Respiratory Therapy 101: Just Keep Breathing

It turns out that sometimes, fungi are extremely useful. First we had Penicillin; now we have Lodamin, which is a promising new cancer drug stemming from an accidentally discovered fungus and some nanotechnological manipulation. Reuters reports:

WASHINGTON (Reuters) - A drug developed using nanotechnology and a fungus that contaminated a lab experiment may be broadly effective against a range of cancers, U.S. researchers reported on Sunday.

The drug, called lodamin, was improved in one of the last experiments overseen by Dr. Judah Folkman, a cancer researcher who died in January. Folkman pioneered the idea of angiogenesis therapy — starving tumors by preventing them from growing blood supplies.

Lodamin is an angiogenesis inhibitor that Folkman’s team has been working to perfect for 20 years. Writing in the journal Nature Biotechnology, his colleagues say they developed a formulation that works as a pill, without side-effects.

How cool would it be if one of the most promising new cancer treatments in years came about as a result of a fungal mishap?

The ER physicians at my hospital are addicted to ABG’s. Our blood gas reports seem to have a crack-like effect on them; they take on hit of the ABG report and suddenly they can’t stop ordering them. It’s not just ABGs, it’s everything: CAT scans, lab tests, and more.

Not all of the ER physicians are like this. A large number of the ER staff only order ABGs if they’re indicated. But we have a large group of serial offenders who will order ABGs on every single patient that comes in: patients with hangovers, patients with GYN complaints, patients with orthopaedic malfunctions and the like.

Most recently one of our serial offenders has begun ordering ABGs on psyche patients. Recently I was asked to stick a needle into the artery of a paranoid schizophrenic who was having some sort of psychotic delusional episode; the patient had been brought in by police after acting in threatening and bizarre ways. Since the patient has a known psyche disorder and their chief complaint is purely psychiatric, why would the doc order an ABG? This doctor has also asked me to get gases on patients who were having homicidal ideation, nervous breakdowns, and a patient who was hallucinating that the Beatles were trying to kill her.

My question is, why? On a patient with abdominal pain or chest discomfort you can sort of justify asking for a blood gas; but on a patient whose only complaint is psychiatric, why would he ask me to stick a big giant needle into their arteries? Why, when a patient is already feeling threatened, would you ask me to go perform painful tests on them? What exactly is he hoping to achieve here?

This same group of serial offenders has developed a habit of ordering full-body CAT scans on everybody. While a CAT scan is very useful, it is not automatically indicated for everybody. Just because somebody says their head or their gut hurts doesn’t automatically mean we should make them ride the donut. The serial offenders will also check off every lab box on the standard order sheet, all the way from the BUN and BNP to the Urine and Stool specimens. Shit, for all the actual “thinking” they do, I could do their job: they walk into the room, interrogate the patient for all of five seconds, and then check every single box on the order sheet.

At that point, the question in my mind is: why even have an ER doctor? Any monkey can check off all the boxes, wait for the results, and then call the hospitalist to admit. The serial offenders don’t even do procedures most of the time; they’ll simply make the paramedics or the intensivists do the procedures for them. I often ask myself why we’re paying them to check boxes and delegate; I could do that just as effectively for a fifth of their salary. And I’d probably have a lot less of an ego about it too.

I should add that not all of our ER doctors are like that. Probably 60 or 70 percent of them are really quite good. The good ones that we have triage and sort their patients, order only what’s indicated, try to expedite the emergency medicine process. They don’t order tests that aren’t indicated, they don’t admit every single patient just because they can, and they do make an effort to perform high-quality medicine. But that bad 30-40% really make the ER a frustrating place to work.

In summary, the few physicians we have who are using inappropriate diagnostics way too much are driving costs and wait times up for the rest of us. They are increasing workloads on their staff, increasing expenses for the hospital, and decreasing efficiency and safety out of the force of their habit and quite possibly out of pure laziness. The few bad apples who inappropriately apply diagnostics are ruining it for the rest of us. How very frustrating.

Today at work there was an interesting airway situation. We had a patient who had had a lengthy and complex course on the ventilator. The time had come to attempt an extubation.

