Respiratory Therapy 101: Just Keep Breathing

All these are things that have been said to me on the medical floors within the last week:

“Jesus fucking Christ, another breathing treatment? I don’t even take these at home. My doctor ordered it? Why would he do that? If you don’t know, why are you even giving it to me?” I have to give props, this is an excellent question.

“Why do you need MORE blood from me? The nurse just took eight vials! It’s the same blood in my veins and arteries, I know it is, there’s no difference! You can’t fool me, I went to nursing school for a semester last year…you just want to run medical experiments on me!”

“No, I don’t want a breathing treatment. Have you lost your fucking mind?”

“So, what are you, some kind of candystriper? What’s that? You went to school for this? Wow…why?”

“Man, I never even seen the dude. I don’ even know who he was. He jus’ come up to me and stab me, jus’ like that!”

“No, no, I don’t think I need any breathing exercises. I haven’t even picked up that sucking tube there. You should check with my Doctor first. …What do you mean, he ordered it? No, he didn’t. I don’t believe you. Can’t it wait until after Jeopardy?”

“Breathing treatment? Oh, that thing? Yeah, I guess I’m supposed to take them at home…I do it maybe a few times a day if I feel like it…yeah, about two packs a day, but that’s not why I’m sick! I’m sick because of that H-A-1-1 thing…yeah, the flu. Naw, smokin’s not bad for you. I guess I’ll take your dumb treatment if it’ll make you happy.”

One thing patients never say:

“Gosh, thanks for doing your best to help me feel better.”

I have to tell you, I love what this job could be. The idea of making people’s lives better by making it easier for them to breathe is awesome. But in reality, we waste a lot of time dealing with treatments that are not indicated. We waste a lot of time trying to convince noncompliant patients that they need their therapy, which they will refuse to take. Sometimes, this burns…me…out.

Tomorrow: Things Family Members In The ICU Say!

I was working in one of our ICUs last week. One of my patients was a kindly little old lady of 96 years. She was a soft-spoken, tiny, shriveled little thing, but she was sweet and alert and fully capable of interacting with the staff beyond the usual condescenscions of “Awww she’s so CUTE.” If one were to actually talk to her like a human being instead of talking down to her like so many healthcare providers do, she was just the coolest person in the ICU. A youngun’ like me can learn from a soul of 96.

At 96 years old, she was ready and prepared to pass away. “I don’t want to live forever,” she told me. “I’ve done what I needed to do.” She had a fully signed and witnessed DNR/DNI form and wanted no aggressive care.

Her family, a staunchly religious group of people, would hear nothing of it. They demanded that we do everything for their mother. They wanted ABGS, they wanted full-blown diagnostics, they wanted a dramatic full-on assault. Despite their mothers pleas that she wanted to be left alone to live out her final days in peace, they talked over her and demanded that she rescind her DNR, which she refused to do.

The attending physician agreed with them, talked with the patient, and ignored her. The nurse and I were at the bedside when he was trying to talk this awake, alert, competent, and reasonable 96-year-old woman out of her DNR. Her nurse couldn’t take it any more.

“Do you want all of this, or do you want to go home?” she asked the patient.

“I want to go home. I want to go to heaven. I don’t want any of this.”  The doctor, not one of my favorite clinicians, stared at her in disbelief.

“Get me a psyche consult, and an ABG.”  I was dumbfounded. The nurse got red in the face and raised her voice.

“A PSYCHE consult? You’re the one who needs a psyche consult! This lady is perfectly capable of making her own decisions!”

“It’s not normal to want to die! Just because she wants to go doesn’t mean we can push her off the cliff!”

At this point I interjected.

“We’re hardly pushing her off a cliff. Everybody has to die sometime. She’s 96. She’s a grown-up. She can make her own decisions.”

“Well, I don’t think it’s normal. I want a psyche consult. And an ABG. She must be hypoxic or something.” I stared at him, amazed. My fists clenched. I wanted to punch him in the face. “I’ll be sure to get right on that,” I told him, and then I walked away.

—-

I  never did get the ABG on that patient. Psyche came to see her, declared her competent to make her own decisions, and left. Last time I saw her, her family was still trying to weasel us into doing drastic measures for their mother. They called in their priest to try and guilt her into rescinding her DNR. They prayed over her bed and asked God to expel the demons from her that were possessing her. I believe in God but I don’t believe in the kind of religion that warps a mind that badly; there’s nothing holy about what those people were doing.

I hope to God we didn’t do anything drastic after I left my shift. That lady was ready to go, and if her time was up, I hope we let her go in peace instead of subjecting her to the horrors of the modern ICU that she explicitly stated she did not want.

Why is it so hard for people? Why is it so hard for Doctors of all people? Somewhere I heard the phrase “All that lives is born to die,” and there’s a lot of truth to that. I know that it’s hard to say goodbye, but the fact is that nobody on the planet will live forever. Knowing that your loved one has to die, why would you deprive them of their autonomy in the last days of their life? Why would you inflict on them sufferings that they have specifically asked to avoid? Why would you do that to someone? There’s no going back from that, no time to heal those wounds. You put your loved one through something they didn’t want, and then they die, there’s no time for them to forgive you.

Sometimes, what we do in the ICU makes a world of difference and can recover someone, lead them along the first steps to the road of recovery. I’ve seen patients in the ICU do exceptionally well and come walking back in, months and months later, to say thank you. But there’s a dark side. I’ve seen us do a lot of painful, pointless things to people who will never recover. And thinking ahead to my own eventual demise, I can only hope that when the time comes for me, it’s a natural and peaceful end to a life well lived, not a chaotic and frantic death amid the insanity of the ICU.

While browsing Second Shift I found a link to an interesting USA Today article about 24 hours in the ER. Worth a quick read.

A friend of mine who works in financial services took a First Responders course some time ago. She was hoping never to need it, just took it as a curiosity. She wasn’t planning to go into any branch of medicine; she wasn’t planning to do any volunteer EMS, or anything like that.

A few days ago, she was in traffic when the car in front of her was struck head-on by another vehicle. She stopped to render aid. The other driver was a foreign woman who could speak no English. Her son, in the back seat, was screaming and kept lunging for his mother. For someone with no medical experience, no experience in EMS or the ER or even the hospital, this was immensely traumatic. But she did the best she could. Where others might have frozen, she moved and did what she knew to do.

With her first responders training my friend was unable to do much other than to stabilize the victim to the best of her abilities, and then sit and hold her hand and wait while EMS arrived. The accident happened in a rural part of the state, and it was 20 minutes before the ambulance came. It was another 20 before the helicopter landed to whisk the victim away. My friend was shaken up badly by this, by the trauma of seeing the accident and seeing the victim. Today, she found that the woman she aided died overnight.

Though she felt that she couldn’t do much, what my friend did was provide a human presence in the last moments of wakefulness in this poor woman’s life. She sat with her, held her hand, gave her what comfort she could. That is something that does not often happen in the mechanical and high-stress world of the ER and the ICU.

My sympathies to the deceased, and my best comforts to my friend. You did all you could. And in the end it may have been the best thing any of us could have done.