Respiratory Therapy 101: Just Keep Breathing

You may have noticed that I am not posting quite as much lately. That is because the RT Burnout Meter is about to burst through the roof. The pressure is building and the waters are getting high here at Sunny Flats, and the dam is about to burst open.

My goal is not to be standing in front of the dam when the water breaks through.

The cause of all this pressure lately is management. Specifically our managers have been under a lot of pressure to cut costs. Since we already own most of our equipment and we get most of our disposable stuff on the cheap, the only places remaining to cut costs are staff and administrative overhead. Cutting administrative overhead would be the managerial equivalent of hara-kiri, and so the only place left for cost cutting measures is…the staff.

Yes. Our management has decided that they are going to reduce our minimum staffing requirements. They have decided that instead of the 25 therapists we normally staff between the ICUs and the medical floors, they will slash our daily operating numbers to a maximum of 18 therapists, which is a 28% reduction in daily staffing.

The big giant obvious problem with this is that we have not reduced our workload by a similar percentage. So what you end up with is a respiratory care department that is chronically understaffed and overworked even beyond the usual. The reduction in therapists per day has affected our daily operations. While we normally staff 2 therapists per ICU we are down to about 1.5 on average; one therapist to a unit plus a couple of drifters who float between units. We have cut our ER staffing in half. We have cut floor staffing and people are routinely going out with 25, 30, 40 patients to see. This is a huge problem not just for respiratory therapists but for PATIENTS, whose care is going to suffer.

Working in the ER with 50% fewer therapists means more missed therapy, more missed diagnostics, more delays in an already slow ER. Critically or seriously ill patients are not being seen as rapidly. The quality of our assessments and interventions is diminishing because we are being asked to do the same amount of work with half as many people. I have personally been on the receiving end of rage from ER doctors and supervisors who are pissed that we are slower and less efficient than usual, and all I can do is shrug and tell them that we’ll do what we can. They hate that but it’s all I can do.

In the ICU, patients are being seen but therapists are being stretched too thin. Thorough assessments and the time to perform quality work are considered luxuries where they once were considered necessities. A distraction such as an emergency bronchoscopy or a trip to the CT scanner would once have been considered a mere nuisance. Those things now are day-killers that will put an RT so far behind that there is no hope of catching up. We can no longer be proactive members of the team; we have been reduced to running between rooms and trying to get everything done without missing something important.

On the floors…well, people just aren’t getting seen. The apathy is unbelievable and I can’t say I blame the floor therapists: there comes a point when you are so overburdened that you can no longer care.

On top of all this, management continues to add paperwork and administration to our job. We now have equipment checks to document, “safety rounds” to complete (a particularly bitter irony, as conditions are rapidly becoming less and less safe despite cubic tons of paperwork), and we must track our time in 15-minute increments as if we worked at a law firm and not a hospital.

The bottom line is this: management is asking us to do more with less and it can not be done. They can either spend money and have quality patient care, or they can cut their budget and demand more from us and get shitty patient care. Unfortunately our managers have chosen the second path. They have been warned of the errors of their ways and they have ignored increasingly frantic pleas from the staff, the doctors, and even other administrators. They insist that The Numbers work out, that it will all be ok, that we RTs are just lazy whiners. It saddens me that we have forsaken the patients and the staff in favor of The Numbers, but so be it.

I only regret that this will not change until a patient is killed or harmed by our unsafe working conditions. I hope and pray that something will change before somebody dies…

…but I am not optimistic.

For once, news about healthcare that seems to be positive. I refer to an article in todays Times about Kendal at Hanover, a nursing home affiliated with Dartmouth-Hitchcock Medical Center way up in New Hampshire.

