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?

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.

We have had a rash of people lately in the ICU who have been expressing frustration at the perceived slowness of their loves ones’ recoveries. I have been glared at when patients fail Spontaneous Breathing Trials and accosted by angry family members who are upset because their loved ones have been on the trache for a month. I have begun to believe that these people are angry because they believe that their loved ones should be recovering much more quickly than they are.

I blame TV for this. On TV, medicine is fast. People don’t get sick for long, and if they do they tend to wake up and be exactly the same as they were before. On TV, patients will awaken from a coma and speak in full coherent sentences. People will be on the verge of death and then suddenly better. TV has a nasty habit of presenting a terrifying illness and then a remarkable cure, but they don’t present the wait in between.

People have got to understand: there is no silver bullet. People don’t just “get better” and walk out of the hospital. They get sick, they get sicker, they linger, they take two steps forward and one back. Very very rarely someone will get sick and then get better quickly. In the ICU especially, people are likely to have long and complex illnesses, not to just miraculously snap out of it.

We have got to do a better job of preparing people for this. People have an insane belief that cures are instant and that if we can’t just give their loved ones a pill to cure them of all their ills, we’re incompetent or apathetic or something. I’m sick of being hassled because people have unrealistic expectations, and I’m at the point where the temptation to whack the thick skull of ignorance with the two-by-four of reality is becoming overbearing.

That is all for now. I’m sure more will come later.

Ah, Complementary and Alternative Medicine! Such a controversial topic, full of intrigue and shady evidence and passionate arguments from many different people. Speaking personally, I don’t have an issue with CAM; indeed, I know and am related to many people who swear by things like acupuncture and herbal remedies. When I was but a wee lad, my mother pumped me chock full of herbal remedies in a loving but possibly misguided* effort to avoid putting “chemicals” into my body.

The problem that I have with CAM is when people use it exclusively, claiming that real medicine is misguided or somehow deficient in ways that CAM is not. I have family members who, when they experience physiological malfunctions, will eschew a trained physician in favor of an herbalist.

Now, in some cases I can see their argument for deficiency in modern medicine. In theory, medicine is “evidence based” but in practice many physicians and practitioners are really “litigation based” or “I learned it that way 20 years ago based.” This does lead to deficiencies in care. However! The fact is that most medicine is based on some body of solid research, where most CAM is based on flowery prose with a minimum of solid research. I’d make the argument that CAM is marketed by people who have an economic incentive, but so is real medicine, so that argument is not a good one to use.

So given the fact that modern medicine is backed by evidence and CAM is not, why do so many people continue to prefer using CAM only? To find the answer, I have turned to that ancient illuminator of the truth: comedy!  The humorous and surprisingly accurate website Stuff White People Like gives us an excellent answer to the problem of CAM:

Because of a rather shady history, white people do not trust the pharmaceutical industry.  Using pretty sound logic, they believe that the drug companies have no motivation to find real cures for things like AIDS since the real profit are in drugs like Viagra and Xanax.

Using their powers of deduction, white people have determined that herbal remedies are unilaterally better than anything produced by a drug company.

Since white people can’t really blame any race for their problems, they need to blame corporations.  In this case, the reason that they are sick or fat or without energy is because the drug companies are in a conspiracy to keep them addicted to placebos.  This helps them shed accountability, and it lets them feel like they are helping the environment by rejecting the polluting, greedy, awful drug companies and taking natural, organic medicine from the earth.

But perhaps it goes deeper.  Hundreds of years ago, another group of people believed firmly in natural medicine and it’s ability to cure disease.  Then white people gave them blankets with small pox and they all died.  So perhaps turning to natural medicine also helps white people feel better about killing natives.

Once again, comedy helps us see the truth.

*Pretty much everything we do boils down to chemicals in action. Trying to avoid putting “chemicals” into your body is like trying to avoid putting “air” into your lungs.

Here’s something that has been on my mind lately.

So. Let’s assume that there is a patient who, in all probability, is infected with HIV. Let’s say he is a happily married middle-aged man. The suspicion of HIV arises when the patient presents with some atypical infectious organisms and a history of sexually transmitted infection. The ID physician suspects HIV and asks the patient for consent to have an HIV test.

The patient refuses and asks us not to tell his wife that we want to test him for that.

