Respiratory Therapy 101: Just Keep Breathing

I have some breaking news for all of you out there. Brace yourselves, because this is big news: Sumdood has been captured!

Yes indeed. We have caught this nefarious criminal way down here in Scumble County, a place which he has drifted through periodically in the past. His capture was a surprise to all of us. It all began…with a trauma.

(Insert wavy flashback effects here)

I was sitting in our RT closet in the Emergency Room, checking my email performing important RT administrative tasks when the overhead page clicked on.

“Trauma Alert to bay one, five minutes out.”

I stood from my chair and ambled across the hallway to the trauma room. The whole team was assembling: the recording nurse, two RNs flanking the bed, and a frazzled trauma surgeon over in the corner muttering angrily to himself. I donned my lead vest and a protective blood-proof gown, and just as I snapped my gloves on the ER doors opened and a couple of medics came in with our trauma. He was a young male who had been assaulted in a strip mall a couple of towns over. After he was transferred to the trauma table, we all swooped in like vultures. I plugged his O2 into the wall and prepared an ABG kit while the surgeon asked him what happened.

“Man…I was sittin’ outside this bar smokin’, right? And sumdood came up to me and popped me inna head. An’ then he stabbed me in the back and the head again.” He was right: his scalp was peeled back and oozing blood, and when he was rolled over there was a large puncture wound in his lower back. He started laughing like mad when we rolled him back onto his back.

“Why are you laughing?” someone asked.

“I got that sumbitch, though. I kicked his ass.” One of the EMTs nodded. “There was another call about a block away right after we got dispatched,” he told us. “Not sure if they’re related though.” Just as he finished saying this, the overhead speaker clicked on again.

“Trauma Alert to trauma two, five minutes out.”

The backup trauma team came flooding into the trauma bay and readied the second bed while we tended to the patient in the first bed. I caught the eye of the other RT and we exchanged an eye roll. Within minutes the doors flew open and a flock of medics once again entered, this time followed by a couple of Scumble County’s finest deputies. This patient looked bad: blood dripped from his skull, his face was battered, and he had other obvious signs of a violent assault. He was intubated and his chest was rising unevenly.  The patient in Trauma One pushed himself up on the bed and looked over in violation of every privacy law ever.

“That’s him! That’s the dude who stabbed me! I got his ass good!” The sheriffs looked over with interest.

“You did this to him?” one of them asked.

“Goddamn right! That mothaf***a stabbed me! Ain’t nobody gonna stab me and get away with it!” He cackled and lay back on the stretcher before being wheeled from the room to a regular ER bed. My role here was complete. I asked the other RT if she needed help ventilating sumdood but she waved me off.

When I left, the sheriffs had placed Sumdood and the first trauma patient under arrest pending their release, and in sumdoods case, his survival. The infamous Sumdood was critically ill, his head injured and his chest wall seriously deformed from the beating that his victim had given him.

I can only wonder what the incapacitation of Sumdood means for trauma rooms and ambulance services everywhere. Perhaps the rest of the summer will be…unnaturally calm.

We shall see.

Recently I was accused by a Californian of not being compassionate enough for my ER patients.  This individual points out that she, a chronically ill person on social security disability and medicare, has apparently used the ER twice in the last five years for asthma attacks.

To that I say, good for you! You’ve learned to use the ER only for emergencies. But you are one of the few who has figured out that the “E” in “ER” stands for “Emergency.” But judging by our patient population, I would say that the vast majority of people have yet to discover that.

The Californian accuses me of not having enough compassion towards my patients. This is probably true: a vast majority of my ER patients I have very little sympathy for. When somebody reeking of cigarettes comes in complaining of difficulty breathing, and then they whip out a 200 dollar cell phone to call somebody on while they’re presenting their medicare card to the registration person, it kind of pisses me off. If you can afford a 200 dollar cell phone and two packs a day of cigarettes, you’ve got too much money to deserve government aid. Why should I feel sorry for this person? Their problems are clearly their own fault and I don’t really see why we should waste our time treating people who clearly don’t want to participate in their own care beyond bitching at their caretakers.

