Respiratory Therapy 101: Just Keep Breathing

Happy New Year, everybody!

I won’t be staying up late to celebrate as I have to work tomorrow. I will spend my first day of 2009 caring for all the drunks and idiots who party too hearty tonight and get hurt, or those who play with fireworks without considering safety. 

But I’m not bitter. In fact, I’m optimistic about 2009. Things have been looking up lately, and I had a nice holiday with my wife. I think I added a solid ten pounds to the frame during the Annual Holiday Sugar And Carbohydrate Binge, but with some good exercise and self-control I should be able to drop it within six weeks or so and get back on track. 

Happy New Year, everybody. Be safe tonight…I don’t want to see any of you tomorrow.

Mr. Frea over at the Respiratory Therapy Cave has compiled a list of the Top Lung Health Bloggers of 2008. These people live with lung disease and write about it, and their blogs are worth a look. Head on over and check out the list!

More for new years ahead. Stay tuned…

The nice ones always die.

I was working in our general medical ICU. I had ten beds to tend to, six ventilated patients and a couple of people on therapy. One of my non-ventilated patients was an eighty year old man with an extensive cardiac history who had developed a whopping case of pneumonia. George had been feeling okay for the first few days in the hospital, but he’d acutely decompensated on the floor and been sent to the unit so we could watch him.

When I came in first thing in the morning, George struck me as the kind of patient I love to work with. He was friendly, engaging, intelligent. He talked easily of the better times in his life. He told me of his jobs, working in an industrial job before switching to teaching and coaching. He told me about his kids, bragged about their achievements, asked me about my own life. He was a joy to care for and interact with.

But let’s not forget, George was sick. He was on a nonrebreather and unable to tolerate even short times off his oxygen. His PaO2 on the mask was a measly 65;  taking him off the oxygen to administer a treatment caused his sats to plummet into the high 70’s. He knew he was sick, too. He’d get short of breath quickly, turn a little blue around the gills, start to look frightened. I got nervous. He was nice and he was sick. That never ends well; sick jerks will live forever but sick nice people don’t. 

As the day wore on, George looked sicker and sicker. He was coughing but not producing and the nurse and I discussed changing him to a high-flow aerosol. I placed him on a 40-liter a minute O2 mask, and he liked it, said he could feel the flow and feel the O2. Unfortunately, his lungs seemed determined to get the better of him. I obtained another ABG in the late afternoon, and on a 90% aerosol his PaO2 was all the way down to 50. 

The decision to intubate electively before an emergency happened was made by George and the ICU doc. We gathered the equipment, knocked him down, and tubed him. I ran through the ventilator routine, tied my tube and checked my numbers. But behind the routine I was upset. I liked George. I didn’t want to intubate him, didn’t want to see him get sicker. I had gotten attached to him. I racked my brain trying to think if anything I could have done would have prevented his downturn, but I think it was probably just going to happen.

I went home in a glum mood. George worried me. But a couple of days off is enough to make you forget and by the time I made it to the house I was focused on getting fed and resting.

A few days later I was in the ER when I suddenly thought about George. I went upstairs to the ICU to check on him and see how he was doing. My hope was that he was doing better.

But when I made it into the ICU, I saw that his room was empty. I asked the ICU therapist where he was but they’d not heard his name.

I looked through our electronic charting notes. Mere hours after I’d gone home he coded and died. He’d gone from awake and talking pleasantly to dead in less than 12 hours. 

Why do the nice ones always die?

As part of our last-minute Christmas shopping today my wife and I were at a chocolatier’s shop. They make fine chocolates, chocolate beverages, and chocolate snacks that you can either purchase and eat there or bring home with you. I bought a couple of small chocolate things for people and got myself a light snack for us to share, then we went and sat in the corner to eat.

As we ate three Japanese woman came in, a young woman pushing in front of her an Extremely Elderly Japanese woman in a wheelchair, trailed by an older but not extremely elderly woman. The Extremely Elderly woman looked very frail and very old, even to the point where she could have been a centenarian. They went to the counter and ordered, and got a small sundae to share.

