Respiratory Therapy 101: Just Keep Breathing

…I’m going to bring some crickets.

I mean, he’s a nice guy and all, but sometimes I think that sitting in an office all day has sucked the sense out of him. He’s so far removed from what happens clinically that it’s almost comical, except he uses his lack of knowledge to make decisions that affect everybody else.

I’m trying to think of a good lede for my paper. I should do it fast because the rough draft is due this weekend. That really crept up on me…I haven’t done freaking anything yet. So this afternoon I sat down, went through the feedback you all have given me, and began the process of pulling quotes and making an outline.

I need a good lead-in to the paper, though. I need a quote that illustrates what we’re dealing with when I speak of futile care. I’m having a hard time coming up with a good one, although I like this one from House of God:

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“But Gomers are not just dear old people,” said Fats. “Gomers are human beings who have lost what goes into being human beings. They want to die, and we will not let them. We’re cruel to the gomers, by saving them, and they’re cruel to us, by fighting tooth and nail against our trying to save them. They hurt us, we hurt them.”

That seems like a good quote. It pretty much sums it up. There comes a point when patients become human beings who have lost what goes into being human beings. And at that point, one has to ask: aren’t we just being cruel? When my grandfather had a stroke, he lost what made him him. He had previously been an intelligent man, an avid reader, a thinker of sorts…not that I always agreed with him but he was active mentally regardless. The stroke stole that from him, stole his ability to communicate, stole his life. We could have had him trached and pegged, had an artificial breathing hole cut into his neck and a feeding tube inserted into his belly…but we didn’t. He would have been a vegetable, relegated to the greenhouse where he would be turned, watered, and fed until he ultimately became septic and died. But that would have been cruel. Instead of doing that to him, putting him through years of misery before a painful death, we simply didn’t insert a feeding tube and we let him die peacefully.

Any other quote ideas?

I was sitting on the couch watching the Macy’s Thanksgiving Day Parade. I was half paying attention, watching a float with singing puppets from the Cartoon Network’s show about a home for abandoned imaginary friends. The puppets were singing some sort of song about desertion and how their friends had given them up, when suddenly the best and nerdiest prank in history happened.

They rickrolled the parade.

I’ll wait for you to say “Oh no they di’int!” so I can say “Oh yes they did!” Right in the middle of their little song, the puppets became distracted by a beat, and suddenly a door popped open and Rick Astley popped out to sing his infamous song. 

That was probably the funniest thing I’ve seen in a long time. I actually laughed out loud, and then came to the internet to share my joy with you all. Maybe this holiday won’t be so depressing after all.

It’s Thanksgiving, one of my favorite holidays. There’s nothing like the family togetherness, the gathering of relations from all different places, the food, the friendship and the giving of thanks. I love the companionship, the conversation, the sharing of food and drink, the smells of cooking food and crisp winter air. There’s nothing like it. 

Sadly, there’s nothing like it at all this year for me, because the family is 1500 miles away and the wife isn’t home. I can’t even go to work because of our holiday scheduling policy. Yes, this year it’s just me and the cats for the holiday. It will be turkey and gravy from a can for them, and whiskey from the bottle for me. I’ll probably clean the house out and then bake something. May as well do something productive. I may go for a run, although if I do that I should probably do it before the whiskey, because running while intoxicated seems like a bad idea.

Even though I’ll be alone this thanksgiving, there’s still plenty for me to be thankful for. Here’s a list.

I’m thankful that I’m not on The Other Side Of The Bedrails. Health is a blessing that so many of us take for granted, and it’s something I cherish and would like to hold on to. 

I’m thankful that I’m still married. It’s been harder than I ever expected but we’ve survived so far… 

I’m thankful that I live in the United States. It’s not perfect, but what is? 

I’m thankful that I have a steady job.

I’m thankful that I get to sometimes make a difference. As much as I complain, every now and then I get to do something that will really make a difference in somebody’s life, and those rare moments almost make up for the thousands of moments that piss me off.

I’m thankful that I have a relatively stable life. I see a lot of people at work and I wonder: how do you live like this, day after day? I can’t imagine how difficult life is for some of these people. For every system-abusing piece of crap, there’s a person who’s genuinely down on their luck, a person with nothing to lose and nothing to live for. It’s terrifying. I’m grateful not to be in the shoes of those I care for.

I’m especially grateful not to have to be among those in waiting. The families of the sick bother me. I tend to view families mostly as an obstacle to performing my duties, but every now and then I stop and wonder: what must it be like, being in the ICU on a holiday, waiting and wondering? Life can be tragic 365 days a year, but something about the holidays makes it especially so. I’m so glad to not be in those circumsances.