However, because of the patient’s borderline respiratory status the attending physician was concerned that reintubation would occur. Reintubation would not normally be a terrible thing, but this patient had an extremely difficult airway; he had been intubated using fiber-optics by anesthesia in the OR, and even then the anesthesiologist had reportedly used the words “a f***ing doozy” when describing the airway.

To summarize: physician wants to extubate but is concerned about reintubation because of a fiendish airway.

The solution that the physician came up with was to insert a rubber ET tube changer into the ET tube, and then extubate the patient while leaving the tube changer in the airway. The theory was that if the patient crashed, we could simply slide a new ET tube over the changer and the problem would be solved. However, this poses some problems.

** First, the presence of an artificial catheter in the airway makes it impossible for the patient to swallow secretions. Even with application of continuous oral suctioning, secretion management is a concern.

** Second, leaving a catheter in the airway is going to increase airway resistance and make it more difficult for the patient to breathe, thus increasing the likelihood of reintubation.

** Third, leaving a catheter in the airway is likely to stimulate the cough and gag reflexes. If the patient vomits with a catheter in the airway, they are going to aspirate.

** Fourth, leaving a catheter in the airway for a prolonged period of time seems likely to lead to soft tissue damage or vocal cord irritation. Either of those problems could easily lead to total chaos.

Regardless, the attending physician wrote the order to extubate and leave the tube changer in the airway. The respiratory therapist (a colleague of mine; I was merely an interested observer) complied with the order. The patient was extubated to an aerosol mask, tube changer sticking unceremoniously out one of the holes in the front of the mask.

What do you think of this situation, dear readers? Drop me a note and tell me what your opinion is on this extubation strategy, and later on I’ll post the sequel to this, in which I reveal what happened to the patient.

There are a lot of patients who suffer from problems that are difficult to label in an appropriate manner. As part of our shift report at the hospital, I am expected to give a diagnosis with each patient that I am reporting off on.  Since I am not a physician and I do not have the power to diagnose somebody, I rely on the dictated history and physical in the patients record to get my information.

Oftentimes when reading the H&P of intensive care patients you are presented with a laundry list of problems. A typical patient could present with type II diabetes, early Alzheimers dementia,  coronary artery disease, COPD, acute renal failure, and obesity. But even a lengthy list like this might not be enough to fully describe the condition of the patient. To really give the full essence of the patient, to accurately convey the experience of caring for them, sometimes you need a little bit more than the regular bland diagnoses.

That is why I am glad that The Happy Hospitalist has jotted down a wonderful list of diagnoses that accurately describe many of our patients in a nutshell. I quote from the top of the list:

ISOBO-  Inappropriate Secretion of  Offensive Bodily Odor

Failure to Parent

Abdominal pain of absolutely no significance

Vitamin IQ deficiency

I’ve thanked other bloggers on here before when they make especially good or amusing points. Today, I will be thanking Panda Bear MD. He has summed up most of what I do for a living in one delightful paragraph (bold emphasis added):

…So let me just state that In the United States, we are terrifically over-doctored.  Much of what we spend is to overtreat either self-limiting things or to throw marginally effective therapy, at least in regard to decreased mortality, at chronic medical problems, most of which are lifestyle related.  Either that or we burn through money like drunken sailors on futile end-of-life care for people who have absolutely no quality of life unless we are now measuring quality by how long you can lay motionless in your own urine before a minimum-wage nursing home caregiver decides to roll you around a little.  Let me give you a few examples of typical patients to illustrate the many ways in which your money is squandered.

“There, you see? She blinked!  I love you Grandma!”