I watched as they went and sat down around a table. The three women shared the sundae, but what surprised me was that the younger woman took the time and effort to spoon-feed her elder. She’d take a small bite, the elder would take a small bite, and then the younger would spoon-feed the Extreme Elder.

Considering all the forgotten old people that I see every day, the very elderly who have been abandoned in nursing homes or dumped in the hospital by families that never visit and never care, it was amazing to see an elder being cared for by her family. It was surprising to see that some families care for their elders. After seeing too many grandmas and grandpas kept alive only for the continued receipt of social security checks, seeing too many elderly dumped in a home and kept alive because families too busy to come care feel too guilty to let grandma die, it was remarkable to see a very old person being treated humanly and loved by her family. It made me happy to watch her eat, watch her enjoy her sundae.

I guess sometimes there are good people out there, too. You just have to take them where you can find them.

It’s been quiet lately at the hospital.

There have been the odd bursts of activity here and there. A few days ago I got a trauma that died in the ER from what we suspect was a cardiac tamponade. Just yesterday we had a code in the hospital lobby that turned out to be just a guy who was outside smoking whose IV fell out and bled all over, causing the lobby volunteer to panic at the sight of blood and call a code in to the switchboard. 

But apart from all that, not much is going on. There’s a Horrible Christmas Tale in the works from a couple years ago, but apart from that there’s just not much going on in my mind. Some would say that that’s my baseline, but bah to them!

I’ll have more posts as soon as the muse strikes me.

You’ve read about my perspective on codes a number of times.

Now, go read what The Happy Hospitalist has to say about them.

You’ll be glad you did.

——

Update: Link fixed!

By way of MonkeyGirl:

Doctors:
(a) The number of doctors in the US is 700,000
(b) Accidental deaths caused by physicians per year are 120,000
(c) Accidental deaths per physician is 0.17

Guns:
(a) The number of gun owners in the US is 80,000,000
(b) Accidental gun deaths per year is 1,500
(c) Accidental deaths per gun owner is 0.000019

So, statistically, doctors are approximately 9,000 times more dangerous than gun owners.

Remember: Guns don’t kill people; doctors do.

Not everyone has a gun, but almost everyone has a doctor.

Please alert your friends to this alarming threat. Doctors should be banned, or at least more strictly controlled, before this gets more out of hand.

Out of concern for general public safety, there should be no statistics published about lawyers for fear the shock would cause people to panic and seek a doctor’s assistance.

 

I like it.

I’d like Barack Obama a whole lot more if he’d take the suggestion in this article to heart:

There’s a beautiful thing President-elect Obama could do on his first day in office to prove he’s serious about being an instrument of real change.

It’d be politically painless. He’d double-cross no special-interest group. He’d offend no important voting bloc. And he wouldn’t have to create a new federal bureaucracy or spend $30 billion to make it happen.

With just the power of his oratory and his yet-untarnished moral authority, our new changer-in-chief could save 7,000 American lives a year, put an end to the physical and mental suffering of another 100,000 men, women and children, and save billions of dollars in unnecessary medical costs.

All he has to do on Jan. 20 is call for the repeal of the National Organ Transplant Act of 1984. That’s the terrible federal law that criminalizes the buying and selling of human organs for transplant operations—and therefore makes it a virtual certainty that the supply of kidneys, livers, and hearts will never meet our demand for them.

Justifications for prohibiting the trade in major human body parts—including that the world’s poor will be forced into selling their children’s organs to Westerners or people will be kidnapped and have their organs harvested—are largely irrational, exaggerated, or bogus, as an Oct. 11 article in The Economist magazine pointed out.

Meanwhile, the “moral” arguments of the ivory-towered medical ethicists, who think treating human body parts like a commercial commodity is an indignity that trumps saving lives, are indefensible. So is the position of the National Kidney Foundation, which recently lobbied against a bill that would have permitted the mere testing of financial incentives.

I like it. Your thoughts?