On that note I think of the wife of this one man I’ve cared for in the last few days. At one point we were doing CPR on him, and the chaplain brought her in to see, because she needed closure, needed to understand exactly how critically ill her husband was. I will never forget the look on her face as she came in and saw us resuscitating him. We managed to get him back, and there was one of those now what? moments. I will never forget the mix of anguish and hope and fear that I saw on her when she realized that he wasn’t dead yet but that it was coming. I hope to never experience that end of my profession. I am thankful that I am on this end of things.

I am thankful to have that knowledge. There’s a lot to learn in this profession if you just let it teach you.

More than anything, I’m just thankful to have a good life. What’s that line from that old song, I can’t complain but sometimes I still do? Much as I gripe and moan here, I live a decent life, and that’s something to appreciate. Not everybody is so lucky. I have a lot to be thankful for. I really do. 

Happy thanksgiving, everybody.

“You want report on that guy? He’s dead but nobody’s done the paperwork yet.”

I love the seasoned therapists. They say the best things.

Trauma Surgeon 1: So this lady’s husband is one weird guy…he didn’t want Neurosurgery to do anything with her, and he’s sort of balking at organ donation. And then when I told him that she’d have an autopsy if she died, he freaked out. 

Trauma Surgeon 2: He did, huh? That is a little weird…

TS1: He asked me if we had to do the autopsy if she died. I told him, ‘it’s the state law. She’s a traumatic injury that dies, she gets an autopsy. Not my choice…’ he was pretty upset. 

Respiratory Therapist (not me): Are they Witnesses or something? 

TS1: These people? (scoffing) No.

TS2: Well maybe he did it. Nobody witnessed this fall, right? Maybe he’s doing it for the insurance.

TS1: Think he bopped her on the noggin, huh? Maybe…but they live in a trailer, man, it’s not like he’s going to get rich if she dies. They don’t seem like the types.

TS2: You never know. Sometimes people do crazy things. A little insurance can be a lot of money.

Me: That’s true…enough at least for a shiny new trailer. 

(pause)

TS1: I guess so. I’ve seen people killed for less.

It’s a wicked world that we live in.

I had the misfortune of being assigned to the Pedi ED today. This is half-nice and half-horrific: it’s nice because I am the main ER backup, which is helpful for the main ER person and pleasant for me, but it’s horrific because the Pedi ED is run entirely by people with no assessment or prioritization skills. They are also extremely persistent. I swear they were so far up my ass today that I could feel them yanking on my uvula. 

I don’t mind doing useful treatments, I really don’t. I like giving treatments to kids who need them, asthmatics in distress and croupy kids and whatnot. But the problem is that in the pedi ED, most of the kids that they order stuff on…don’t need it. They’ll order albuterol and atrovent times three on a child with clear lung sounds who is in no distress…they seem to be incapable of ordering a treatment times one, or even better of not ordering treatments on kids who don’t need them. It’s bad medicine at it’s finest: we’re giving treatments just because we can, regardless of whether the patient needs them. It’s not evidence based practice; it’s shotgun medicine. 

After the phone rang for the thousandth time today, I was ready to scream. It’s not just inconvenient, it’s dangerous. It’s the phenomenon of the boy who cries wolf: after a hundred useless calls that are framed as urgent and extremely important, you are less and less likely to believe them. 

I don’t mean to speak ill of all pediatricians. I know there are good ones out there…we even have one who works in the ER, and it is like paradise when she is there. Therapy is appropriately ordered, kids are properly assessed, and things just seem to run more smoothly. I love pediatricians when they’re good because kids are harder to manage: it’s a whole different world from adult medicine, and it’s challenging in a lot of ways. A good pediatrician is a gift from the heavens…but a bad one makes you want to pull your hair out by the roots.

I guess they call these things Memes. You know, those little game things you put on your webpage. Well, TOTWTYTR has decided that I am worthy of a meme thing.

The rules are simple:

Pass it on to five other bloggers, and tell them to open the nearest book to page 56. Write out the fifth sentence on that page, and also the next two to five sentences. The CLOSEST BOOK, NOT YOUR FAVORITE, OR MOST INTELLECTUAL!

A lot of my books are spread out since I’ve moved a few times in the last four or five years. Several boxes are at my parent’s house in the great north woods, and a few others are at the in-laws’ house. But I’ve still got a decent collection of books here. Since I usually write from the laptop while sitting on the couch, the books on the coffee table are closer than the books in my bedroom or on the shelf.

Too bad, too, because some of the books in the bedroom or on the shelf would make you all think I was (to borrow a phrase from TOTWTYTR and a phrase heard often in my homeland) wicked smaht. Incidentally, my favorite book of all time is probably the five-book trilogy of the Hitchhiker’s Guide to the Galaxy. Love it.

