Respiratory Therapy 101: Just Keep Breathing

“Mr. D came in last night, somethin’ wrong with his bowels or somethin’. He was a DNR but the ER doc talked the family into trying to resuscitate him and now he’s intubated. He’s septic or somethin’ cuz he’s breathing fast.” I nodded and looked at Mr. D, who was breathing a phenomenal fifty times a minute. His thick and distended abdomen heaved as he worked against the ventilator. His mouth opened in the classic “guppy breathing” posture as he worked.

“Do you know anything else about him?” I asked the night therapist. She eyeballed me quickly and shook her head.

“Nope. I’m off. See you tonight.” I nodded back at her and went to work.

Over the course of the morning, I spent a couple of hours with Mr. D. I put him on our ARDS protocol, ran mixed venous blood samples. I put in an arterial line, which was something of a personal triumph for me because even the Intensivist couldn’t insert one on this gentleman. The nurse and I played with PEEP and pressors and tried to balance oxygenation with perfusion. It was an uphill battle. Finally, at noon, the family asked us to cease our efforts. Mr. D died within three minutes after I extubated him. I was standing outside his room when his wife pulled the curtain back. Her eyes were blooshot. She grabbed me by the arm and began sobbing.

“Is he supposed to turn blue? What should I do?” She burst into tears and began sobbing hysterically all over my sleeve. I looked over her shoulder. Mr. D was bright purple, and as I watched he heaved his last breath and gave up the ghost. He was a family man, worked diligently in his church, served his country in the army for twenty years. Within twenty hours of coming to the ER for serious sudden abdominal pain he was dead. His family was devastated.

Down the hall, I had another patient, a middle-aged ex-IV drug user, unemployed woman who had come to the hospital more than two months ago because she didn’t feel right. She progressed into respiratory failure and got intubated in mid-December. Her family refuses to give her a tracheostomy because “she wouldn’t want that,” yet they refuse to let us withdraw support because she “wants everything done…” except for a trach, evidently. We’ve explained to them how her tube is surely eroding her throat, but they won’t listen. This woman has been on and off the oscillating ventilator, she has been in and out of surgery a number of times, and she is not neurologically intact in any meaningful sense–yet she is not brain-dead. She emits a smell that could stun a musk ox at a hundred yards. She absolutely refuses to die, and her family absolutely refuses to let us withdraw support. She never worked, she spent her life abusing drugs and grunting out babies, and she sits in our ICU and wastes your tax dollars to the tune of 5,000 dollars a day so that her high-quality life of staring into the middle distance and having tubes and lines inserted into her can continue indefinitely. We are no longer treating her for any curable condition; we are now keeping her alive for no reason. If she was aware of what was going on, I’d call it torture, but luckily for her she’s in a persistent vegetative state.Her family visits for about five minutes a day and then pronounces that “The Good Lord will make her better!” and leaves. I suspect that they are attending the church of the idiot pastor, but I can’t prove that.

Sometimes the contrast between my patients astounds me.

(This is an unusually theological post. I’m no seminarian but I’m pretty sure that I’m right about this. Read on.)

One of the most important lessons to learn in the practice of modern medicine is that no matter how hard we try, we can’t possibly save everybody. Indeed, over a long enough timeframe we can’t save anybody. But I think that this lesson, that we can’t save them all, could be applied just as well to some other professions. Like pastoring.
In one of the ICUs we currently have a rather young patient. The lad in question was out performing minor felonies with his friends when he was involved in some sort of major traumatic incident involving most of his body, but especially his head. His friends, the ever-considerate minor felons that they were, put his lifeless body in the trunk and dumped him in front of the ER.

After a major workup it has been determined that he is just this side of brain-dead. He’s not technically “brain dead” because he still breathes, but he is in a deep vegetative state and he will probably never wake up. Even if he did, it would be irrelevant; the higher sections of his brain were crushed in the incident.

Despite all of this, and because of a lot of ambiguous wording by lawyerphobic physicians and the normal processes of denial, the lad’s family seems to believe that not only will he awaken, he will be his old normal self. But their expectations and wishes don’t meet reality, so they brought a pastor with them when they came to visit.

I happened to be in the doorway of the room next to the lad when the pastor was holding a prayer service. My attention wandered, but I got bits and pieces. Until one particular tidbit of the pastor’s prayer caught my ear:

“Lord, let your healing powers FLOW through this boy. May his healing and his full recovery be an example of just how perfect you are! Let this boy’s healing speak to your power! Christ, we know you can fix this boy and we know you will fix him and glorify your name through him!”

