Respiratory Therapy 101: Just Keep Breathing

Second Shift had a link up about an ER in Georgia that is letting people text-message the ER to see how long the current waiting time is. As I said on the 2s blog:

If you have the wherewithal to text message the ER, I can guarantee you 100% that you do not need to be there. Were I in charge, I would design a system that predicted 14-plus-hour waiting times for anybody who texted, specifically to keep those useless piles of carbon away from my ER. Machiavellian and evil? Maybe, but then, I never claimed to be a nice person.

Seriously. If you can text the ER you’re not sick enough to need to be there. Put another way, if it’s a true emergency, you won’t be texting. Period. Go home. Stay away*. Let us use the ER for actual emergencies instead of your impatient sniveling about minor complaints that have no business in the ER. Nothing pisses me off more than walking into a room and finding some healthy 25-year-old text messaging while in the ER for “abdominal pain X 4 hours” or “fever.” Call a f***ing internist and make an appointment like a reasonable human being, you ignorant douches**. Last time I went to the ER was for an extremity fracture, and that was after I drove myself to work and clocked in with the intention of working. If I can drive to work and start a shift with a broken arm, you can suck it up with your congested sinuses, or drive to CVS and buy some decongestants. You have no business at the hospital. Period. ROFL DOOD.

A friend of mine asked, what about a parent whose kid broke their arm and wants to go to the fastest ER? In that case, if it’s a real and serious extremity fracture, you’ll be moved to the front-ish of the line at triage. I can see some validity to this system, but the fact is, idiots will abuse it, and I want no part in facilitating their abuse of the system.

*The article says that people who can’t afford a doctor go to the ER, so this program is aimed at reducing wait times. My question is, if you can’t afford a doctor, how are you paying for your cell phone? And all those minutes and texts? And the 2-pack a day smoking habit? And all the Michelob you drink? And the gas for your 1976 Buick that’s got spinning rims or NASCAR stripes custom-applied? Some people are genuinely poor; some people are just poor money managers. And you spending your money for heart pills on a sure-fire bet at the dawg track is not an emergency, mmmkay?

**I’m a bit cranky tonight, hence the abusiveness. Forgive my language.

My apologies to all female readers offended by stereotypes. Feel free to send me a virtual kick in the nuts for this.

At work, just before punch-out time, a bunch of us were standing near the time clock, which is near a vending machine. A nurse walks up and puts a dollar in the machine and pushes the COKE button.

The machine whirrs, and nothing happens.

“That goddamn thing took my money and didn’t put anything out!” she says.

Without thinking about it, I say back to her…

“It must be a woman.”

Reader “G”: my apologies to you. You emailed me like four months ago with a question, and in the quagmire of paperwork and other goings-on in my life, I lost track of it. I have probably done it to dozens of others; sorry folks!

Anyway, G emailed me and asked me some good questions. I emailed her back, but I figured I would post the Q/A here as well, because in the eons since she emailed me she probably changed her email address. Here are her questions:

Say you have a patient. It’s an old patient, with a primary Dx of pulmonary fibrosis. Sure, he has some underlying obstructive disease, but his main problem–the source of his ills–seems to be the fibrosis. He has become increasingly hypoxic, requiring a partial rebreather during the day and a BiPAP at night. The physician orders “Albuterol nebs Q4 hours.”

While giving the albuterolnebulizer to the patient, he desaturates and becomes more short of breath. SpO2 readings are in the 70s, so the RT who does not trust pulse oximetry (me) gets an ABG showing a PaO2 in the low 50’s and an O2 saturation of 83%.

Naturally, the physician is notified.

The physician, when notified that the patient feels worse after the neb and has experienced serious refractory hypoxemia correlated with the nebulizer therapy, orders Q2 treatments, which will be 100% ineffective when dealing with pulmonary fibrosis.

Logic, please? I fail to see the reasoning behind the physician’s order. Perhaps another set of eyes will be able to enlighten me as to why we are increasing the frequency of an ineffective treatment that seems to make the patient worse…has the hospital taken out life insurance on this guy?

Say, did you hear about the Minnesota mom who fled with her son rather than subject him to court-ordered chemotherapy?

At first, I might have been offended by these actions…the herbal medicine and natural remedies for cancer that this family has opted for are doomed to fail, and probably have sealed the fate of this unfortunate cancer-ridden lad. Fleeing with your son rather than subjecting him to chemotherapy seems irresponsible and unfit behavior for a parent.

But then, I thought about it.