Or how about your “chronic pain” patients? Before somebody else sends me a pissed-off email, let me state that I’ve seen some people with bona fide chronic pain, people who can’t even move or get up because of nerve damage or pinched discs. My mother herself had a herniated disc one time and I truly hope to avoid the pain of an experience like that.  But more than I see people with actual pain, I see people who are chatting happily away on their cell phone and laughing with their buddies until a doctor (or someone who looks like one) arrives, at which point they suddenly writhe about in agony and claim to be allergic to everything but morphine. They’re not sick, they just want to get high, and I’d rather that they generated a real medical emergency by playing in traffic. Then they could have something to complain about. They too need a reminder that the ER is a place for emergencies, not a substitute for your dealer.

So who do I feel bad for in our ER? I feel bad for the homeless who come in out of desperation, for the 40-year-old with the aortic aneurysm who is going to die and leave his wife and children. I feel bad for the miscarrying 25-year-old who did everything right. I feel bad for the asthmatic who was just trying to enjoy their day when their lungs turned on them. I also sympathize with the cancer patient whose body is slowly eating her alive, for the 65-year-old stroke alert who’s never going to wake up.

So don’t tell me I’m not compassionate enough. I feel bad for the people who are having true emergencies. I really do, and I really hope I am never in their shoes. But the people who just come around to get their drugs, or to get some attention, they get no sympathy from me beyond general pity that their lives have turned out this way.

Ah, the ER. Home of the genuine medical emergency. And of late, the whiny, ignorant, unhygienic and entitled.

“Sure,” the attitude goes, “I may be unemployed. I may be undereducated. I may be living off of your tax dollars in my trailer home while sucking down Marlboros and Miller Lite like there’s no tomorrow. But no matter how little I am willing to contribute to society, they owe me. And I will begin to collect my deserved spoils by hauling my fat ass to the ER by ambulance to complain endlessly for hours on end about my minor aches and pains, which surely do not come as a result of my extremely sedentary lifestyle or my ridiculously poor decision-making skills vis-a-vis my personal health; no, my problems come from society at large. Surely nobody would have the balls to hold me accountable for the consequences of my own excesses. And why should they? After all, it’s the duty of the suckers who work hard to subsidize the lifestyle of parasitic creatures like myself!”

Not that I am bitter.

The thing is, on some level I feel bad for these people. These are people who have turned utter defeat into a lifestyle. They not only have lost the desire to even try to live a productive life, they have lost the desire to do anything more than simply exist. They have no tools to work with, no education, minimal experience at anything beyond graft. I really do pity them. I would not want their lives. I truly wish that there was a way to help them.

But on the other hand, simply flinging money at them like a drunken sailor at a stripclub is not going to solve their problems. The problem is much, much deeper than a simple lack of funds; the problem is a lack of motivation to even try. When the system rewards those who don’t contribute, what incentive is there for them to even try?

I’m sure there are angles and shades of gray I’m not even seeing in this situation. But at least I’m trying to think about it. Any input from the audience?

Here’s an interesting situation that I ran into today. I was in the ER treating a child with a persistent cough (who would doubtless be cured by my nebulizer) and chatting with the mother. The mother was a thirtysomething lady, with a weathered appearance, slightly unkempt, bad teeth, slight odor of cat pee about her. The baby was well-nourished, slightly lethargic but not in any visibly acute distress. He was a normal size for his age. He was pale but the mother’s complexion suggested paleness. All in all, a normal Scumble County family: economically depressed and undereducated but basically okay.

But then things got weird.

The mother was giving the child a blowby treatment while I documented on our charting forms. She was chattering away at him as mothers are wont to do with babies. She kept a rolling patois of nonsense going, and then she stopped and looked at her baby.

“Boy, he sure is liking this stuff.”

“Some kids love it, some kids hate it. Doesn’t he take it at home?”

“Yeah but he’s taking it better here. This must be the good stuff!” She breathed in deeply, catching some of the mist from the nebulizer. She paused for thought and continued to nebulize her child. Suddenly she spoke. “You know what he looks like? he looks like he’s gettin’ stoned on this!” She laughed a delightfully coarse cackle, catching her smokers phlegm in her throat and rattling as she laughed.