Now, according to “medical ethics,” the right thing to do is to honor the patient’s autonomy and not test him. His private health information is his and his alone, and regardless of the circumstances we must honor his wishes. But how can this be ethical? His refusal to be tested doesn’t just endanger his health: it endangers the health of his entire family. Doesn’t his right to swing his fist (by refusing the HIV test) end at someone else’s nose (the potential effect on his wife and daughter’s health)? Let me add here that I’m not advocating that we force him to act on the results of the test; I’m just advocating for his family members, who I think have a right to know if he’s infected so they can take reasonable precautions against becoming infected themselves.

What really gets me about this is that we in medicine routinely fail to honor patient autonomy. Physicians will override DNR wishes, family members will refuse to recognize living wills. Patients who wish to die are deemed incompetent and kept alive against their will. When it comes to death and dying, we are only too happy to override patient autonomy. But when it comes to a lethal infectious disease that poses major public health risks, we honor patient autonomy like Jesus himself is going to smite anyone who doesn’t.

How is this ethically correct? The behavior of healthcare practitioners in general is inconsistent at best in this regard. Further, I can’t think of any good reason not to test the patient.

What if he is afraid of the results, you ask? Well, that’s a stupid question. If we didn’t tell people what was happening to them because we were afraid that they would be afraid, then we’d never tell anybody anything.

What if he doesn’t want to know? I’m sorry, but if he doesn’t want to know if he is sick then why did he present asking for treatment? If he didn’t want to know that he was sick he probably wouldn’t have sought medical attention.

What if he doesn’t want to know because he’s afraid of the social stigma? Frankly that’s not our problem to deal with.

And finally…

Patients have a right to refuse, you say. That’s true. They do have that right. However! We routinely ignore that right when people display signs of being mentally incapable of making decisions. For example, a psychotic patient who declines treatment is going to get treatment whether or not he likes it. Doesn’t the right of the patient to refuse become a gray area when it’s a public health issue? I don’t want to advocate infringing on his civil rights, but I do think that his refusal to be tested puts his immediate family in a not insignificantly risky position.

I honestly can’t think of any good argument against testing him. And it drives me insane that this man is willing to risk infecting his family with HIV just to put off his inevitable fall from grace and save a little face in the here and now. It sickens me and to be perfectly honest I find myself disgusted by this mans actions. Judgmental? You bet, but we’re all judgmental on the inside. I’m just letting it out today.Discuss.

I had an interesting patient yesterday.

It began in the morning when I got an admission from the ER, a 23-year-old kid who presented with serious shortness of breath and got intubated. But that’s not all. His X-rays demonstrated the classic signs of Pneumocystis Carinii pneumonia. For those of you not in the know, Pneumocystis pneumonias are not common except in immunocompromised patients, historically patients with HIV. The patient also presented with serious cardiomyopathy (his EF was measured at 5 to 10 percent) and a history of methamphetamine abuse.  His family is convinced despite the evidence that their son was some sort of angel. Of course he was an angel! Just a meth-addicted condomless irresponsible angel who was perfectly happy to live his life at the expense of others while spending his under-the-table money on tattoos and drugs.

Personally, I don’t know what to make of this. On the one hand I find it distressing to see somebody so young in so much trouble. I feel sad that his life turned out this way. On the other hand, he’s definitely made his bed, and now he has to lie in it–and unfortunately he’s lying in it at yours and my expense as he was uninsured. I suspect he’ll die, but not before he lingers for a long time and runs up an enormous bill.

Somebody remind me why it is that we do this. It seems to me that the hundreds of thousands of dollars we’re going to spend treating this useless pile of carbon with no prognosis would be better spent on preventive medicine to prevent other people from failing at life as badly as he did. But instead of doing that, we’ll dump tons of cash and resources into a futile case and tell ourselves that we’re doing the right thing. Am I crazy, or am I the only sane person living in a madhouse?

I often wonder if I am actually very crazy and simply unaware of it. If I am crazy, I think I have some kind of Crazy Power Disorder, where beneath my mild-mannered exterior is a raging megalomaniacal egotist who is just waiting for a chance to get loose. I often begin to wonder if I am crazy like this after making judgments on the lives of people who I have never met. For example, one of my patients today.

The patient is a 43-year old man who is in the hospital for a coronary artery bypass graft. He is an unemployed morbidly obese drug-using government-check-cashing drain on society who has recently decided to further his pursuit of scumdom by developing a meth habit. For reasons unclear to me, somebody thought it would be a good use of time and resources to enable this mans lifestyle by fixing the problems he gave himself, and so it was that he underwent a coronary artery bypass grafting today.