I’ve seen people who have chemotherapy. Many survive. Many do not. But chemo is not a friendly, fun process; and if a child or a parent really objects on religious grounds, if the child says he’ll fight chemo until they restrain him, why force this on them? What business is it of mine to make sure these people do The Approved Medical Thing? How dare we force these people to undergo treatment they clearly do not want? I would be righteously pissed off if I declined a medical treatment and was forced into it by the courts. There are obvious exceptions, such as mentally ill people who are dangerous without medication or juveniles without guardians. But when the guardians are just ignorant, or when they hold beliefs contrary to those of science, how do we justify stepping in? Are the parents mentally ill for holding obscure religious beliefs? Are you willing to classify all religious people as mentally ill, so they can be subjected to government-ordered medical therapy?

The life of a child is at stake, but there are bigger issues at play. I am very uncomfortable with both ends of this situation: ignorant or misguided parents make me sad for their children, but letting the state force people into medical treatment smacks of Big-Brotherism and Nanny State badness.

My opinion? Leave them alone. It’s a sad enough situation without sending the parents to jail and subjecting a child who doesn’t want it to chemotherapy.

You know it’s going to be a long day when you open the door to the ICU and a naked patient runs screaming past you out the doors, blood running from a torn-out arterial line, torn-out foley on the floor behind them, surgical dressing half-removed and chest tubes flapping in the breeze, screaming “HELP ME JESUS, THEY’RE NOT REAL NURSES! AAAAAAAAAA!!!!!”

Yeeeeeeeah. That’s when you just turn around and go back home.

We coded the young man for an hour before we stopped. He was a walkie-talkie with a bad aorta, walked into the hospital and wound up in the surgical ICU while we decided what to do with him: do we operate and risk him dying on the table? Do we not operate and hope it doesn’t burst? Do we stall and see what happened?

Ultimately the aneurysm decided for us and ripped open in the middle of the day. We tried, but when the aorta pops, there’s only so much you can do. We tried. We intubated and bagged and squeezed fluids and ultimately wound up doing CPR while his belly inflated like a balloon as our fluids and his blood pooled in his abdomen.

After the code was over, I was charting in our computer system. It demanded to know his capnography results and then dropped a charge for them. It demanded a tally of minutes of CPR and dropped a charge for them. It demanded a full summary of my time so my boss could track my time and decide from the comfort of a well-appointed office whether or not I was working hard enough.

It was totally dehumanizing. I don’t mind charting, and a factual summary of events is needed to investigate and probe the circumstances of this mans untimely death. Billing is necessary to allow the hospital to stay afloat.

But something about the computer system, about boiling down the last few minutes of this guy’s life to a mere tally of productivity points and dollar signs, really made me sad. Sunny Flats Respiratory Care has gone from a department focused on quality care to a department focused on generating revenue.

What a sad thing.

Two weeks is not enough time to be alive.

Sometimes in the madness and the fray I lose sight of what I’m in this for.

I’m in this for the nice people.

Just the other day, a few of my patients were:

*A very sweet old black lady. She told me stories of the times she lived through. She told me of the racism and the hate, the struggles to overcome, and the way she had lived was inspiring. She had maintained faith and hope throughout her life. She had raised a nice family. She had been happily married until heart disease claimed her husband twenty years ago. She was an inspiring and sweet person to talk to and a joy to treat.

*An old retired book salesman. He and I discussed the financial markets and the wide world of reading over albuterol cocktails.

*A jovial old man with a fascination for Ireland and tattoos. He had several Gaelic tattoos on his upper body and he delighted in telling me, with a dirty cackle, exactly what obscene things they said. His delight at the mischief of his body art was contagious.

Sometimes, I need to remind myself of the cool people I interact with. There are some fine people out there, and sometimes, it’s a joy to take care of these people.

That’s why I am still doing this. For the nice people.

I was standing in the ambulance bay today talking on my mobile phone when I saw a patient exit the door of ER triage. He was a young man wearing a yellow duck-bill respirator of the type we are giving to people with flu-like symptoms as part of Porcine Illness Hysteria Month here at the hospital. He removed the mask and began coughing violently, to the point where he bent over and hawked up a massive wad of phlegm on the pavement.

I watched with interest as he moved across the ambulance bay, whipping out a pack of cigarettes and a lighter and sucking down the cancery goodness of his addiction while he walked. He alternated long drags on the cigarette with wild hacking coughs, smoking three cigarettes before going into triage again.

An hour later, I got paged to give him a stat! breathing treatment. His triage notes read patient c/o SOB, coughing, fever.

All the albuterol in the world won’t fix what’s wrong with this guy.