Respiratory Therapy 101: Just Keep Breathing

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.

It’s time for installment number four in my long-neglected series on The Rules of the House of God. Today’s rule: The Patient is the One with the Disease.

At first, rule four seems obvious. Many of you are saying, “Of course the patient is the one with the disease. That’s why they’re the patient, you jackass.” But if one looks at the rule in the context of the book it becomes more meaningful. It confronts some of the demons that young, idealistic people in medicine often have to face: the hypochondria that comes from seeing endless streams of sick people, the paranoia that comes with the hypochondria, and the specter of mortality.

Hypochondria

Hypochondria is an easy thing to develop. It is especially easy to develop when one spends a lot of time with sick people. It is not uncommon to face patients day in and day out who present with minor complaints and wind up becoming critically ill or dying. People present with a chest cold and wind up dead a week later; the headache becomes a brain tumor or viral meningitis; toe pain turns out to be terminal bone cancer.

When I first got into Respiratory Therapy, I was very young and very idealistic. I wanted to help people and I wanted to feel like I was saving lives and making a difference. I assumed that fixing people’s breathing would be easy and that it would be appreciated. I was completely unprepared for the magnitude of the suffering that my patients were experiencing. I simply had no idea how sick people could get, and what really got me was that these people were exactly like me, and too often there was nothing I could do to alleviate their suffering. I felt powerless and frightened.

Paranoia

Eventually it began to wear me down and I started to get paranoid. I’d have a stomach cramp and immediately wonder if my appendix was about to burst. I’d get a headache and flash back to a patient with viral meningitis whose new home was heavy on lush hardwood and conveniently located beneath six feet of sod. It began to affect my attitude and my performance: since these patients were doomed anyway, why were we bothering? What’s the point? I got depressed. The job wasn’t what I signed on for; by virtue of a sheltered rural upbringing and simple naivety I was unprepared to face sickness and suffering.

And then one day it hit me: no matter how bad I feel I’m not the sick one. I can stick a needle into some guy and not feel a thing*. As the rule says: The Patient is the One with the Disease. Realizing that helped me get over my shock and my frustrations enough that I can function relatively well as an RT and as a human being…although I do still have a tendency to question the reasons for much of what we do.

The Specter of Mortality

To me the rule is definitely about hypochondria and the process of learning to deal with suffering, but it is also about mortality. In the book, Shem embodies mortality in a patient known only as The Yellow Man. The Yellow Man is a patient who develops hepatitis under a suspicious set of circumstances. One of the resident physicians working alongside the narrator misses this diagnosis. Because of this, the patient worsens, becoming progressively more and more sickly. The mental and physical health of the resident begin to suffer; he feels overwhelming guilt about the part he played in The Yellow Man’s illness. Eventually the Yellow Man dies, and the resident commits suicide by flinging himself from the roof of the hospital**.

Reading into the story a little bit, it becomes apparent that the resident felt deeply guilty for what happened to the Yellow Man. In his efforts to help, he hurt; and instead of learning from his mistake and moving on, he became consumed by guilt and responsibility. Ultimately, he took on the disease of the Yellow Man; not in a literal sense but in the sense that he was unable to function normally as long as the Yellow Man remained ill. The resident embodies the rule: he fails to learn that the patient is the one with the disease, and as a result he is unable to function. He is so stricken with grief and guilt from his mistakes that when the patient dies he commits suicide. The lesson is vital: if you forget that The Patient is the One with the Disease, bad things will happen. Always.

Conclusion

And so we can see that the rule isn’t a callous statement about physical pain or a degrading statement about the health of sick people. It’s a warning, a reminder that if you forget which side of the bedrails you’re on you’ll be unable to function. It is vital to remember that the patients are the sick ones. It doesn’t mean that we can’t feel bad for them; quite the contrary. It’s a reminder that if you carry the sympathy too far, if you take things personally and dwell on them, you’ll die a little bit inside every day.

Be careful out there. Don’t forget which side of the rails you’re on.

*except one time when a guy kicked me in the head while I was getting an ABG. I felt that one.

**It’s not a “warm fuzzies” sort of book.

Man. I had to terminally extubate another patient today. This brings my total over the last six weeks to well over half a dozen, somewhere around eight or nine I am guessing. This is far more patients than I terminally extubated even in the year or so leading to my arrival here at Sunny Flats…not that it bothers me particularly, but on some level it still feels strange to me to flip the switch and yank the tube. I know it’s laughably naive, but on some level I guess I wish it was different; I wish we actually did save lives instead of just cheating the reaper.