When I got report on this man and realized I’d seen him before, and when I realized that he was still abusing drugs and refusing to care for himself, my immediate reaction was rage. Why do we do this? Why do we enable this mans defective lifestyle? There are those who argue that maybe this will be the impetus for him to turn over a new leaf but I simply can not believe that. If he is like every single person I have ever met, he will not turn over a new leaf; he will try for a day or two and then go back to what he was already doing. We’re not going to cure his ills: we are going to enable him to continue his selfish, destructive lifestyle. We are the codependents to his alcoholic, the enablers to his addict. We are making it worse by fixing him. I find myself thinking, If I were in charge we’d just let him die, because otherwise he will never learn. And that is a scary thought to be thinking: it occurs to me that I am disregarding the life of another human being simply because I find him to be a repulsive pile of scum. And then, after that emotional burst, I remember logic, and realize that he was disregarding his life long before I was.

After all of this, I sit down and I find myself wondering: am I crazy? Have I gone off the rails, or am I just being honest with myself and not being sucked into the delusions of some of the aspects of modern medicine?

Any opinions? Am I crazy?

Here’s a fascinating tidbit: Penguins can return to the surface after long dives with “blood oxygen levels,” presumably the Penguin equivalent of their PaO2, that are approaching zero. Evidently their hemoglobin is structured differently form ours in some insane way that makes it more efficient, so that penguins can dive to untold depths for up to 26 minutes and survive. To put that in perspective, if I held your breath for 26 minutes you would be what we in the medical world call “dead.”

So, what can we learn from this? Maybe someday we can develop a new medication based on penguin hemoglobin that will improve survivability in patients with severe diffusion defects or ARDS-style syndromes.

Fascinating.

Forgive me for the relatively poor quality of this post. It has been a long and tiring few days; I was working in the ER Friday and did 32 blood gases, 35 treatments, a couple of BiPAPs and transports and general nonsense so I was beat. And today I had a lengthy and insane day in which everything happened at once right at the end of the day. On the bright side, I did intubate two people within ten minutes, bringing my total to five. Not many but it’s still exciting to me. Anyway, enjoy this post about The Screamers.

We have had a lot of screamers lately in the hospital. In addition to a lady who sounded exactly like a train, I’ve had a number of encounters with screamers lately–more so than usual. I’m not sure what is bringing them all in but it has made life interesting.

The first in this chain of screamers came when I was relegated to the floors. Floor care is not normally something I mind, but the way that floor care is stacked here in Sunny Flats one therapist typically winds up with something like thirty patients to see and they’re all spread out across our million-square-foot physical plant. “Floor care” here means “get out your walking shoes and bring a Sherpa along.”

Anyway, I had hiked all the way from our main RT office across the hospital campus to East Three. I ran several treatments, and oddly enough most of my patients had been fairly normal. This was odd; East Three has a Reputation. Soon enough I discovered why. I strode into a room and saw my patient, a 90-year old lady lying supine and staring at the ceiling. I checked my treatment list and saw the legend “HoH” next to her name. Knowing now that she was mostly deaf I took a deep breath and shouted.
“Hello, Mrs. Redacted! I’m here to give you some breathing medicine!” I reached out and softly tapped the patient’s shoulder. She began a Slow Roll, turning her steady unblinking gaze from the air in front of her face to my general direction. She opened her mouth and took in a slow, raspy breath–

“HEEELP MEEEE! H-E-L-L-E-L-P! HEEEEELP MEEEE!”

I winced. The volume of her voice was unexpected compared to the size of her body and the age of her lungs. She took another deep breath and screamed again.

“HEEELP MEEEE! H-E-L-L-E-L-P!” She continued screaming for the duration of her treatment and for some hours after. What intrigued me was her spelling; most patients don’t spell, but the manner of her misspelling seems odd to me.

:::

Today, in the CCU, I was assigned to an elderly patient who had self-extubated just before my arrival in the morning. She had self-extubated mainly to facilitate her desire to scream, which she did liberally.

“STANLEY! STANLEY! GET THIS NOSE OFF OF MY NOSE!” was her first chant, but soon enough she replaced it with “I CAN SEE MY BLADDER!”  and then “STANLEY! I WANT POTTY!”

Nobody knows who Stanley is.

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.