Now. I’m not especially pious in the traditional sense, and I’ve never attended seminary or any sort of religious training. But I know bad religion when I hear it. False hope mixed with bad theology and a truckload of desperation makes for some might bad religion, and while there’s a lot of good to be found in religion it can be badly misapplied. From a medical and a theological standpoint, this pastor was practicing bad bad religion.

Let’s analyze the medical aspect first and the theological aspect second. If I offend you and/or you feel a need to refute me in the comments, please do so respectfully or you will face the wrath of the delete comment key.

Medically speaking: miracles happen every now and then. I’ve seen people recover from illness who I’d written off for dead months before. I’ve seen people come back from the very brink of death. I know that sometimes my negative prognostications are wrong, and that sometimes hope is needed for patients and their families. But I also know that this lad’s brain is gone. Not only is it damaged beyond any repair, it’s growing mold. Nothing is going to bring him back, and anybody who tells the family otherwise is a liar. As I have said before: dangling the carrot of false hope is a terrible idea because it makes the inevitable whack with the stick of reality that much more painful. False hope is abominable, and medically speaking the pastor’s prayer was full of nothing else.

Theologically speaking the pastor’s prayer was filled with bad religion. First and foremost: the point of Christianity is not to live this life forever. The point of Christianity is to make the best of what you have and then go see Jesus. The entire religion is based around human error and human mortality. Everybody is expected to make mistakes, and everybody is expected to die. And with the grace of God, in death you are to have new life. That’s the entire religion in a nutshell. And yet this pastor seems to be willing to overlook this most fundamental aspect of her religion when she begs and pleads with God to change his mind and bring him back to a world that her own religion tells her is evil. But instead of telling the family this, instead of reminding them that all that is born was born to die, instead of giving them hope of the afterlife while they are staring into the maw of the inevitable, she tells them it will be okay. She tells them that Jesus is going to wave his magic Jesus Wand and the boy will pop out of bed, cured of both his brain injuries and his felonious nature.

Not only is this astonishingly bad theology for a pastor, this is the worst kind of lie that can be told. Ultimately, when this boy dies and Jesus never waves his Magic Jesus Wand and the boy isn’t cured, the family will be both saddened by his death and disillusioned by the perceived failure of their prayers.  The pastor’s prayer is destined to fail on every single possible level, unless you count the few moments of false hope delivered right after the prayer as a success. I’d entertain the argument that making the family feel better in the moment is a worthy cause, but I don’t buy it. Ultimately this is going to make it worse for them. Promising that God is going to do anything is bad form for a human being of any religion; but the circumstances here make this an especially grotesque parody of what the religion is supposed to be about. Christianity is about hope for the next life, not an indefinite extension of this one. And I think that that truth is too often lost in the politics and the badness these days.

After all, you can pray all you want to, but you can’t steer a train.
Less religious posts to resume shortly.

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

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

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

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

Mielikki has written what may be the most deliciously punny take on talk-like-a-pirate day ever. It’s entitled…“C-P-Aaargh.”

It gets better from there. Just go read it.

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In the ER today we had a patient who ingested something like 130 pills of various sorts. He had recently been discharged from a local psyche facility, where they had prescribed him an enormous amount of medicine and no supervision. In the spirit of evidence-based medicine, I’m going to go ahead and say that the evidence suggests that the processes at the psyche hospital are probably not up to snuff.

In other ER news, I met my nemesis at the hospital today. No, it isn’t the ever-worrisome Sumdood: he is far too much nemesis in one package for me to handle. Instead, my nemesis seems to be a physician who I will be nicknaming “Doctor Dork.”

Doctor Dork is about five-ten. He sports a pair of totally dorky glasses*, wears black jeans instead of scrubs, and has a shrill and whiny voice more typically associated with basement-dwelling nerds than with charming emergency physicians. Even all of this is tolerable: however, his total presentation…his mannerisms, his lack of interpersonal skills, and his generally unpleasant demeanor make him possibly the most dorky person in the entire world.

Doctor Dork also has the gift of being able to make a controlled, normal situation into a scene of total chaos. During an intubation today, he was sequentially yelling at the RT, the nurse, and me to do things that we had either already done or were actively doing. He turned a controlled, easy intubation into a nightmare scenario for all of us simply by being a total douchebag. I have decided that he will now be my nemesis: anybody so annoying and utterly incapable of being calm and rational should not be in emergency medicine, and the urge to subtly drive him to the edge of a stroke is very difficult for me to resist. The question is, how can I drive him to stroke without endangering patients? The argument could be made that patient safety would improve with the removal of this physician: this is a man who routinely writes orders for insane things, like arterial blood sticks for problems like lower extremity pain.

I’m open to suggestions here. Drop me a line and let me know.