From page 56, sentence five and a few others, out of the closest book:

This frame, so slightly clad, was a sort of crystallization around me, and reacted on the builder. It was suggestive somewhat as a picture in outlines. I did not need to go out doors to take the air, for the atmosphere within had lost none of its freshness. It was not so much within doors as behind a door where I sat, even in the rainiest weather. The Harivansa says, ‘An abode without birds is like a meat without seasoning.’ Such was not my abode, for I found myself suddenly neighbor to the birds; not by having imprisoned one, but having caged myself near them. I was not only nearer to those which commonly frequent the garden and the orchard, but to those wilder and more thrilling songsters of the forest which never, or rarely, serenade a villager–the wood-thrush, the veery, the scarlet tanager, the field-sparrow, the whippoorwill, and many others. 

~Henry David Thoreau, from Walden; or, Life In The Woods. 

I like Thoreau’s philosophical ramblings. After all, his thoughts were murder to the state…

…Anyway, I need to pick five other people to do this thing. So I choose: 

Laurie Edwards of A Chronic Dose;

Frylime, over at a quasi-medical autobiography;

Glenna, over at G’s-Spot;

Trauma Junkie, over at Surviving Respiratory Therapy School;

and Rick Frea, over at the Respiratory Therapy Cave.

Anybody else out there, if you want to play, feel free!

I got an interesting response to my ethics post the other day. Here is the comment:

Why should it be up to you who lives or dies? You would make that decision because you believe the person to be useless, in very bad shape, and a drag on resources? Perhaps your assessment of the hopeless status of the patient is correct, perhaps it isn’t. Maybe the next patient you decide you won’t treat has a reason for living, that is invisible to you, but because you deem that person unworthy of maximum effort, they will never have a chance. Better they fail on their own, rather than you deciding for them.

What kind of time frame wil you have? Will you establish a cut-off date like “Don’t give any care to anyone who looks like they will die in 48 hours.”

You have a job to do. That job is to give everyone the best possible chance you can at survival. If you have reservations about who should get the best that you have to offer, you should find another career. People come to hospitals as portals of mercy.

I got your comment and I am intrigued by it. I think you misunderstand me. You ask why it should be up to me who lives or dies. I am not saying that I, the respiratory therapist, should be in charge of who lives or dies. I am asking: just because we can keep somebody alive, should we? This is not as black and white as you think it is. When people say to us “do everything,” they don’t know exactly how much we can do. I’ll give you an example.

We have a patient at the moment who came in to us after he collapsed on a porch. He is indigent, with no family that will speak for him. He was formerly able to walk and talk, but after months and months in the ICU he has wasted away to a skeleton. He literally looks like a survivor of a concentration camp. He is incapable of moving his body. He is covered in bedsores as his skin has broken down. He is incapable of eating, talking, moving, or doing anything. Merely touching him causes searing pain to him; moving him, drawing blood, or doing anything else causes agony. His entire existence is pain. We can keep this man alive indefinitely; but it it humane to do so? Would you do this to your dog or your cat? I would not want to live like that and I am sure he would not either. His prognosis is grim: he has zero chance of surviving, yet we continue to treat him aggressively. Why? Why are we torturing him like this?

I am not advocating that we pull the plug on viable patients, I am advocating that we speak for the patients when care crosses the line from humane lifesaving efforts to inhumane prolonging of suffering. I am not saying that we need to establish a time frame; I am saying that we need to develop a better system of communicating with families and patients about how much we can do and how much they really want us to do. Do you want us to take your grandma, cram a breathing tube into her throat, pound on her chest to compress her heart, stick needles into her groin and extremities to give meds and draw blood? How far do you really want us to go? My own grandfather died a few weeks ago, but instead of demanding that they give him full CPR and keep his body alive on a ventilator in the ICU for weeks or even months at a time, we simply let him pass peacefully and with dignity.

You close by saying “You have a job to do. That job is to give everyone the best possible chance you can at survival. If you have reservations about who should get the best that you have to offer, you should find another career. People come to hospitals as portals of mercy.” We do give everybody the best chance at survival, but prolonging care at the end of life is not the same as giving somebody the best chance they have at survival. Care crosses a line from humane and lifesaving to futile and torturous quickly. If you asked everybody in medicine who was uncomfortable with doing absolutely everything to absolutely everybody to quit, then there would be very few people left in the hospitals. The real world is not as black and white as you seem to see it. The hospital in real life is not like the hospital on a soap opera: people don’t sit up after a round of CPR and say, “Wow! I feel better! I think I’ll go take a walk!” No, typically, they linger for a few days or weeks and then die anyway.

Finally, you say people come to hospitals as portals of mercy: that’s true. So why don’t we show them some? You’ve obviously never seen exactly what we can do to people to keep them alive. And there comes a time when we cross the line and are merely prolonging the suffering of another human being. The kindest thing you an do sometimes is to let somebody die.

All I am saying is: just because we can, does not mean we should.

One of my favorite dramatic cartoon quotes ever. Dorky moments aside, Peter says that yes, some of us do in fact have the brain worms. And he’s even got a video to back it up:

Creepy, no?