This I could take. But it got weirder.

I was done my charting so I watched her interact with the baby. She was a normal, happy mother. But suddenly the patois changed.

“Ohhh, you’re such a cute little boy! Yes you are!  Breathing your medicine! Getting stoned, smokin’ on your pipe! This is the good stuff isn’t it? Yes it is! This is the meth-am-phetamine!” She continued on like this for several minutes until her nebulizer was done.

So, the question in my mind was this: I am a mandated reporter. If I suspect child abuse or endangerment, it is my legal responsibility to report it. It is illegal and unethical for me to ignore what I believe to be a dangerous situation. So, what is the situation exactly? The baby seems healthy apart from a cough. The mother is attentive and caring towards her baby. She smells of cat urine, an odor associated with methamphetamine, but then she claims to have cats. She has bad teeth, but she lives in Scumble County and probably can’t afford a dentist. She’s pretending to give her baby a meth neb, but then some people have an odd sense of humor. Perhaps she was just being weird.  The situation didn’t make me immediately think “holy crap I need to call the sheriff,” but it did make me feel a little uncomfortable.

So, the question is: what to do? Is this covered under mandated reporting, or is this simply a Scumble County redneck who has poor taste in joke-making?

This is part three in the ongoing series of articles about the Rules of the House of God. Parts one and two can be found by clicking the links on this page.

Rule Three is short and sweet:

At a cardiac arrest, the first procedure is to check your own pulse.

Although House of God was written to expose some of the darker aspects of modern medicine, it can contain some startlingly good advice. Some of it is spread out through the book subtly; some of it, like rule three, is short and to the point. It’s a simple rule, a slightly tongue-in-cheek rule, but one that I honestly believe they should be teaching in BLS and ACLS courses. And it doesn’t just apply to cardiac arrests: it applies to emergent situations of all kinds.

Why does it apply to every emergency situation ever? Simple: in an emergency, people get shot full of adrenaline from those lovely little glands atop the kidneys. Adrenaline triggers the fight or flight response. But in this modern world, we’re trained subtly over many years to hold back our responses, so while people’s bodies rev up their brains shut down. The upshot of all this: you, perhaps slightly more seasoned with emergencies, walk into an emergency and find a room full of people standing around, eyes wide and hearts pounding, doing absolutely nothing more than staring at a dead guy. Sometimes there’s a couple of more seasoned people doing CPR, and sometimes they even remember to bring the code cart, but more often than not you’ve got a crowd of gawkers and nobody useful.

This could be averted  if people simply remembered those words of wisdom: in a cardiac arrest (emergency), the first procedure is to take your own pulse. The act of physically moving your fingers over your radial artery and counting the beats brings you back into the moment. It forces you to be aware of your own body, and in a sort of primitive biofeedback way it calms you down. Now, slightly calmer and slightly more aware, you can begin to think.

Let me give you an example. Just the other day at Sunny Flats, I was on the Code Team when a Code 99 was announced on one of the medical floors. I grabbed an airway box and set out with the rest of the code team and their various accouterments: the critical-care pharmacist and his PDA, the ICU nurses with their defibrillator and drug cart, and the charge nurse to monitor and record.

When we got to the room a couple of minutes later, this was the scene: there was a young guy laying flat on his back with a grossly distended abdomen. The charge RT’s had already arrived and were attempting to intubate the patient. The patient’s nurse was standing by and had just finished a round of CPR. The floor charge nurse was recording. These people had taken their own pulses, stepped back and thought for a moment. This was a smooth-running code. A couple of less-experienced people flitted about in a tizzy, but the more experienced folks kept them in control. There was no shouting, minimal chaos, and all things considered it went fairly well.

Compare this to some of the codes I’ve been to, where there’s screaming and shouting and chaos, and the difference is obvious. When everybody is calm and in control of their own functions, emergencies run as smoothly as they can. Of course, sometimes this is not very smooth anyway, but that’s the nature of the beast. Simply remembering to check your own pulse first can ground you in the moment and help you remember not to panic.

And really, that’s all you need to know about how to handle emergencies. Don’t panic. Check your own pulse.

