Respiratory Therapy 101: Just Keep Breathing

One thing I’ve mostly avoided in the years of my career has been contact with disgusting body fluids. I’ve narrowly escaped rivers of liquid stool, lakes of spilled urine, pools of tacky blood and fountains of vomit. I’ve narrowly dodged the gale-force flatus of a 400-pound man who was facedown on the floor. Whether through pure luck, a sixth sense, or simple good timing, I’ve been able to avoid being hit with anything disgusting for several years straight.

Today, my streak came to an end. I was assisting one of the ICU nurses with a turn, something I am more than happy to do simply because working in intensive care is a team effort. We were turning a patient who has recently been bestowed with a tracheotomy. The turn went from mellow to slightly more frantic when the patient suddenly became distressed. The heart rate went up, the respirations increased to a frantic pace, the blood pressure skyrocketed. Without even exchanging a word the nurse and I quickened our pace, stuffed the old blankets beneath the patients back and flipped them over the hump.

At that moment several things happened. As the patient rolled over the hump the ventilator tubing disconnected from the trache. The disconnect caused the trache to pull. The pulling of the trache caused the patient to cough madly. Time slowed down to a crawl. I watched from a distance as a giant wad of tan phlegm came flying out of the patients throat. I turned my head and braced for impact.

And then it hit me. It was rather like a very unpleasant rain shower. The patient had scored a direct hit. I winced in disgust. I could feel the clammy muck spattered about my face. I left the room to the sound of the nurse laughing (in a sympathetic way) and found my way to the closest sink, in which I dunked my head.

And so it goes in the wonderful world of respiratory care.

Good: Patient meets parameters for extubation. Termination of mechanical ventilation and removal of the ET tube commences.

Bad: Patient immediately develops audible stridor. Accessory muscle use noted.

Worse: Administration of two back-to-back racemic epinephrine nebs does not improve the stridor. Patient begins paradoxical respiration at a rate of almost forty. Stridor worsens. Physician is called but is stuck in elevator. Emergency Backup Physician is called.

Even Worse: During the physicians first attempt at intubation, the patient coughs violently and sends yellow-blood-tinged sputum flying across the room, spreading infectious disease and generally being nasty.

Even More Worse: During physicians second attempt at intubation, the patient wretches and a funnel of gore gurgles up from within his innards and percolates in his mouth before being sucked down by the patients rapid inspiration. Suction recovers some but certainly not all of the gore.

Worser than all that: Once the airway is in place and confirmed with lung sounds and CO2, the ventilator is connected. The ventilator tubing fills with vomit and needs to be changed immediately. The gore was evidently much worse than anticipated. It is chunky. RT tries heroically to avoid adding their own vomit to this already impressive collection of emesis.

The worsest: Before all this, the respiratory therapist told the family that “99 times out of 100, this goes smoothly.” Evidently nature abhors the implied promise of smoothness in medicine.

:::

You’d think I’d have learned that by now, but apparently I’m a lordly work of irony.

This is a story that will stay with me for the rest of my life. No matter how I try to forget this little gem, it will always remain locked inside of my brains somewhere, just waiting to come out. Anybody who’s offended by the fact that people have genitals should stop reading this right now.

It was a cool day in the early fall in the Great North Woods. I was working an extra shift at Our Lady of Immaculate Grace, a day shift for a change, and the effect of the sunlight and the odd hours (for me) were combining to make my day an exercise in caffeine-driven medicine. Luckily for me, the day was turning out to be on the slow side, and so it was that I was sipping a steaming cup of coffee and admiring the gorgeous fall day through the window of an empty room when I felt the pager vibrate at my hip. I swallowed my coffee and glanced at the screen.

PLEASE CALL ER 8120

I put down my coffee and picked up the phone in the patient room. The ER phone rang once, twice, three times. Finally the secretary answered.

“Emergency.”
“Respiratory.”