I see this patient or some variation at least once on most shifts.  An incredibly frail, some might say cadaverous, woman, somewhere in the neighborhood of ninety who has been in a nursing home for a decade and was doing all right with her end-stage renal disease, advanced senile dementia, and congestive heart failure until about a year ago when something broke loose during dialysis and she suffered a stroke, turning her from a demented elderly lady who had broken her hip twice to a demented, aphasic, ancient lady; completely immobile except when indifferently turned by the staff of the warehouse in which she is stored.  Because she can no longer swallow the surgeons obliged her family with a PEG tube (to pour liquid food directly into her stomach) and to protect her airway she breathes humidified oxygen through a tracheostomy (a hole in her neck, with another tube sticking out of it). On a philosophical level we can debate the nature of quality of life but I’m going to go out on a limb here and suggest that laying in your own feces on eroded bed sores is not much of a quality of life.  In other words, we’re not talking about a hale and hearty nonagenarian who will live to be a hundred provided she can avoid being admitted to the hospital.  This is a patient who is living on borrowed time, one who will not last another six months despite our best efforts and yet, in those last six months we will spend large sums of  money on her, probably more than the total spent in her whole pre-stroke life, in an inexplicable quest to stave off death, spending money at an increasing rate the closer she gets to actual “reaper” death and not the living death to which she is condemned.

Thank you, Panda Bear MD! Your writings have both amused me with their wit and saddened me with their truth. Because I’m too lazy to write anything of my own tonight, I’ll leave you dear readers with a link to another excellent article by Dr. Bear entitled How I Am Learning to Throw Money Away With Both Hands and a Big Shovel. 

Normally I am a very quiet person. My normal persona could probably be described as mild-mannered, but sometimes…such as for example when I am working in the ER (Scumble County’s best and the State’s busiest) and under a great deal of duress…I can get a bit snappy.

Today I was working in the Pedi ER. I don’t mind the Pedi ER too much: the nurses are nice, the patients are usually less angry than in the adult ER, and the patients are less likely to be ill secondary to their own actions. Despite all of that I do get aggravated when the Pedi ER doctors get on one of their kicks and begin ordering nebulizers on everybody.

The over-zealous nebulization in the Pedi ER is compounded by the fact that our standard respiratory order sheets have the “asthma protocol” orders at the top of the page. The asthma protocol order is for three Proventil/Atrovent nebs spaced by twenty minutes. Combine that convenient placement of the neb orders with the fact that many pediatricians overuse nebulizers anyway and you have the makings of doomsday.

Anyway, this morning around 11:00 I sort of lost my cool. I had been called for three children who had been ordered on the asthma protocol, requiring me to do nine nebulizers in short order. One child was coughing too much, the other was coughing not enough, and one child had a snotty nose. I looked at the orders, looked at the assessments, and thought for a moment. I turned to the nearest nurse.

“You know, I’m perplexed by this.”

“You’re perplexed?”

“Indeed I am. You see, the doctor has ordered albuterol treatments for all three of these children. One of them is coughing too much and she thinks it will stop his cough. One of them is not coughing enough and she thinks it will loosen him up. And the third child is full of snot, which has nothing at all to do with nebulizers.” The nurse gave me a funny look and shrugged.

“What can you do?” she asked me. A little spark inside of me suddenly burst into flames.

“I suppose,” I said in a slightly louder voice than normal, “that I could go and ask the damn doctor why she orders the same treatment for contradictory reasons. Does the chemical structure of the drug change on her whim? Can she magically make the drug change effects?” I took a deep breath and crescendoed. “Or is it possible that she’s just too freaking lazy to assess her patients and order appropriate treatments?”

I turned to stalk into one of the rooms that I had been ordered to go into.

And I ran directly into the doctor. The very same one who I had just finished badmouthing.

There was a moment that could best be described as horribly awkward. She stared at me, and I stared right back. It was too late to apologize or make nice. The moment continued for an uncomfortably long time. Some primal part of our brains wouldn’t let either of us cede dominance to the other. I imagined two gorillas in a staredown. It helped me keep eye contact.

Finally the doctor broke the silence and handed me a chart that was in her hands.

“Albuterol treatment in room five,” she said. I stood there, chart clutched in my hands as she walked away. I stood for a moment and watched her as she turned and walked unconcernedly down the hallway.

Two docs, two days. Apparently I am a one-man wrecking machine. I guess the only thing I can do is to laugh about it and hope that maybe I made an impression.