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

Go and read this over at ImpactED nurse. Go on, go and read it and then come back.

What bothers me about this isn’t that he drove nails into his head to drive away evil spirits. Indeed,much of the literature recommends driving nails into the head to cure Evil Spirititis. Making new openings to allow the spirits to escape or trying to spike them with a nail makes sense under the circumstances. No, it isn’t the patient’s logic that bothers me. What bothers me is his lack of pattern recognition. It seems to me that after the first two or three nail-skull interfaces failed to resolve the Evil Spirititis, he would try an alternative therapy like exorcism or hard drugs. It’s a classic case of poor pattern recognition, and maybe it’s how they know he is crazy. After all, the definition of insanity is doing the same thing over and over and expecting different results.

Wow! According to some amazing new research, government programs for the needy place an undue burden on emergency services. Who would have possibly guessed it?

Now, before I get a thousand snippy comments from people who are angry that I am suggesting that the poor should be denied emergency services, let me clarify this. The reason that so many of these destitute bums* wind up coming to the ER is that they lack any other options. As I understand it, Medicare and Medicaid don’t typically pay well enough for private physicians to be willing to accept patients whose only means of payment is through those programs. This means that an enormous percentage of these people have no primary care physicians to do things like monitor chronic illness or manage minor ailments, and as such these people wind up presenting to the emergency room with bullshit complaints. People who aren’t in the field don’t seem to get this: our Fearless President recently stated that he thought it would be okay for people to just go to the ER rather than see a private doctor.

Now, even if we reformed Medicare/Medicaid and made it possible for the destitute* to go and see primary docs, we’d still have a fair number of problems in the ER. We’d still get the dumb-asses who come in pretending to hurt just to get drugs, the people for whom the question “what number from one to ten is your pain” is an invitation to suddenly drop their 200-dollar cell phone and pretend to writhe about in agony, screaming “it must be a twelve!” The only ways to get rid of these people are to either shoot them (generally considered unethical) provide them with terrible service so they don’t come back (frowned on by paper-pushers) or to perform large numbers of punitive diagnostics such as spinal taps and blood gases with 14g needles (also unethical.) I’m a believer that enough documented abuses of the ER should be grounds for refusal to treat; plenty of people get snotty and whiny about this, but they’re not the ones dealing with whiny liars all day.

But even if we got rid of the financial burdens and the lying whiners, we’d still be stuck with a big problem in the ER: overdiagnosis. By this I mean the overuse of expensive diagnostic exams for no real reason other than the ER doc feels like it or the ER doc fears a lawsuit if he doesn’t get this diagnostic. I was the victim of many useless diagnostics in a recent ER shift in which I performed 16 blood gases and four arterial lab draws with BGs in twelve hours. Of the 20 blood-gases I ran that day, maybe three of them were indicated: one on an unresponsive intubated patient, one on a decreased LOC, and one on a diabetic in DKA. The other 17 blood gases were drawn and analyzed mainly because one of our ER doctors orders them on everybody who comes in for no relevant reason. Now, a blood gas analysis costs somewhere around 200 dollars, so if you add it up I billed for 3,400 dollars in useless diagnostics over twelve hours. This is a problem in other departments, too: an enormous percentage of our patients get things like CT scans simply because people are out of ideas and want to feel like they are doing something. After all, even an unindicated useless exam is more something than nothing. Incidentally this is a clear violation of Rule 13, which I will be essaying about at a later date.

Anyway, the point I am driving at is this: the emergency medicine system is badly broken. No longer is it a system in which people having genuine emergencies are seen and treated by physicians who only use evidence-based medicine to solve simple and complex medical cases. It has become a catchall, a safety net in which the dregs of society are caught and given treatment based on either (a) the preferences of aging physicians who don’t believe in evidence or (b) the fear of lawsuits from irate patients. Genuine emergencies still come in frequently, but they are sadly overlooked and forced to queue with the patients who are in the ER just because they have nowhere else to go. Only if we can solve the problems of government healthcare, whiny liars, and overzealous physicians will the emergency room be returned to its proper place in the hospital: a place for patients in crisis to go and be treated.

Any ideas?

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.