Yes, that’s right. Underneath the misanthropy and the casual disdain for many of my patients, sometimes I really do want to help them. I think that on some levels I am perpetually frustrated by the inability of anybody to really do anything for most of these people. Sure, we can treat the meat and keep people alive; but what’s the point of doing that if their life is just going to be a bunch of misery? In the course of talking to my patients I find that most of them respond better to casual conversation than to any medicine. People really like it when you show an interest in them, and patients just light up if you spend a few minutes getting to know them in more than the cold clinical sense. Maybe it’s just me but I often think that the conversations I have with most patients on breathing treatments do them more good than any albuterol ever will.

Getting back to the terminal weans, it does feel a little funny to be doing so many of them all of a sudden. But I don’t really mind it. A lot of the time, what we are doing in critical care is simply animating meat. I can keep your body alive almost indefinitely: but does that necessarily mean that I should? Sometimes the kindest thing to do to a person is to just let them die with some sort of dignity intact, and too often people die looking like a rabbit in a trap: that final look of shock or terror before the deadness sets in; the panic and confusion of CPR and resuscitation; days and days spent hooked to drips and things before the final bit of life leaves.

Bah to all that, I say. May as well skip the lot of it and just die naturally. And failing that, sometimes it’s best to know when to cut your losses and give someone the closest thing to a natural death that we in the ICU can arrange.

Any thoughts, audience?

“The moment I saw him I thought, ‘TB! TB!’” I nodded and listened as one of my ICU preceptors spoke to me. “He came in with hemoptysis* and night sweats, ten pounds weight loss in a weeks time, and radiodensities all over his right lung. And look at him!” She jerked her head in the direction of the patient’s room. “He just looks like a TB guy.”  She was right about that: he had the semi-homeless looking beard and generally dirty appearance of one who has had more than their share of hardships in life, and as we all know certain hardships definitely raise the risk of infectious disease acquisition.

I talked with the ICU preceptor as she prepared to transport the patient to the CT scanner. Poor dude, I thought to myself. TB’s just no good. I cleaned his ET tube with the suction cath and then stepped back as the transporters maneuvered the stretcher out the door like sea-captains maneuvering oil tankers through the straits of Hormuz.  Within a few moments he was gone, and I took off my N3 respirator and went to get a drink of water before beginning second rounds.

Time passed uneventfully. My ventilated patients were mostly cruising; one with improving ARDS, one at the end of the road because of HIV. I nebulized some old dudes who were ventilator-free and then waited around for the return of TB man. I looked at the clock. An hour-and-a-half? Where is this guy? Is there a problem in CT?

Just as I was about to head out in search of my preceptor and TB man, the ICU doors swept open and she walked in.

“Where have you been? Where’s TB man?”

“That was the weirdest thing ever. They were scanning his head because he’d been found unresponsive, right? Well all of a sudden the rad tech goes ‘aw, shit’ and we all look at the screen, and he’s got this enormous mass on his frontal lobe. We called his attending, attending called surgery, and he’s in the OR right now getting his brains cut open.”

I took this in. TB man had a mass in the head? I’ve heard of TB massing elsewhere in the body, where it’s less potent than respiratory TB, but never before have I heard tales of brain TB. My preceptor and I debated this oddity for a few moments, and then shrugged it off and went to look at some X-rays over coffee.

Later, TB man returned from the OR. I donned my respirator and my rubber gloves and went into the room to steal the ambu from Anesthesia, which is a tradition dating back to the early days of respiratory care. Nobody knows why we do it: they’re capable of bagging a patient, and we don’t really need to take the bag from them, but for some reason we feel this deep-seated urge to take it from them as soon as they walk into a room. Anyway, TB man was back from the OR and I was setting him up, marveling at the effect that the covering of every persons features with a TB mask was having on the atmosphere of the room. It seemed more clinical, somehow less human. Thoughts from psychologists?

Back to the story, TB man’s nurse talked to the anesthesiologist while I scribbled down my vent parameters and sweated behind the respirator mask.

“What did you all find down there, anyway?”

“Brain mass. Looks like cancer, probably it began in his lungs and mets to the brain.”  Before I could help myself I spoke, something I shouldn’t ever do.

“Thank God for that,” I said. “It’s only cancer.”

