Respiratory Therapy 101: Just Keep Breathing

Rick over at the RT cave has a classic post up about a classic respiratory care patient. An excerpt:

Chances are you’ve seen this patient at a hospital near you. I will provide a picture of him. Let me know if you’ve seen him.

1. Summer teeth (that’s sum ‘er there, sum ‘er not)
2. The sum he has is not white
3. Gray scraggly beard down to his nipples with bread crumbs on it
4. Hard, crusty feet a dark brown or even black color
5. His toes look like they might fall off
6. His ankles are swollen (edemitous)
7. Strong BO (that’s body odor)
8. White stuff in hair. What is it???
9. Dark brown spot on the draw sheet he was lying on
10. Really nice, but very blunt
11. Looks mean, may look intimidting, but sweet as a teddy bear

Classic RT patient. More at the link!

Man. What the old lady said to me the other day got me thinking. 

I’m not old by any stretch of the imagination. I’m still in my youthful glory days. But where I am is not where I wanted to be.

In RT school, I imagined doing this for a few years and then moving on, going to PA or Perfusion school or doing something more…actualizing. I dreamed of moving on, moving up. Being a therapist is good, and I have no disrespect for career RTs–on the contrary, they have my admiration, and I have learned more than I can say from some very seasoned RTs. 

But at the same time, all that learning considered, I’m not doing what I really wanted. Instead of doing that, I got married and settled into a job that I’m seriously up-and-down about in a state that, while it offers many amenities that I enjoy, is totally alien to me. And to top it all off, I’m not even sure if medicine is the right field for me. It works, for now, but it just feels weird.

When I was younger and thought of myself, I envisioned a different life. This isn’t what I wanted. And as much as I like the benefits of this job, as much as I’ve learned and as many people as I have helped breathe, being a respiratory therapist is not what I wanted to do.

In fact, I never imagined myself in medicine. I wanted to be a pilot. I pictured myself roaring through the skies over the countryside, ferrying cargo and passengers to and from. I imagined myself in stormy skies, imagined the live or die terror of landing on icy runways in zero visibility. I imagined the stress and frustration and adrenaline of holding with 40 other airplanes over metro airports, not the stress and frustration and adrenaline of having 40 patients to nebulize. I imagined the sheer ass-clenching terror of bringing a plane into an airport in 40 mph crosswinds, not the ass-clenching terror of losing an airway in a critical patient. I imagined the smooth skies at 30,000 feet, the sheer physics-defying thrill of aviation. THAT is what I want. My eyes gleam when I think about it.

Don’t get me wrong. I know being a pilot is not a Dream Job. Flying is stressful. Dealing with airports is stressful. The airline industry is troubled. There are problems with being a pilot just like there are problems with being a respiratory therapist. It’s not the glory job it used to be. But in spite of it all, I’d really much rather be sitting in the cockpit than sitting in the ICU. I’d rather by flying an regional prop plane than flying a computer-on-wheels through the halls of sickness. 

It’s been almost eight years since I flew last. I don’t know why I stopped. Flying was the most amazing thing I have ever done. Helping people breathe is good too, don’t get me wrong, but it’s not what I really want. I don’t want to wake up when I’m older and it’s too late and realize that I let my life get in the way of living. I don’t want to realize one day that I missed my calling.

It’s time to go back. It’s time to add some more hours to the logbook. It’s time to fly.

It’s time to convince the wife. 

This could be harder than I thought. 

Today at work, a 95-year-old woman who had been confused became reoriented. She started talking to me.

“I woke up and I had no idea where I was or even who I was. It’s terrifying to wake up here and not know…not know anything.” Her eyes opened wide and she looked at me from behind her oxygen mask. She reached out and clasped my hand.

“I spent my whole life doing things I didn’t want to and now I’ve lived a long time and I can’t remember anything.” There was a long pause.

I’ve found that often, if you remain silent, people will keep talking and tell you things that you might not ever find out otherwise. The old woman looked me in the eyes.

“It wasn’t worth it, son.”

Amid all the negativity here at RT 101, I decided I should post a happy story.  If you’re bored by technical details, read the first paragraph after this one and then read the last one and you’ll still get the gist of it. Questions? Drop a comment. 

The other day I was working in the trauma unit. One of our patients was an elderly man who had been struck by a very large motor vehicle in a parking lot. He suffered the usual host of injuries: fractured ribs, a broken collarbone, lung contusions, fractured pelvis, etcetera.

I walked into his room to begin my daily routine and took a look at his ventilator settings. He was on a low rate, high tidal-volume mode with 100% FiO2 and 10 of PEEP. “Huh,” I said to nobody in particular. I looked up his morning ABG: on those settings, his acid/base balance was perfect, but his PaO2 was a mere 80. Not so hot, for 100% and 10 of PEEP; in fact, that gives us a p/f ratio of 80, which is Holy-Shit-Gonna-Die land. 

I scratched my head and looked at the patient for a moment. My mind began working. He was in a perfect setup for ARDS: elderly, traumatic injury to the chest wall, probably some underlying pulmonary issues, intubated, high peak pressures. Not good at all. I tweaked a few settings, decreasing his tidal volume and increasing his respiratory rate to get his peak pressures back under control. I bumped his PEEP to 12, just to see what would happen, then stood back and watched the monitor for a few minutes. He seemed happy with those settings, so I went about my business and came back half an hour later for an ABG.

On his new settings, two hours after his AM ABG, his acid/base remained good but his PaO2 was a nauseating 55…on 100% and 12 of PEEP. I called the trauma surgeon. His advice to me:

“Shoot, man, I dunno. You’re the vent guy…just do whatever you want and write the orders from me.”

