volume control and upped the respiratory rate. Something had to work.

But nothing seemed to do it. The CO2 kept climbing. The nurses pushed their dozenth liter of saline, their fifteenth unit of blood. The patient’s chest tubes were full and required changing. I suctioned more and more blood from her ET tube; it pulsed up into the vent circuitry with every exhalation, passing through the HME and creating a river of blood inside the ventilator. The suction canister showed 600 cc of blood…almost two units worth.

Time passed. The patient bled. The labs worsened. The family came and cried over her, sobbed and begged her not to give up. A nurse from another floor showed up, horrified to find her kin in our care. The patient’s blood pressure began falling and the family left. Time marched along rapidly as we threw ourselves into saving our patient.

At three o’clock her blood pressure began plummeting until, with a final gush of blood into the ET tube, she went into pulseless electrical activity. We initiated CPR, pumped her chest, bagged the hell out of her and pushed drugs. The patient’s family came back into the room with the chaplain and watched as we tried to bring this woman back to life. Blood was spurting into the ET tube with the compressions; the new chest tubes were full already. The husband came through the crowd as we resuscitated, and the doctor had us hold compressions. I stood there holding the ambu bag as he bent down to his wife, tears mixing with the blood on her face.

“It’s okay baby…I’ll watch the kids…let go. I love you.”

I stood there helplessly, holding the bag in my hands, wishing I was a thousand miles away from this horror. The husband let out one final sob, kissed his wife gently on her face, stroked her hair, turned around, and walked away in the arms of his children.

The surgeon nodded at me. I put down the bag and stepped back. The nurse preparing to resume compressions stepped away. Quietly, ever so quietly, the surgeon bowed his head. “Three-twenty,” he said, and then he turned and left the room.

Sometimes, the best you can do just isn’t good enough.