Kendal at Hanover is apparently not your usual nursing home. For one thing, they apparently focus on giving the elderly a choice in medicine that they may not even know they have: the choice to say “no.” According to the article, the staff at Kendal are very assertive in speaking with residents about the choices they face at the end of life and the implications of those choices. I quote (emphasis mine):

Slow medicine, which shares with hospice care the goal of comfort rather than cure, is increasingly available in nursing homes, but for those living at home or in assisted living, a medical scare usually prompts a call to 911, with little opportunity to choose otherwise.

At the end of her husband’s life, Ms. Gieg was spared these extreme options because she lives in Kendal at Hanover, a retirement community affiliated with Dartmouth Medical School that has become a laboratory for the slow medicine movement. At Kendal, it is possible — even routine — for residents to say “No” to hospitalization, tests, surgery, medication or nutrition.

Charley Gieg, 86 at the time, was suffering from a heart problem, an intestinal disorder and the early stages of Alzheimer’s disease when doctors suspected he also had throat cancer.

A specialist outlined what he was facing: biopsies, anesthesia, surgery, radiation or chemotherapy. Ms. Gieg doubted he had the resilience to bounce back. She worried, instead, that such treatments would accelerate his downward trajectory, ushering in a prolonged period of decline and dependence. This is what the Giegs said they feared even more than dying, what some call “death by intensive care.”

First: the right of patients to refuse treatment. This is a right that I think many patients don’t even know they have. I can’t count the number of times that people have demanded to know why they “have to do this,” only to be totally surprised when I tell them that they have a right to refuse care. The principle of patient autonomy dictates that we should not force treatment upon people who do not desire it, and while we are very good at following this principle most of the time I think we could do a lot better if healthcare providers were a little more aggressive in informing people that they have a choice.

We could also do a little better about talking to the families of those who have been incapacitated. Often, families make a choice that the patient would not want because they are not ready to let go. This is a difficult situation at best, but what the patient wants should come first; the family is an afterthought.

Second: death by intensive care. This describes probably half of what we do in the ICUs where I work. We have a lot of patients who are just in the ICU transiently: septic people, surgical mishaps, recovering heart surgeries, trauma patients, and so on. These people will recover and leave. But we also have a lot of chronic elderly patients who are going to linger in the ICU for several months and then die. We can animate a slab of carbon for quite some time, but just because we can doesn’t mean we should. I can’t speak for everybody, but when I die, I don’t want the last two months of my life to be spent in an ICU. That’s no way to go.

In conclusion: I like the idea of Kendal at Hanover. I think that we in the healthcare industry should follow their lead: we should lay out the fact that everybody dies and then offer people control over the end of their own lives. Pretending that medicine will keep everybody alive forever is only going to make it worse. Mortality is a fact. We can either hide from it or face it head-on, but we will never escape it.

30 years old with terminal cancer of a non-removable deeply essential organ. No family. No friends. No wife. No children. Just a man alone with his tumors, wasting quietly away in the ICU where we can do absolutely nothing beyond meaninglessly prolonging his suffering.

That, my friends, just plain sucks.

A success:

The patient presented approximately one month ago after a severe motor vehicle collision in which he was mostly paralyzed. He went into ARDS and had a prolonged and difficult ventilator wean. The patients care was complicated by his paralysis, but through intensive prophylactic respiratory care including EZ-PAP therapy and inspiratory muscle training, he pulled through and was discharged to rehab. He will never walk again, but he isn’t dead, either.

A failure:

The patient presented with acute abdominal pain. To avoid complications I will avoid the specific diagnosis but abdominal surgery was performed and the patient was placed on the med-surg floor. Due to substandard monitoring and a healthy dose of apathy, nobody noticed as her heart rate and temperature climbed while her BP fell. Eventually somebody cared and called the Critical Assessment Team, who transferred her to the ICU. We were unable to get a blood pressure and her heart rate was 160. Ultimately it was determined that the patient had developed necrotizing fasciitis at the surgical site; by the time it was discovered she was too sick to save. Ultimately the patient died.

:::

A  success and a failure. Such is life.