Now, those orders would make some people hopping mad, but I like to play with the ventilator. I gleefully hung up the phone and talked with the nurse. We had plenty of blood pressure, so I could afford to mess with his intrathoracic pressures and not worry too much about affecting his BP. “Anyway,” the nurse told me, “I’ve got levophed that I can go up on if you need it.”

So, I turned to the ventilator and began to think. Perhaps pressure control would be indicated: a constant driving pressure instead of the varying pressures of volume-control would be beneficial in this case. Perhaps some more PEEP would be good, too. So I set my inspiratory pressures at 28, my PEEP at 15, and my inspiratory time to keep the I:E ratio 1:1. An hour later I drew the gas.

Bad news. The PaO2 was better, above 100 even, but now we were acidotic. His PaCO2 had climbed and dumped his pH to the 7.24 neighborhood. So I went into the room and noted that his blood pressure remained remarkably good. Feeling confident, I bumped his pressures up to 30, and waited. 

Another ABG.

Perfect.

In the course of half an hour, his PaO2 shot up by seventy points. His PaCO2 dumped and his pH normalized. I began to work my way slowly backwards, weaning the FiO2 and PEEP gradually. By the end of the day, I had managed to get his PaO2 up into the low 100’s while simultaneously dropping the FiO2 by 40%. I dropped his PEEP back to 10 and managed to hold him on those settings. Today, a few days after I was given the opportunity to do as I see fit, he was extubated. What his long-term prognosis is I don’t know; but I do know that if everything goes well, at least he won’t die from ARDS on a ventilator in our ICU. Even though I know the long-term may not look good for this unfortunate guy, I feel like I actually helped somebody for a change. I feel pretty good about that. 

(I was going to end this with that quote about “to know that one person has breathed easier because of you blah blah blah” but I can’t find it. Mad props to anyone who can find it for me…)

A tip to the management here at Sunny Flats, who are wondering why morale is low:

If you want us to love our job, stop micromanaging us. It doesn’t feel good to have you breathing down our necks, checking after us, writing us up and “coaching” us for every bullshit infraction. If you want us to provide quality care, give us lighter patient loads: it’s hard to give good care when you’ve got an enormous number of patients to see. If you want us to stop hating you personally, don’t pretend to be our friend and then slam the knife in as soon as we turn our backs. Don’t blow us off when we have legitimate concerns about patient safety or staffing. Even if you can’t do something it would be great if you would pretend to listen instead of just cutting us off and blathering about “the staffing rubric says this.”

Stop lying to us. We know you are. You can’t even make eye contact with us. Stop trying to be funny, it makes it look like you care even less.

In short: grow up. Let us do what we do. Minimize direct supervision. Stop following us and spying on us. Get rid of the “secret” list of people who you want to fire but can’t. Give us less insane assignments. You want to know why people quit? It’s because of you.

I’ve always been a little bitter, a little burned. But the last few weeks I feel like I’ve aged, gotten more and more bitter, burned to a crisp. I used to not dread going into work in the mornings, but now I just sigh and hope for the day to be over soon so the pain will stop.

It’s often said that you need to separate yourself from your patients or you’ll go insane. It’s true. While it is important to be able to sympathize with your patients and relate to them, it’s important to keep that distance so you don’t get attached.

If you don’t do that, it will affect you. I saw several seasoned ICU nurses in tears a few weeks ago when one of our chronic patients, a quadraplegic who had been with the hospital for well over a year, passed away. I was disappointed to learn of the death of that patient, but not to the point of tears. Distance works.

The only place I’ve had trouble keeping my distance in is the NICU. I can not work the NICU, and those who can have my respect, because it’s the one place I’ve ever been that beat me.

When I was in respiratory school, we had to do a four-week NICU rotation at the Major Medical Center in the Big City. I was terrified. With adults you have a lot of room to move before you do something that will kill somebody. With neonates, you so much as breathe on them wrong and they’ll code and die. They are fragile, they are innocent, and they scare the hell out of me.

On my second week in the NICU, we received from an outlying hospital a set of triplets. They were 26-weekers, very tiny, very critical, right on the edge of where they could be kept alive. They hadn’t even been named yet: instead they were Triplet A, Triplet B, and Triplet C. I remember working hard to keep those little babies alive. I remember looking at them and realizing that I could fit them in the palm of my hand. They were so tiny, so fragile, totally helpless. The parents were devastated by the premature delivery, and were involved, caring, concerned.

When I left the first week of my NICU rotation, all three triplets were alive. They were doing very poorly. Prognosis was bad.

When I came back the second week, B had died.

When I came back the third week, C died just after the end of my clinical day.

And when I came back for the final week, A was gone.

How do you prepare yourself for something like that?

That’s why I don’t work in the NICU.

Your result for What Your Taste in Art Says About You Test…

Non-conformist, Visionary, and Independent

24 Abstract, -18 Islamic, -20 Ukiyo-e, 15 Cubist, -21 Impressionist and -30 Renaissance!

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I’m drunk and bored, so I’m reviewing the search terms for this website. Here is a sampling of terms that led people here:

*Raw Ass Tattoos

*Fat Guy Crucifix

*Great Swallow Tattoo Chest (WTF?)

*Respiratory Therapist Quotes

*Trucking Respiratory

*Respiratory Therapy Does It Pay

*Respiratory Jokes

*Respiratory Therapist Hate My Job

This is enlightening, but I’m not sure how. The answer surely lies in more gin.

Almost as bad as drunk dialing, which is why I will be saying nothing further tonight whatsoever.

Recent changes in our staffing matrix inspired me to create this:

Need I say more?