“Hang on.” There was a thud as her phone hit the desk. I heard a distant who needs respiratory? Some muffled speaking responded and the secretary returned to the phone. “They need a blood gas in room one as soon as possible.”

“I’ll be right down.” I hung up the phone, chugged the remainder of my coffee and went to find the student. After all, if I can get paid to have somebody else do my work in the name of learning, why not? I wandered into the ICU and found the student checking one of our vintage 1980’s PB-7200 vents.

“Want to get a blood gas?” The student looked up and nodded. I found his preceptor and told them I was stealing him for a few minutes, and then the student and I marched through the halls, twisting around bends and descending stairs until we were in the basement ER of Our lady. On the way I explained the ER to the student.

“There’s a board behind the desk that has all the patient information on it, so you can copy their names and stuff before you have to do anything. Make sure you get a blue-card* stamp on them and check your orders.” We entered the ER through the Secret Staff Entrance and I went to examine the board. Something was off: under the DIAGNOSIS column for room 1 was the legend priapism. I turned to the secretary.

“Hey, you said room one, right?”

“Yeah. Here’s the chart.” I grabbed it from her and examined the cover sheet. The box for ABG was checked off. I figured that somebody had forgotten to write in a new diagnosis and shook off my doubts. I grabbed a blood-gas kit, beckoned to the student and went to the room. I knocked on the doorframe, pushed the curtain back…and saw what was quite possibly the last thing I was expecting to see.
A middle-aged man was reclined on the gurney. His legs hung over the foot of the gurney and he was on his back staring intently at the ceiling while a white-coated urologist peered intently into his disturbingly tented johnny. I stopped dead in my tracks and blinked once, then twice. I glanced at the student, who had his head cocked to one side and seemed perplexed by the scene before us. The urologist ceased his peeping and turned to us, eyeing the student and me over the top of his reading glasses.

“Ah, respiratory. Good. I need you to get a blood gas–” here he pointed at the unfortunate patient’s engorged member–”on this.” He rolled his stool back to let us in and gestured at the johnny-tent.

There was a long and awkward pause. Dare I say that my posture stiffened a bit? The student, on the other and, was wilting into a flaccid pile of collegiate awkwardness in the corner. I stared at the urologist, and he stared back at me. The patient stared at the ceiling and probably tried very hard not to think about what the urologist had just asked me to do. The atmosphere was a bit tense, to say the least. Finally I spoke.

“I’m sorry, you want me to do…what?”

“I want you to get a blood gas. On his…you know. On his priapism.”

“You want me to what?!” I turned bright red in embarrassment and shock. Nothing in the world could have prepared me for this. I never learned about this in RT school; our blood-gas models were plastic arms, not fake penises. I was deeply and truly shocked that someone would ask me to stick a needle into another man’s genitals. Perhaps I have not spent enough time in the city but this truly seemed unusual to me. The urologist, not sensing my confusion, simply nodded at me, saying: of course I want you to do that. Just another day in the life, right? I stammered out an objection.

“I…um…no! No, I absolutely will not do that. That is so not even in my scope of practice to be jamming this needle into that man’s penis.” The patient, already tense, turned white at the mention of this act. The urologist’s resolve seemed to harden at this point: my denials of service served only to infuriate him.

“You will so! I need a blood gas on it to see how long it’s been like this. He says maybe four hours, but I need a CO2 and a lactic acid to be sure. And you’re the people who draw blood gases, right? So do it already! You just put the needle into the corpus cavernosum and you’re there. Easiest thing in the world. Simpler than wherever you usually get them.”

“That’s as may be, but no way. Absolutely not. Nyet, nein, nay, no. If you get me the blood I will run it but I am not going to do that. I’m going to go wait by the nurses station and you can bring me the blood to run.” I left the syringe on the table, turned on my heel and left. I wanted to apologize to the patient but the embarrassment would have been unbearable for both of us.