“Mr. D came in last night, somethin’ wrong with his bowels or somethin’. He was a DNR but the ER doc talked the family into trying to resuscitate him and now he’s intubated. He’s septic or somethin’ cuz he’s breathing fast.” I nodded and looked at Mr. D, who was breathing a phenomenal fifty times a minute. His thick and distended abdomen heaved as he worked against the ventilator. His mouth opened in the classic “guppy breathing” posture as he worked.

“Do you know anything else about him?” I asked the night therapist. She eyeballed me quickly and shook her head.

“Nope. I’m off. See you tonight.” I nodded back at her and went to work.

Over the course of the morning, I spent a couple of hours with Mr. D. I put him on our ARDS protocol, ran mixed venous blood samples. I put in an arterial line, which was something of a personal triumph for me because even the Intensivist couldn’t insert one on this gentleman. The nurse and I played with PEEP and pressors and tried to balance oxygenation with perfusion. It was an uphill battle. Finally, at noon, the family asked us to cease our efforts. Mr. D died within three minutes after I extubated him. I was standing outside his room when his wife pulled the curtain back. Her eyes were blooshot. She grabbed me by the arm and began sobbing.

“Is he supposed to turn blue? What should I do?” She burst into tears and began sobbing hysterically all over my sleeve. I looked over her shoulder. Mr. D was bright purple, and as I watched he heaved his last breath and gave up the ghost. He was a family man, worked diligently in his church, served his country in the army for twenty years. Within twenty hours of coming to the ER for serious sudden abdominal pain he was dead. His family was devastated.

Down the hall, I had another patient, a middle-aged ex-IV drug user, unemployed woman who had come to the hospital more than two months ago because she didn’t feel right. She progressed into respiratory failure and got intubated in mid-December. Her family refuses to give her a tracheostomy because “she wouldn’t want that,” yet they refuse to let us withdraw support because she “wants everything done…” except for a trach, evidently. We’ve explained to them how her tube is surely eroding her throat, but they won’t listen. This woman has been on and off the oscillating ventilator, she has been in and out of surgery a number of times, and she is not neurologically intact in any meaningful sense–yet she is not brain-dead. She emits a smell that could stun a musk ox at a hundred yards. She absolutely refuses to die, and her family absolutely refuses to let us withdraw support. She never worked, she spent her life abusing drugs and grunting out babies, and she sits in our ICU and wastes your tax dollars to the tune of 5,000 dollars a day so that her high-quality life of staring into the middle distance and having tubes and lines inserted into her can continue indefinitely. We are no longer treating her for any curable condition; we are now keeping her alive for no reason. If she was aware of what was going on, I’d call it torture, but luckily for her she’s in a persistent vegetative state.Her family visits for about five minutes a day and then pronounces that “The Good Lord will make her better!” and leaves. I suspect that they are attending the church of the idiot pastor, but I can’t prove that.

Sometimes the contrast between my patients astounds me.

(This is an unusually theological post. I’m no seminarian but I’m pretty sure that I’m right about this. Read on.)

One of the most important lessons to learn in the practice of modern medicine is that no matter how hard we try, we can’t possibly save everybody. Indeed, over a long enough timeframe we can’t save anybody. But I think that this lesson, that we can’t save them all, could be applied just as well to some other professions. Like pastoring.
In one of the ICUs we currently have a rather young patient. The lad in question was out performing minor felonies with his friends when he was involved in some sort of major traumatic incident involving most of his body, but especially his head. His friends, the ever-considerate minor felons that they were, put his lifeless body in the trunk and dumped him in front of the ER.

After a major workup it has been determined that he is just this side of brain-dead. He’s not technically “brain dead” because he still breathes, but he is in a deep vegetative state and he will probably never wake up. Even if he did, it would be irrelevant; the higher sections of his brain were crushed in the incident.