I’m thinking of adding two new weekly features to the blog. First is the “Hopeless Case of the Week,” presented not to bang on about the horrific existential questions posed by our own mortality or about the dehumanizing nature of medicine, but instead presented to make people consider what exactly it is that we are doing. Sometimes I think that we as a collective make extreme efforts to “save lives” with no actual consideration of what it is that we are doing, of what exactly that means. Often what we are doing is just playing God. I believe that we should examine our true motivations for doing this. Doing the things we do without examining the reasons seems like a bad idea, and by pointing out the futility of much of what we do I hope to provoke thought.

A good example of a case like this is my patient from earlier this week who, after almost dying in a hospice home was rushed to the ER, where he was resuscitated and transferred to the ICU. Why would we do this? Why would anybody take a man who has clearly stated that he no longer wishes to take extreme measures to avoid death, send him to an emergency room, and then allow him to languish in a critical-care unit on extreme survival measures? The chain of decisions leading him to where he was is understandable but flawed on some fundamental level which I’ll explore later if I remember.

The other feature I am thinking of adding is Success of the Week. In addition to considering why we do the things we do and examining the interestingly futile side of medicine, it would be beneficial to examine the oft-overlooked successful and positive side of medicine. Since RT is by its nature a field that is often balanced more on the “failure” than “success” side of the scale, I’d be happy to accept submissions from readers about their success stories.

Your thoughts on these ideas, everyone? Good ideas, bad ideas, or just products of a deranged mentation?

A new Change of Shift has been posted. Go ahead and read it, there’s some good stuff in there.

In the course of my spiderlike web-browsing activities I came across a page that discusses the viewpoint of a patient hospitalized with pneumonia. Of course she never mentions the respiratory therapist, but there is some degree of comfort in anonymity.

Anyway, it’s an interesting peek at the patient’s perspective. Check it out if you’re interested.

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.

I had to do a terminal wean the other night. Those are never fun: the sound of someone sucking down their last few breaths as the ET tube goes out, suctioning the airway out, hoping that the patient doesn’t die before the family comes back into the room while also hoping that they don’t suffer too much either.

This wean was particularly bad. The patient has (had) these really awful, purulent thick secretions that were clinging to the ET tube and that got stuck in the mouth. That on top of the “death breath” made me want to throw up, but puking on patients is often perceived as bad form.

So, I extubated the patient, cleaned up their mouth a little, and scooted out of the room with the ventilator while the nurse finished cleaning up the patient. I didn’t want to run into the family with the ventilator in my hands, so I took a back way out of the ICU.

And there I was, pushing this ventilator (complete with the I/E lines and everything, covered in a big clear plastic BIOHAZARD plastic bag per policy) down the hall, whistling a happy tune and trying not to think too much about what I had just done.

I turned a corner, still whistling…

…and ran directly into the deeply upset family of the man whose ET tube I had just removed. This was a surprise: apparently they had decided to take the back route into the ICU, the route that nobody ever takes, in order to avoid seeing or being seen by a lot of onlookers who would stare at them while they were busy mourning.

They looked at me. They looked at the ventilator that I was pushing.  I looked at them. They looked at me for a moment. I didn’t know what to do: smiling is friendly, but they’d think I was a dick. Sympathies would be semi-inappropriate from me at that moment. What do you say? “I’m sorry I took the life support–this machine right here!— off of your dad/husband/grampa. Hope you have a nice day.”

In those few seconds when the family and I were staring at each other, I holding their (now-dead) relatives ventilator and they holding back their tears, I felt worse than I have ever felt before. It was without a doubt the most awkward moment of my entire life to date.  I just pushed on past them. We never spoke a word.

I hate terminal weans. I hope the family doesn’t hate me. It’s just part of the job.

Some poor three-year-old had to get airlifted to Big City after eating an entire bottle of Mommy’s Special Candy last night. I don’t recall what exactly the kid took, but he took a hell of a lot of it. He was totally limp and unresponsive when EMS brought him in. We went ahead and intubated the poor guy, and then he started seizing and vomiting all over the place. Of course, Mom and Dad were totally shocked that a child would take a bottle of pills off of a low-lying table and eat the whole thing. I mean, it isn’t like unsupervised children who have never been given any parental guidance (except possibly on how to properly use the beer bong) would be at all curious about a bottle of special grownups-only candy pills.

The poor kid. If he dies, he never really got to live; if he lives, his life seems to have a lack of good prospects in its future.

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In other news. MDOD has an excellent analysis of the autopsy of that woman who died in the ER in California who everybody is all upset about. Call me callous, but my initial impression is that maybe she cried wolf one time too many and paid the piper for it.

Finally, Babs RN has a great piece on modern thought and the problems that it brings that people are far too eager to ignore. Go and read it now. It is well worth your time.