It was a brief wait before the Urologist brought out a tube of blood for us to run. The CO2 was pretty high; the lactic acid was 17, an astonishingly high number indicating that he’d had a problem going on for quite some time now. The urologist was pleased with these results, and evidently solved the problem by draining all of the blood from the penis through some sort of needle. I was curious to see exactly what was done…but not that curious.

:::

To read the tales of a real-life urologist, see Keagirl’s blog! She’s been busy with Sudoku lately but hopefully will be back soon.

*The blue-card stamper was a machine in which a plastic card with patient demographics was inserted between a sheet of paper and a gigantic stamping machine. It is a precursor to the more modern adhesive patient labels.

You hear some interesting things in the hospital. I was making my rounds through the ICU this morning, clipboard in hand, when I heard a commotion from a room.

“No! Robert, No! Don’t roll in it–aw, jeez.” A tracheostomy gurgled from behind the curtain and I heard a coarse cough as something thin was barked up through the tube. I paused outside the door and flipped through my paperwork. Was I to see this man?

A horrific squishing noise came from behind the curtain. Something splattered. I shuddered and died a little on the inside: a splatter is never, ever a good noise in a hospital.

“Oh God! Don’t touch it! DON’T PUT IT THERE! AAAAGH!” The trach thundered again as the patient protested these unwelcome interventions in his finger-painting from hell. The nurse was sternly lecturing the patient about proper hygiene as a teenage PCA tried not to vomit. I turned around and walked away: there are some situations I just don’t want anything to do with.

:::

Apart from that and an unexpected two-hour trip to the cath lab today it was uneventful here in Sunny Flats. I’m off for four days, which is good because I’m rather tired and it’s beginning to affect my non-working life. Check back, though: there’s some stuff I’ve been working on that should be up later in my weekend.

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.

In the course of doing my laundry today, I discovered that one of my new scrub tops has been covered in blood. I don’t know how I missed that yesterday or why nobody said to me “Hey dude your top’s covered in blood,” but I can only assume that it was busy and nobody really wanted to talk to blood-drenched guy.

I exaggerate, but the quantity is alarming. I suspect that it’s drippings from a lab draw I had to do yesterday in the ER…sometimes even when you pinch the tubing on the butterfly needle you can get a little leakage. Especially if you’re doing an arterial lab draw alone and you have to screw the damn syringes in by hand because using a Vacutainer on an artery is…well folks, it’s just not a good idea.

Anyway. I rubbed some stuff on the bloodstains and put it in the wash, and we’ll see how it comes out…but as the title says, if this top wasn’t a biohazard it would be a perfect costume for the evening’s festivities.

Happy Halloween, everybody. Remember: those razor blade stories are just urban legends designed by the media to propagate fear, so don’t waste the ER’s time by bringing in candy to be unless your jaw begins to bleed after you pop that tasty snickers. And to AJC up there in the Halloween Capitol Of The World, good luck with the weirdos tonight.

My smelly patient from yesterday died this morning. No surprises there, I guess: it’s not often that people live through a perforated ventricle. A bigger surprise awaited a nurse later on in the day today: she lifted a patient’s johnny up, and found that his intestines had burst through the packing around a wound-vac in his abdomen. It’s not every day that you see loops of bowel in the ICU environment.

Anyway, everybody else is doing this and so I will too, because I am unable to come up with original content tonight.

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First: I saw the best patient ever today. She was a young lady who needed a blood gas, and not only was she cheerful and cooperative, she was absolutely charming even with a needle stuck in her artery. I was totally impressed with her as a patient and left her room smiling and feeling satisfied, an unusual occurrence. Another patient of mine had a very curious family member who was considering a career in RT, and I spoke with him for a while and hopefully was able to sway him in the direction that’s best for him. Those are two really positive, awesome things that happened today that offset the sad case of Mr. Crusty.