Despite all of this, and because of a lot of ambiguous wording by lawyerphobic physicians and the normal processes of denial, the lad’s family seems to believe that not only will he awaken, he will be his old normal self. But their expectations and wishes don’t meet reality, so they brought a pastor with them when they came to visit.

I happened to be in the doorway of the room next to the lad when the pastor was holding a prayer service. My attention wandered, but I got bits and pieces. Until one particular tidbit of the pastor’s prayer caught my ear:

“Lord, let your healing powers FLOW through this boy. May his healing and his full recovery be an example of just how perfect you are! Let this boy’s healing speak to your power! Christ, we know you can fix this boy and we know you will fix him and glorify your name through him!”

Now. I’m not especially pious in the traditional sense, and I’ve never attended seminary or any sort of religious training. But I know bad religion when I hear it. False hope mixed with bad theology and a truckload of desperation makes for some might bad religion, and while there’s a lot of good to be found in religion it can be badly misapplied. From a medical and a theological standpoint, this pastor was practicing bad bad religion.

Let’s analyze the medical aspect first and the theological aspect second. If I offend you and/or you feel a need to refute me in the comments, please do so respectfully or you will face the wrath of the delete comment key.

Medically speaking: miracles happen every now and then. I’ve seen people recover from illness who I’d written off for dead months before. I’ve seen people come back from the very brink of death. I know that sometimes my negative prognostications are wrong, and that sometimes hope is needed for patients and their families. But I also know that this lad’s brain is gone. Not only is it damaged beyond any repair, it’s growing mold. Nothing is going to bring him back, and anybody who tells the family otherwise is a liar. As I have said before: dangling the carrot of false hope is a terrible idea because it makes the inevitable whack with the stick of reality that much more painful. False hope is abominable, and medically speaking the pastor’s prayer was full of nothing else.

Theologically speaking the pastor’s prayer was filled with bad religion. First and foremost: the point of Christianity is not to live this life forever. The point of Christianity is to make the best of what you have and then go see Jesus. The entire religion is based around human error and human mortality. Everybody is expected to make mistakes, and everybody is expected to die. And with the grace of God, in death you are to have new life. That’s the entire religion in a nutshell. And yet this pastor seems to be willing to overlook this most fundamental aspect of her religion when she begs and pleads with God to change his mind and bring him back to a world that her own religion tells her is evil. But instead of telling the family this, instead of reminding them that all that is born was born to die, instead of giving them hope of the afterlife while they are staring into the maw of the inevitable, she tells them it will be okay. She tells them that Jesus is going to wave his magic Jesus Wand and the boy will pop out of bed, cured of both his brain injuries and his felonious nature.

Not only is this astonishingly bad theology for a pastor, this is the worst kind of lie that can be told. Ultimately, when this boy dies and Jesus never waves his Magic Jesus Wand and the boy isn’t cured, the family will be both saddened by his death and disillusioned by the perceived failure of their prayers.  The pastor’s prayer is destined to fail on every single possible level, unless you count the few moments of false hope delivered right after the prayer as a success. I’d entertain the argument that making the family feel better in the moment is a worthy cause, but I don’t buy it. Ultimately this is going to make it worse for them. Promising that God is going to do anything is bad form for a human being of any religion; but the circumstances here make this an especially grotesque parody of what the religion is supposed to be about. Christianity is about hope for the next life, not an indefinite extension of this one. And I think that that truth is too often lost in the politics and the badness these days.

After all, you can pray all you want to, but you can’t steer a train.
Less religious posts to resume shortly.

It was an exciting new year’s day in the Medical ICU today. Normally, the Medical ICU is a sort of weird place: it is full of chronic patients in various stages of maturation and aging, much like the Wine Cellar from Hell; you have your more recent vintages like the fruity yet tannic 29-year-old diabetic in DKA and early multi-system failure, and then you have your old classics in a Magnum, like the 76-year-old cancer-riddled COPDer with undertones of chronic renal failure and a distinctive VRE bouquet. Wine aside, my point is that the MICU tends to attract long-term patients and as such it is a change of pace from the surgical ICU where I spend most of my time.