It had been a long day in the ER. The clock had ticked past six just moments before, and it was with an air of relief that I sat down on the stolen doctor’s wheely stool in the office. It had been busy: running around intubating people, doing blood gases, BiPAPing little old ladies and so on. I had spent some time assisting the pedi ER therapist with his ridiculous load of asthma patients and I had been going non-stop for the better part of the eleven hours of my day.

So it was that I heaved a sigh of despair when the Spectralink phone rang.

“Respiratory.”

“I need a blood gas in hallway bed two. But don’t hurry. She just got up to pee and it’s not that urgent.” I grunted my assent and then wheeled over to the door of the office to peek at the patient in hall two. I saw a middle-aged lady shuffling down the hall, in no respiratory distress at all, followed by a doting daughter and her baby. This is a total waste of time, I thought to myself. I bet if I wait on it they’ll forget all about it. I wheeled back into the office and reclined against the dirty wall. Pedi ER’s therapist came in and joined me in blissful repose, and we sat in the office and tried not to move for a few minutes.

Our reveries were interrupted when the door to the RT office was bashed in. An enormous man in green scrubs printed Hospital Property stomped into the room. I jumped a little but maintained my composure and my posture. He was a tall man and he stomped right on into our small office until he was crowding both the other therapist and me.

“Hey! Didja get me that blood gas yet?” he bellowed in a long Texas drawl. He stood in an impatient posture and glared at the two of us.  I assessed the situation and tried to think of the best reply.

“Um…no. Is the patient critical? I saw her walking to the bathro–”

“OF COURSE she’s critical! I’m only waiting on YOUR LAB to admit her! I need it!” He was not quite yelling, but he was not quite using his inside voice. His tone was that of someone who is used to people asking how high? when he says jump and on those grounds I immediately felt a clash with him.

“Well then, I’ll go ahead and get that for you.” We locked eyes, I planted firmly in my rolly chair and he planted firmly into the tiled floor of our office until he turned and stomped out of the room. The Other Therapist and I exchanged a look.

“What an asswipe,” said Other Therapist to me. “Who does that?” We made some more choice comments about the shouting doctor, and just before I could get up the door smashed open again and the doctor barged in bearing a chart.

“Hey! It’s this lady right here!” He pushed the chart right up into Other Therapist’s face and opened it to the page with the patient labels. “How many do you need? Huh? How many?”  I slipped in behind the angry man and grabbed two stickers.

“Just two,” I said quietly. He turned and wordlessly stalked from the room. Other Therapist and I again sent each other a look: what the hell was with this guy? I left the office and went to get the gas. As I expected, it was normal, perfectly 100% normal.  I printed the test results and walked around until I found the doctor, then I slapped it on the counter in front of him.

“Here’s your stat gas. It’s perfectly normal.” He grunted at me and I turned and walked away from him. When I got back to the office, the night shift had arrived and were settling in.

“Man, that guy’s a total ass,” I said. I repeated the incidents of the last hour to the night therapist who was replacing me.

“Wait a second,” he said to me. “This is a tall guy, green scrubs? Was his name Dr. Melted*?”

“Yeah, that’s him. I don’t think he was happy with us…” Other Therapist interjected at this point. “Yeah, he probably thinks we’re really lazy, I think we looked like the guys from Delta Delta Delta or whatever the frat was in Animal House.”

The night therapist looked at us with an expression of mixed horror and humor.

“Um, I hate to be the one to tell you this…but Melted is the director of emergency services here. He owns the ER. You just mouthed off to the director of the ER. You may as well have gone and pissed on the CEO’s desk.”

Needless to say, I was shocked by this bit of information. Had I known of it previously, I may have been a little less jerky towards the doc.

Whoops.

*close to but not actually his real name

The old lady lay gasping for air on the bed. I clicked the laryngoscope blade, a #3 mac, into the handle and checked the light as The Brazilian Intensivist (B.I.) worked his way to the head of the bed.

“Help…me!…not enough…air!” The old lady continued her gasping and panting, the effort of her respirations shaking her ample pannus and chest as she rolled her eyes in their sockets and cried for help.

“We’re going to fix it, Mrs. Redacted. Just hang on.” Her nurse, a compassionate young lady, gathered sedatives as the B.I. eyeballed the patient.