Mr. Crusty was encrusted in weeks worth of filth. His disgustingly large omentum was covered in fungus and dried liquids, and his toenails appeared to require the services of a professional arborist. He was, in short, totally incapable of caring for himself in any meaningful way. This had not prevented him from living alone in his own filth, where he had apparently slipped on something abominable and landed on his head on a floor covered in effluvium.

Mr. Crusty was officially a DNR patient, until the physician called his family (Crusty Junior, a few towns over) and asked them if they were OK with Crusty Senior’s DNR status. Crusty Junior was in direct violation of Geraghty’s Law of Grieving (thanks PJ), which states that there is an inverse relationship between the volume and duration of grief and the amount of love and care demonstrated for relatives in the past. Needless to say, we intubated Crusty Senior and dragged his mostly-dead, filth-encrusted butt up to the ICU.

This is a perfect example of the Hopeless Case of the Week.

What we did was to take an 80-some year old man, who stated that he did not want life prolonging measures, and perform some of the most aggressive procedures we have on him to placate his yokel family. We spent a great deal of time, money and resources to “save” the life of a man who (a) has stated that he does not want to be saved in the presence of his physician, and who (b) has absolutely no quality of life outside of the hospital. We violated his wishes to make his family happy. Not only is this a really bad use of critical care resources, it’s a violation of the implied contract between patients and caregivers, and that disheartens me.  Why did we do this? What did we achieve? If nothing else we can ask these questions and maybe think a little bit about what it is that we sometimes do to people.

Mr. Crusty is this week’s best candidate for the Hopeless Case of the Week so far.

This is a bit off-topic, but there are just no words to describe how bizarre and wrong some things are. This would be one of those things. Warning: disgusting and possibly NSFW.

I’m off to go eat a salad, or possibly just some bread. Anything but those particular delicacies.

There has been a movement lately in the medical profession to allow family members to become more involved in the care of their loved ones. Concessions such as open visiting hours are now becoming more and more frequent, and to a certain extent I can understand the rationale behind this. Family members can make a big difference in a patient’s morale and they should be involved within reason. But there need to be limits on where families can be and what they can be allowed to see. After a certain point, it is outright foolish…even traumatic and dangerous…to allow family members in. Here is a perfect example. Warning: this story gets fairly gory. I have never before seen this amount of vomit in one place, frat parties and ancient Rome included.

This is the story of Mr. V, an unfortunate man who had cancer of the stomach, and his wife Mrs. V, who loved and cared about her husband very much despite his many shortcomings. Mr. V had been admitted to the ICU because the combination of stomach cancer, COPD, liver disease, hepatitis, and a bevy of electrolytic issues was making it difficult for him to stay alive. To make matters worse, his respiratory status was declining rapidly. He was on a noninvasive ventilator, but it was just not adequate enough to keep him breathing. The on-call pulmonologist asked me to get a blood gas. The results were awful: I don’t recall exactly, but his pH was in the 6.8 region with a CO2 just short of 100. And that on a BiPAP of 15/10 with an FIO2 of 75%. I approached the pulmonologist, a tall graying man with a neat white shirt and a tie.

“Good evening, Dr. K. How are you doing?”

“Not bad, considering. I hear you have blood gases for me.”

“Indeed I do. Would you like to play ‘guess the pH?’” Dr. K cocked an eyebrow at me, knowing that this game was rarely played with healthy patients.

“Um…7.15?”

“No, but close. It’s 6.8.” Dr. K looked at me in alarm. “It’s arterial. It pulsed into the syringe. I can do another if you’d like…”

“No. I trust you.” Doc K sighed. “I better go talk to the wife.”

Dr. K went into the room and explained the situation to Mr. V’s ever-present wife.
“Mrs. V, your husband is having a lot of trouble with his lungs. We need to put a tube in his throat to help him breathe better, but because he can’t answer our questions we need to make sure it’s okay with you.” Doc K is big on consent.

Mrs. V thought about this proposition. She agreed to let us intubate her husband, but she had a caveat.

“I’d like to be in here when you do it…”

(more…)