But today, I got an SICU overflow patient. He was an unfortunate new year’s reveler who was out for a drive at some point in the festivities when he crashed his car and was ejected. His body was broken pretty badly, and his head was smashed in and leaking brain lubricant. His lungs were totaled: on 100% oxygen and 15 of PEEP his PO2 was 70, which (if you do the math) gives you a negative P/F ratio, which is always a negative prognostic sign.

On another note, one of this patient’s fingers was mostly severed in the accident. The EMT’s had bandaged it, and then the trauma docs had simply re-bandaged it and turfed the damage to some other doctor’s group to avoid liability should he lose the finger. When the patient arrived in the MICU, most of his finger was hanging by a flap of skin, carefully arranged under a bandage. This was the least of my concerns at first, since I was busy managing his lungs and doing CPR and things like that. But eventually, The Finger became an item of interest. It began when some doctor ambled into the room.

With one surly motion, he glared at all of the gathered staff who had just resuscitated the patient. He thumbed through the chart, glanced briefly at the finger, and then muttered something to himself and plopped down to write a note and some orders. We bustled around him as he worked, but finally he stood up and addressed the nurse.

“His finger’s dead. Go ahead and cut it off.”

“You don’t want to do it?”

“No. You do it.” With that he turned and left.

And so it was that, an hour later, a small crowd was gathered as one of the MICU nurses sawed away at the remaining skin with a scalpel. After a couple of expedient swipes with the blade, the fingertip fell off and plopped into a denture cup, rolling with the slope of the bed like the head of some tiny guillotined hand tyrant*.  A couple of people made gurgling noises and left, but I was curious. I’ve never held a dismembered body part before.

I picked up the denture cup and examined the finger of my patient. The blood brought out small details and I could see the intricate whorls and swirls of his fingerprints, the damage to the nail where he had scraped it. The bone and nerves and vessels were vaguely visible at the base of the digit. I rolled the fingertip around in the denture cup while the nurse dressed the wound, pondering this. As many EMS personnel and others could surely tell you, holding a severed human digit in your hands is a surreal experience. I am used to dealing with broken bodies, but actually handling a dismembered body part…however small…was very strange to me. Holding a small piece of another human being is a very weird feeling.

The fingertip eventually got transferred to a specimen cup, washed in saline and sent out to the path lab for reasons not clear to me.

Shortly after we cut his fingertip off, the patient coded and died.  He was only 24.

*Leave me alone, I’m tired. I can say phrases like that when I’m tired.

It’s been a long and sad weekend at Sunny Flats. The unit I was assigned to over the weekend handles most of the trauma cases that present to the hospital. For some reason we’ve had a sudden spate of young trauma victims. I’m not usually one to be overly affected by trauma; I may bitch about it and ponder the implications of it a lot, but it doesn’t usually bother me on a deeply emotional level. This weekend was a little different: we had two teenagers who were pronounced brain-dead, a couple of people my age who died, and a number of senseless and depressing cases that have gone from bad to worse.

One of the saddest cases was a young man who came in over the weekend. He had gotten bored and invited some friends over to his house. Apparently, he had somehow obtained a revolver and wanted to impress his buddies. They came over and he pulled the gun out. Since boys will be boys, and since stupid is as stupid does, the lad pulled out the gun and the group of boys began to check it out. The young man decided to impress his friends.
“Hey guys! Check this out!” The young man spoke these words and grabbed the revolver. He spun the chambers rapidly and then pointed the gun at his own head in a mimicry of Russian Roulette.
Perhaps he thought that revolvers have a safety (they don’t) or that by spinning the chamber rapidly he could tell if there was a round in it (you can’t.) Perhaps he made the Cardinal Mistake of Gun Safety and assumed that the gun was unloaded. Perhaps he was actually convinced that the one-in-six odds of losing Russian Roulette were good. Whatever went through his head, he made The Other Cardinal Mistake: he pointed a gun at something that he didn’t want to kill.