“This is going to be a hard one. Probably take me a long time. Maybe you should get some extra things ready just in case.” I nodded at the B.I. and handed him the laryngoscope. I placed an 8.0 tube next to the patient’s head and affixed a CO2 detector to the bag-valve mask. The B.I. continued to look at the patient. As the nurse administered her sedation, he began to bag the patient in synch with her own respirations.

“Yes. She has a thick neck, lots of edema, sort of dry. She will be difficult to intubate.”

I nodded and concurred with the B.I. He seemed content bagging the patient, so I turned my back on him for a moment and rooted around in the airway box for a tube-tie to secure the ETT should he place it. I estimate that I was in the box for a total of about five seconds. I turned back around, and much to my surprise the B.I. was removing the laryngoscope from the patient’s mouth and holding the tube in one hand.  This was confusing: he had apparently been able to intubate the difficult patient in a matter of seconds with no adverse attempts, suctioning, repositioning of the head or cricoid pressure. I gave him a look of bewilderment and awe. He straightened his back and gave me a slow smile.

“Sometimes, this can be a tough job.”

A tough job indeed, sir. A tough job indeed.

Panda Bear MD has summed up my feelings on social justice and socialized medicine in one lovely paragraph:

But that’s the problem with Social Justice, especially as it is used to justify giving everyone free health care. It makes the assumption that everyone is a victim and doesn’t allow for the possibility of the freeloader who not only exists in droves but is aggressively selected for in every nanny-state ever created. People may be lazy but they aren’t stupid and, as most people do not love their jobs, if the conditions are set to obviate the need for work many people will tend to do as little work as they possibly can. This sort of society is not sustainable for more than a generation or two as our cousins in Europe are starting to realize and it is certainly going to bankrupt our nation if we continue down the same path. In fact, the number one problem in all of the Western Democracies boils down to the unsustainable growth of entitlements paid to non-productive citizens by a dwindling pool of productive workers.

Thank you, Panda!

As someone I work with put it: just because everybody’s got the right to be driving around in a Mercedes doesn’t mean I should have to buy it for them.

As you may recall I had some rage issues with a nurse in the PACU a little while ago. Today, much to my delight, I met that same nurse in the PACU when I had to wheel over a “wake-up vent.”

When I saw her, I made eye contact and then simply turned and ignored her. This made her decide to agitate me. She nudged the anesthesiologist, a mellow bearded man sitting next to her documenting, and spoke to him.

“Hey, last time this guy was here he freaked out when I extubated somebody.” She was all smirks and giggles, the unspoken message being: look at this clown! Thinks he’s all that and he can’t even take an extubation. The anesthesiologist looked up at her.

“Oh really?” He gave me a quizzical glance. I remained silent,dialing some settings into the vent.

“Yeah, he got all angry at me when I did it.” At this point I spoke up.

“That’s because we do it the right way, and you do it the wrong way. And you know that’s fine. I’m not here to pick a fight, and if you guys want do it the wrong way then that’s fine. But over in the ICU we like to do it right.” The nurse scoffed at me and the anesthesiologist looked over at her.

“How did you do it?”

“Just like you guys do. I just popped the balloon off and pulled the tube out.” The anesthesiologist cocked an eyebrow.

“Um, that’s the wrong way. You can’t do that.”

“What? Why not?”  She gave the doctor a wide-eyed stare, incredulous at being corrected by the person she was hoping would back her up. Sensing an opportunity I chipped in at this point.

“Because if you don’t take the air out of the balloon first, then you could theoretically cause vocal cord paralysis or damage the cords. There could be swelling and even airway compromise. You could really screw somebody up that way. Ripping the pilot balloon off is no guarantee that the air will leave the cuff, which is why we prefer to deflate it first. It’s a small risk but to prevent it only takes a few seconds.” The anesthesiologist nodded and went back to his paperwork with a final word of advice to my nemesis “Yeah. You should really be deflating the balloons.” I resisted the urge to jump across the table and scream“In yo’ FACE!” at the nurse, and instead settled for giving her a shit-eating grin and sauntering out of the unit, vindicated.

Round two:

RT 1

PACU RN 0