Second Shift had an interesting post up about an ER in Georgia with a novel approach to patients presenting with non-emergent complaints: they’re going to ask them to pay or prove that they can pay if they don’t present with an actual emergency. This could cause some problems with EMTALA but I like the idea of hassling people who come to the ED without an emergency. We need to find a way to discourage abuse of emergency services. 

Personally, I have a different idea for those presenting to the ED with non-emergent complaints. You know how the police will fine or arrest people who chronically call them for no reason? I think we should adopt a similar system in emergency medicine.

My suggestions is that all EDs hire a couple of big burly foul-tempered guys named Vito to stand around near triage. Any time that somebody presents with a non-emergent complaint, The Vitos will inflict an emergency of their choosing on the patient to justify their admission to the ED. Come in without an emergency? No problem! An emergency of our choosing will be assigned to you so you can understand the difference between an emergency and an inconvenience.

After a few broken long bones, crushed skulls, popped eyes, or deeply stabbed organs, I suspect that many of our chronic ED abusers would simply decide to get their drugs from a dealer, stay at home, or maybe get a PCP like a responsible adult. I’m sick of seeing people in our ED who have no business being there, and I think my “Vitos” program would seriously discourage people from continuing to abuse our services.

Content? We don’t need no stinking content! Also, I’m going to be away for a few days, so this will act as some nice filler.

With that in mind, here’s another meme. It’s 100 questions about things you have or have not done. You’re supposed to bold the answers you have done. I’ll tag EVERYBODY! Just leave a link to your copy of the meme in the comments. Ready set GO!

1. Started your own blog.

2. Slept under the stars. I enjoyed it.

3. Played in a band. I played trumpet in the high school band and spent a couple of summers at a jazz camp.

4. Visited Hawaii.

5. Watched a meteor shower.

6. Given more than you can afford to charity.

7. Been to Disneyland.

8. Climbed a mountain. Nothing like Everest, Denali, or Kilimanjaro but I’ve climbed a few smaller peaks.

9. Held a praying mantis. No. I have however had my head torn off and eaten after sex once or twice.

10. Sang a solo.

11. Bungee jumped.

12. Visited Paris.

13. Watched a lightning storm at sea. Only from dry land, but it is spectacular to see lightning on an angry sea.

14. Taught yourself an art from scratch. I’m counting baking as an art so I can say Yes.

15. Adopted a child.

16. Had food poisoning. Oh yes. I had violent food poisoning a few months ago…spent a good portion of my night face-first in the toilet, retching away. Thought I might actually need to go to the ER, but my goal is to avoid ever doing that again so I stayed home and let it pass. 

17. Walked to the top of the Statue of Liberty.

18. Grown your own vegetables.

19. Seen the Mona Lisa in France.

20. Slept on an overnight train.

21. Had a pillow fight.

22. Hitch hiked. I’m trying to spend as little time as possible buried in shallow roadside graves.

23. Taken a sick day when you’re not ill.

24. Built a snow fort. I got to build some big ones when I was a kid…it was awesome.

25. Held a lamb.

26. Gone skinny dipping.

27. Run a Marathon. I’ll get there.

28. Ridden in a gondola in Venice.

29. Seen a total eclipse.

30. Watched a sunrise or sunset. I used to watch the sun rise over the bay from the windows in one of the hospital towers when I worked nights in one of the hospitals in the Great North Woods. And I watched the sun rise over the rural townscape when I worked nights in Our lady of Perpetual Guilt waaay up North. And when I was a lad, I spent time at a Quaker summer camp, and every night for vespers we’d go sit silently in a field and watch the sunset. I enjoyed it.