:::

Freakonomics today reports that there is a new study out from the APA that was designed to test whether there was any connection between anger and lung function. Apparently there is a correlation:

“The data pool consisted of 4,629 healthy adults between 18 and 30, living in Minneapolis, Birmingham, Chicago, and Oakland. Subjects were asked to blow into a machine to determine lung function, then answer a 50-item questionnaire agreeing or disagreeing with statements like “I am easily angered.” The results showed that, after adjusting for age, socioeconomic status, smoking and asthma, higher hostility scores were consistently associated with lower lung function for black men, black women and white women. The association was not present, however, in white men.”

Of course it should be mentioned that correlation is not the same as causation. There could be other factors at play in this connection, although it’s almost the opposite of what I would expect. I’d think that all of the yelling and deep breathing typically associated with angry people would act as a sort of perpetual lung-expansion exercise, similar to incentive spirometry…incentive screechometry, almost.

:::*(angry cartoon image stolen from Tom’s Cartoons)  :::

On an unrelated note, I found the following photo on a Reuters article about the Chinese military. I’m no gun expert (I’d love to learn) but it seems to me that holding targets like that requires either an enormous amount of faith in the shooter, a death wish, or a lot of institutional stupidity. It’s entirely possible that it is some combination of all three.

I’ll never forget that first terminal wean.

It was the dead of winter here in the Great North Woods. The grimness of the middle winter had sent many patients our way. The psyche patients were depressed and cabin-fevered, the oldies were slipping and breaking bones on the ice, and the lungers were feeling the sting of the sharp winter air.

But it was for none of these reasons that the weaning patient was brought to us. No, he was brought to us for other reasons. He had come in to have elective throat surgery in an effort to correct his sleep apnea without losing any of his much-treasured body fat. But something went wrong. When he came back to the ICU from the OR, we were all horrified by the mangled mess that was his airway. Where his throat used to be was an enormous, gaping stoma. An anesthesia tube jutted out at an awkward angle, held in place by sutures covered in sterile gauze. Somebody had slipped. Things were not looking well for this mans throat.

Over the course of a week, he was brought to and from the OR countless times. He was infected, debrided, closed up, reopened. They got his throat to close but he couldn’t breathe on his own. He remained intubated for days and days; the ENT people and the pulmonary people and the maxillofacial people tinkered with this mans body, but to no avail. His long downward spiral had begun.

Eventually they were able to close his throat, but he had suffered a couple of minor MIs and a stroke. He was septic. His heart was giving out slowly, and it was looking unlikely that he would make it. The ICU physicians called a meeting with the family and the hospital ethics committee to discuss the course of action. It was decided that the best course of action was to end his life before it was taken from him.

And that duty fell to me. I was working with a therapist named Jeff, a guy who lived far away but made the drive to Our Lady for reasons not clear to anybody. Whenever questioned about it, he’d simply say “I used to be a trucker” and change the subject. Jeff and I were told by the day shift that the family was at the bedside, and that at 8:00 the physicians would write the order and discontinue supportive measures. Jeff turned to me.

“Have you ever done this before?”

“No.” Jeff looked at me from behind his hermit’s beard.

“It’s time you learned.” I didn’t object, and so the decision was made that I would do the primary work of extubating the man.

8:00 rolled around. The ICU doc of the evening strolled in with a cup of coffee and spoke with the family, making sure that they understood that there was no turning back now. The chat went on for fifteen, twenty minutes. I sat nervously in the fishbowl behind the nurses desk, watching with interest and wondering about what I’d have to do. Finally, the time came. The family left. The doc came up to me and showed me the order:

“Discontinue: (1) mechanical ventilation, (2) ET tube, (3) all pressors, (4) parenteral feeding. Do not resuscitate. Comfort measures only.”

I called Jeff and he came in with me. The man lay supine on the bed, the tube sticking out between his cracked lips. The ICU nurse moved about the room, removing lines and turning off drips and preparing the patient. Jeff coached me.

“Just make one smooth move. He won’t even feel it. Deflate the cuff, pull the tube back, and turn off the vent.” He passed me a 20-cc syringe, and I drew the air out of the cuff. The ventilator beeped in alarm as the breath it tried to deliver slipped around the cuff.

“Cough for me, sir.” I said it more out of habit than out of any hope that he would cough. I pulled the ET tube out, carefully laying it on the Chux pad that the nurse had thoughtfully put beneath his chin, cautious not to dribble tube slime all over the fresh sheets and the patients chest. Nobody wants to hug grampa goodbye and get a chest full of mucous. The ventilator screamed in protest, and I reached over to flip it off. A question burned in my mind.

“How long before…?”