The boy pulled the trigger. The hammer fell. The bullet exited the barrel of the gun, entered the boys head through his temple and exited through the back of his skull, removing a significant portion of brain and skull in it’s exodus.

Apparently he lost his game of Russian Roulette.

His friends ran like hell. One of them called 911. When the medics arrived, he was still alive and breathing but they had to pack his head with towels to prevent brain matter from dripping out of the remains of his skull. By the time he got to us in the trauma unit from the ER, it had been determined that his injuries were probably not survivable.

In the trauma unit, part of his brain fell out of his skull. I wasn’t present for this particular episode, but people who have seen ten times more trauma than I have were clutching their bellies in nauseated agony and weeping in the halls. I have literally never seen healthcare workers with this level of experience break down like that, and I can only conclude that whatever happened in that room was pretty goddamn awful.

He was pronounced brain-dead shortly after this and then harvested. Since the boy was young and healthy until he shot himself, they got almost all of his organs and his death will at least help a few people have another shot at life.

Tomorrow is a day off for me. After this weekend, I could use it.

I just found out via e-mail that a person I worked with up North died. She was a vibrant, healthy 22-year old who just graduated nursing school. She was very likeable, very fun to work with and very intelligent. She could have gone on to do some awesome things, not in a “change the world with a big boom” way but in a “many small differences can change things a little” way. I have to say, for all my bitching about other people there are some people who I genuinely enjoy working or being with, and this person was one of them.

She went to the ER with general malaise and dropped dead for no immediately discernable reason.

Meanwhile, the hordes of middle-aged malcontent overdosed losers who populate our ICUs and abuse our ERs will never. ever. die.

I’ve said it before and I’ll probably say it again. It’s a sad, sad world that we live in, and I personally am sad tonight because of the death of this lovely person.  She leaves behind her parents, her siblings, her long-term boyfriend and her 8-month old son. Rest in peace my friend.

Busy, busy day in the ER today.

Four suicide-attempt overdoses, all intubated. One who vomited casserole all over, one who was fighting underneath her sedatives, one who was speaking in tongues and one who just laid there staring into oblivion.

One elderly man found down in his home, evidently there for several days. He had an abcess that you could lose your watch in on his backside. He was a bit leaky from most of his orifices, and even when all of them were corked up with various tubes and hoses he managed to leak around them. I felt bad for him but didn’t really want to get any of him on me, so I tried to keep my distance. When (shortly after intubation) he was found to have a pH of 7.01 (normal 7.4, his was way acidotic) the nurse told me to hang out because we would be bringing him upstairs soon. She called me later and told me we were going to transport “right now!,” so I tracked down my favorite supervisor and asked her to help me move him. I hooked up the BVM to the O2 and began to bag while my favorite supervisor took the ventilator upstairs for me. Something was amiss.

The nurse. She was gone. She came back, left, came back, left, and so on. Eventually I surmised that in her head, transporting “right now!” means transporting “in about half an hour.” So I bagged, and changed O2 tanks, and bagged some more until we went upstairs.

In addition to those five, we also had one patient who came via family. Her family mentioned that she was just acting unusual and breathing a little hard, and much to my surprise her ABG showed her CO2 to be a whopping 150 (normal 40…150 would be deadly in most people.) So we intubated her and took her upstairs eventually.

In addition to that we coded a skeletal old lady, consciously sedated a whole bunch of people, and did dozens of stacked “asthma” nebs.  All of this happened between about 1130 AM and 330 PM, and then we had a twenty minute lull.

And then a couple of guys decided to flip their SUV and so we had to take care of them, in between transporting our other intubated patients upstairs.

My ass is kicked. It’s time for a beer.