31. Hit a home run. Hahahahaa…no.

32. Been on a cruise. Overnight to Nova Scotia.

33. Seen Niagara Falls in person.

34. Visited the birthplace of your ancestors. Sort of. I’m descended from drunken French Canadians, and I’ve been to (and been drunk in!) Quebec, but not for the purpose of visiting the birthplace of my ancestors. Given the family history I’m thinking they were distilled rather than born…

35. Seen an Amish community. No but I have driven past the Shaker villages in Maine.

36. Taught yourself a new language. I tried, but no.

37. Had enough money to be truly satisfied. Briefly. Then I got married. You fill in the ending.

38. Seen the Leaning Tower of Pisa in person.

39. Gone rock (wall) climbing.

40. Seen Michelangelo’s David.

41. Sung karaoke.

42. Seen Old Faithful geyser erupt. No, but I want to go out West and see Yellowstone.

43. Bought a stranger a meal at a restaurant. I’ve wanted to, but cash supplies have been low for the last few years.

44. Visited Africa. No…I’m sure it’s nice in some places but generally speaking I’m not a fan of plagues, war, famine, and generally being (through no real fault of their own) the center of world misfortune. I work with a number of Africans, and while they often have interesting stories of their homelands, one thing you don’t hear a lot from them is “I want to go home.”

45. Walked on a beach by moonlight. Once, in Maine. I’m not even romantic but I have to admit it was nice.

46. Been transported in an ambulance. Only as a student.

47. Had your portrait painted drawn. I got caricatured once!

48. Gone deep sea fishing.

49. Seen the Sistine Chapel in person.

50. Been to the top of the Eiffel Tower in Paris.

51. Gone scuba diving or snorkeling. I’ve snorkeled a little.

52. Kissed in the rain. No.

53. Played in the mud. No.

54. Gone to a drive-in theater. No.

55. Been in a movie. No.

56. Visited the Great Wall of China. No, but maybe if China opens up more I will be able to someday.

57. Started a business. No.

58. Taken a martial arts class. No.

59. Visited Russia. No. Could be fun.

60. Served at a soup kitchen.

61. Sold Girl Scout Cookies. Boy Scout Popcorn…

62. Gone whale watching. Yes. For behemoths, they’re hard to spot.

63. Got flowers for no reason.

64. Donated blood, platelets or plasma. I donated blood several times, but not lately.

65. Gone sky diving. No, but I would love to.

66. Visited a Nazi Concentration Camp. No.

67. Bounced a check.

68. Flown in a helicopter.

70. Visited the Lincoln Memorial.

71. Eaten Caviar. No

72. Pieced a quilt. No.

73. Stood in Times Square. No.

74. Toured the Everglades. No.

75. Been fired from a job. Not yet!

76. Seen the Changing of the Guards in London. No.

77. Broken a bone. I fractured my radial head a few years ago. It hurt. I can’t imagine how much big breaks hurt.

78. Been on a speeding motorcycle. No, and after seeing the many ways you can die on one, I’ll avoid it…he said after professing a desire to jump from a flying airplane.

79. Seen the Grand Canyon in person. No, but the Wife has, and she liked it.

80. Published a book. No but I’ve been told to look into it.

81. Visited the Vatican. Do I get a hat?

82. Bought a brand new car. Yes…and I miss that car…

83. Walked in Jerusalem. No.

84. Had your picture in the newspaper. As part of a group.

85. Read the entire Bible. I’ve read good portions of it but not the entire thing.

86. Visited the White House.

87. Killed and prepared an animal for eating. No.

88. Had chickenpox. I was six. It sucked.

89. Saved someone’s life. That’s a tricky question. I’ll say yes. I guess I’ve been part of a team that’s saved a life. I did spare one old lady the ventilator once by advocating for BiPAP instead of intubation, which I suspect saved her life…she’d have been hard to get off the vent.

90. Sat on a jury. No.

91. Met someone famous. Yes but I can’t answer specifics because of privacy laws.

92. Joined a book club. No.

93. Lost a loved one. Grandparents…

94. Had a baby. Not that I am aware of…

95. Seen the Alamo in person. Never been to Texas.

96. Swam in the Great Salt Lake. No.

97. Been involved in a law suit. Not yet.

98. Owned a cell phone.

99. Been stung by a bee. Several at once…stepped into a flock of angry bees once…ow!

100. Read an entire book in one day. Several times.

Anybody who wants to play, feel free!