“Depends. Sometimes they go for hours. Sometimes they go for minutes. C’mon, let’s get this vent out before the family comes back.” We made sure the RN didn’t need anything else from us and then skedaddled out of the ICU, abandoning the vent in the dirty room until we could get it cleaned up later on.

I went back and sat in the fishbowl, watching the patients monitor. The nurse let the family back in, and within ten minutes of the discontinuation his heart slowed down and stopped. It was over: he was dead.

:::

For all the fuss they made in RT school about this sort of thing, and about the ethics of these situations, it was remarkably easy to do. I thought about it a lot over the next few days, turning over the situation in my head again and again, thinking about the man and his family. It took me a while to sort everything out in my head, but ultimately I came to realize that it wasn’t my decision. I didn’t decide to take him off life support, and I didn’t decide to send him to that botched surgery. Indeed, the only decision I made was to carry out an order that I could have easily asked someone else to do. Further, the man’s life was likely to end in a horrific code, and this way his family got to say goodbye.

Sometimes, death isn’t so bad. On that note, check out this hilarious video about coping with death. I’m not sick, it really is funny. Seriously, check it out!

Some of my favorite things in life are totally absurd. Some philosophers would tell you that everything in life is actually absurd, but this is an RT blog and not a philosophy blog, so that will have to wait.

Anyway, back to my favorites. I like things that don’t make sense, things that reveal that despite all appearances life is actually a lot less meaningful and a lot more absurd than any of us would like to admit.

Sometimes things like that happen in the medical world.

It was two o’clock in the morning, that disorienting time of night when everything begins to feel like a dream. Sometimes at that hour I feel like I’m moving underwater, and the easiest thing to do is just to sit and space out until something happens. And that is exactly what I was doing when the overhead speakers popped into life, jump-starting my adrenal glands. Code Blue, Fourth Floor, Code Blue, Fourth Floor. I leaped into action, jumping up from my seat and grabbing my stethoscope as I began pounding down the hall, running for the stairwell.

My legs burned as I hit the top of the stairwell and bolted into the hallway. All the way at the end of the hall, the white light above a patients room was blinking, signifying the need for codish people like myself. I jogged lightly to the end of the hall and found a giant ISOLATION sign staring me in the face. An aide handed me a yellow gown and I tossed it on over my lab jacket, throwing on a pair of gloves and shoving my way to the head of the bed. As per usual on the floors, nobody was doing anything: one nurse was straddling the patient and pumping his chest, and another was dreamily holding an ambu-bag in the vicinity of the patients head. At least she got the right end, I thought.

I grabbed the bag and tilted back the patients head. Suddenly I was staring into a lake of brown liquid that was pouring out of this decrepit old mans mouth. I noticed the bald head, the bony protuberances all over his body, the adult diaper. This guy had to be ninety years old, and instead of dying in peace we’d keep his body suspended for a few days until he grew immune to our drugs and died anyway out of spite. I hate it when this happens.

“Suction!” I snapped. “I need some suction!” A floor nurse handed me a yankauer, which I plopped into the pool of liquid with no result. “Turn on the suction! Why is the suction not on?” Someone was kind enough to turn on the sucker for me, and I evacuated a good quantity of the Mystery Liquid before slapping the mask onto the patients face and squeezing some air into him. He was hard to ventilate. No surprise there. ER Doc and the ICU team arrived in the elevator, pushing their own code cart that experience had taught them to bring. The exhausted floor nurse who had been doing compressions stepped down and was replaced by the prankish ICU orientee.

“Alright, folks, what happened here?” The ER Doc gathered a brief history from the floor nurse: 89-year-old male, sepsis, MRSA, pneumonia, CHF, renal failure, dementia, and so on. She gave the history and then briefed us on the issue at hand:

“He’s still a full code, we talked to the family today but they weren’t ready to make a decision about that yet.”

“Bummer,” said ER Doc, examining the rhythm on the heart monitor. “Alright, go ahead and give him some epinephrine to start, and then lets go ahead and get that airway taken care of*.” My co-therapist, Cindy Lou Who (CLW), prepared an ET tube and a laryngoscope for the doc as the code went on around us. Things moved at a leisurely pace: it was pretty clear that this was a code for the family. The patient wasn’t going to live. Why hurry?

A few minutes and a few cycles of drugs passed in this leisurely fashion. I pumped the bag, feeling no assist from the patient. The patient’s heart monitor still showed us no rhythm. His dead eyes stared up at the ceiling. ER Doc looked at the patient, looked at CLW and me, and then addressed the room.
“Does anybody have any other ideas? This is pretty futile.” I scanned the room. Nobody spoke, and just as ER Doc was about to call it off, Floor Nurse jumped in.

“I think we should do one more round. I would feel a lot better talking with the family if we’d just do one more round.” I glared at ER Nurse. This was just cruel, now: a literal flogging of the dead horse. ER Doc shrugged and gestured at us all to resume CPR while ICU Orientee, now off compressions and on Rx duty, prepared another round of code drugs. We pounded the old man for another ten minutes. A full round of CPR, a full round of drugs, another ten minutes of cadaver abuse.

There was a rhythm on the monitor. Sinus Brady. I looked at CLW, CLW looked at ER Doc, and ER Doc looked at the monitor with an expression of total surprise. There was silence in the room.  CLW leaned over and spoke lowly to me.

“Now what?”

“I don’t know.” I squeezed the ambu-bag and watched the room. Someone reported that the patient had a pulse that corroborated with the monitor. I reached down and fingered his carotid. It was weak and thready, but there was a pulse. I looked at CLW in disbelief. “This has never worked before.”

“Get me a BP,” ER Doc ordered. Military ICU Nurse grabbed a BP cuff and liberated my stethoscope from me to listen for a pressure.

“I’ve got 88 over 60,” she reported.  “What now?”

:::

What now indeed? There we stood, a crack team of lifesavers who had not actually expected this code to work. It was the precise definition of irony: a group of people who are dedicated to saving lives were standing around in disbelief and disappointment that they had succeeded with their stated goal. None of us wanted this man to live: his life consisted mostly of pain and confusion. His ICU stay would assuredly be short and brutish, and then he would run up an enormous bill and die anyway, leaving his family saddened and destitute. I assert that it would have been better for him, for us, and for his family if he had simply died quietly in his sleep.

:::

ER Doc spoke up again. “Let’s get him moved down to the ICU, start a levophed drip, call in the family…” He rattled off a bunch of orders. I handed CLW the bag and went downstairs to prepare a ventilator for the patient. He followed me down a few minutes later, attended to by the ICU staff, and we watched him overnight. His body was teetering on the edge: his BP would drop precariously, his heart wasn’t working, his kidneys couldn’t take our pharmaceutical onslaught.

I felt bad for the old man. His body lived through the night and the next couple of days, and then he died anyway. Like anybody could have seen that one coming.

Sometimes, the effort of saving a life…just isn’t worth it. That’s my outrageous assertion, and you can take it or leave it, but I think it stands: all we achieved was to make the mans body suffer and dangle the carrot of false hope before the family, only to whack them in the ass with the hard stick of reality when they leaned forward to nibble at hopes delicious orange body. It’s bizarre. But it’s what I do for a living.

*Here at Our Lady, RTs are stuck in the dark ages. We can’t intubate and we have minimal protocols. Sunny Flats, where RTs intubate and do A-Lines and run the show by protocol, will be an enormous improvement.

So last night I was supposed to be working alone. Flying solo on the night shift sucks, because inevitably you get called to one of the lockdown units and then there’s a crisis halfway across the hospital campus and you sprint over there and then you need to be resuscitated because you had to run up four flights of stairs and half a mile across and then down two flights of stairs, after which you must do battle with the Nefarious Night Shift Floor Waxing Guys before you can cross the Waxy Floor Of Doom and slip into your patients room.

Not that I am speaking from experience or anything. Anyway, back to my story.

I was supposed to be working alone last night, but fortunately for me Lafawnduh offered to stay a little late to help me catch up. By the time we finished first rounds in ICU and on the floors, it was eleven o’clock and the house was settling in for the night.  Earlier in the evening, Lafawnduh and I had placed an order for food with the ICU team, who had dispatched a spare aide to go get some delicious Indian food. Now that our work was done and the food was cold, Lafawnduh and I had a chance to sit down and microwave something. (The first thing I learned as an RT student was to always eat when you can because you never know when the chance will arise again.)

So we popped the Indian food into the microwave, filling the office with the delicious aroma of curried this and something vindaloo and so on. I grabbed a spoon and tucked into some tasty red curry; Lafawnduh was eating something with lamb in it.

A few moments passed. I began to feel funny. Suddenly, with no warning, my chest seized up with the familiar clenching panic of an asthma attack. I began to hear myself wheezing. My heart was pounding, and the sudden sensation that I had a vehicle parked on my sternum made my eyes widen in horror. I haven’t had an asthma attack in years. I looked over at Lafawnduh, who was posed almost exactly like me: eyes wide, hand clutched over the heart, heaving breaths in and out.

The ultimate in ironic situations had happened: the only two RTs in the hospital were having asthma attacks. This is not good.

I grabbed my rescue inhaler and a spacer and puffed a couple of shots of Albuterol into my chest, flinging the inhaler at Lafawnduh and trying to control my respirations. A pager went off. It would have to wait: an asthma-attacking RT is of no use to a patient. Lafawnduh squeezed off a shot of the Albuterol, and we sat there wheezing. A few minutes elapsed. Nothing happened.

I rolled my chair back to the closet and grabbed an O2 cylinder. Lafawnduh, thinking the same thing, grabbed some O2 tubing and a couple of nebulizers.

We sat in the office, puffing our nebulizers, feeling very silly indeed. Half an hour later, after some Duoneb and some oxygen, my life had returned to normal. I looked at my half-eaten dinner, and my stomach rumbled. I pondered sucking down some more of the food and chasing it by squirting some albuterol in my diet coke and chugging it, but I decided that it would be safer to throw out the leftovers.

I made some toast instead.

:::

In other news, welcome ADDRRT to the blogroll. Also, my fellow RT blogger over at G’s Spot has been published on Salary Stories with an excellent description of what exactly it is that respiratory therapists do all day. Congrats and thanks, Glenna!

Sorry to keep posting these “coming to an ER near you” posts, but I can’t seem to stop.

I was reading “Found Magazine” when I came across this beauty:

If you can’t make that out, it says “Dear pizza guys — I need to find out you name (& I hope at least the addres is right). Did you feed my husband while I was away? Thank you.”

Somehow, this disturbs me. It raises so many questions. Did the writer of the card ask the pizza guys to feed her husband, or did she simply leave her husband at home and hope that the pizza guys would feed him? Is her husband capable of feeding himself? If he isn’t, is it responsible to leave his nutritional status in the care of a pizza shop?

Someday, this man will be brought into the ER, starving and hysterical, covered in bedsores with toenails long so bad they’ll need a saw to cut them off. His future diagnosis eludes me, but “failure to thrive” seems to be a good catchall.

Despite my position within the system in the USA, I’m actually pretty ignorant about the state of modern medicine. Despite what politicians on both sides of the aisle will tell you, it’s a very complicated issue involving everybody from insurers to lawyers to patients and the people who care for them. Any change to a behemoth system like this is going to take a long time to enact and it is going to be a rough, patchy transition. That’s just reality: there’s nothing we can do about it.

What I do know is this: despite all of the shortcomings of our system–and there are many–we do a pretty damn good job most of the time. Considering that we work under micromanaging nitwits who understand business but not healthcare, and considering that we are often faced with a lot of legal obstacles and complicated social situations in our jobs, most of the time we manage to treat people without killing them or hastening their demise.

This is unlike healthcare in most places in the world. I once went on a mission trip with a group (CURE intl.) that runs hospitals in places like Malawi and Kabul, although being a coward I opted for the safer city of Santo Domingo to go and volunteer my services.

My “services” were not really used during the trip, which disappointed me in many ways. But I did get a unique chance to sit in on orthopedic surgeries at the private hospital that this charity runs. The charity uses their own facility because the facilities run by the government are abhorrent: people can wait for days to be seen, even when they have fairly major and debilitating injuries like femur fractures or other major trauma. God help the person who has a heart attack; the hospitals are almost totally unequipped to handle anything. I did not get to go inside the city hospital, but the outside looked poorly maintained at best.

The charity hospital’s major focus was on children who had developmental orthopedic problems or untreated trauma, things we wouldn’t normally see in the USA. The surgeon was a gent from California who divided his time between the D.R. and Haiti, where he had some interesting experiences; once the power went out, and he had to perform a major repair on the hand of a ten-year-old who had grabbed a machete in dubious circumstances in the dark, illuminated only by the screen of his laptop held aloft by the anesthetist.

Anyway, the poor folks in the DR don’t stand a chance if they get injured or sick. Their system has failed utterly. Our system is not perfect, and it is badly in need of repair, but it is not nearly as bad as the system in the D.R.

Click these for a bigger image.

The above picture is of the legs of a ten-year-old. He has never walked.

This is another deformed leg that the surgeons needed to fix.

A work in progress on a young girl with an abnormally angled lower leg.

The anesthetist’s station.