Respiratory Therapy 101: Just Keep Breathing

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

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

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

ISOBO-  Inappropriate Secretion of  Offensive Bodily Odor

Failure to Parent

Abdominal pain of absolutely no significance

Vitamin IQ deficiency

Markie, over at Mark On The World, has been thinking. He asks a question that I have been asking myself for ages:

Seriously, if a patient continues to behave in an unhealthy manner despite all evidence and advice to the contrary, when is it okay to stop treating? People with psychological conditions are forcibly treated, making it lawful to step in because the patient cannot distinguish reality, or is unable to care for themselves. The current popularity of blaming everyone else for our own condition is valid in a court of law (”They made the hot coffee too hot and I was burned”, “I can’t stop eating McFood, they must put something in it”, “I never would be this fat if they didn’t make Twinkies”….). Isn’t this a similar type of crazy living in a fantasy world?

Shouldn’t the healthcare providers be able to say “no” to the people unwilling to care for themselves in any meaningful way? Part of me thinks hell yeah! this is a possibility, and the other thinks that first part is sick. As nurses we’re here’s to help. But where is the line? Isn’t enabling exactly what we’re doing at some point?

I think it’s an excellent question. If somebody is unwilling to take steps to change their own behavior to improve their health, can’t we assume that they’re uninterested in their own health? If they’re uninterested in changing their behavior, why should we waste resources and time treating people who do not have any desire to get better? I’ve seen hundreds of patients whose chief complaint, verbatim, is “I can’t breathe good enough to smoke no more.” And while I can sympathize with the terror and horror of being unable to breathe (I’m asthmatic) I don’t really have a lot of sympathy for someone who takes a cigarette break while they’re in between nebulizers. What we are doing at that point is pretty much rearranging the deck chairs on the titanic. We can shuffle them around all we want, but the iceberg has already breached the hull and the ship will sink no matter how neatly those chairs are arranged. There are thousands and thousands of similar cases out there, draining resources and causing the cost of healthcare to spiral ever upwards for those few people who are actually sick through no fault of their own. You know. The people who need modern medicine.

Oh well.

You know, I always wanted to be a pilot. Being an RT sort of just happened to me. And I like it. Just like any other job it has its ups and downs, but on the whole? It’s not too bad. Pretty much I spend my days wandering around in the ICU managing ventilators and sucking mucous and blood out of people like some sort of grotesque underpaid vampire. I do get frustrated by the utter futility of a lot of what I spend my days doing, and more than once I’ve wanted to pound someone elses my head against a wall over and over to let the stress out. But on the whole, being an RT is a decent job.

And I will never, ever have to have a night quite like this one. You have no idea how much that pleases me.

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

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

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

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

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

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

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

Thank you, Panda!

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

First and foremost: over at the Respiratory Therapy Cave there is an overview of 2007, the year of the RT weblogs! Go ahead over and check it out.

Now on to the content of the day.

I was babysitting another RT’s ICU yesterday while she was in CT scan with a patient. I was planted behind a desk, keeping my ears open for vent alarms or the telltale sounds of the crash cart, when the doors to the ICU swung open and a harried-looking CCU nurse burst through the doors. He was dragging behind him a stretcher, attached to which were another stressed-looking nurse and a miniature teenage transporter. I stood up and looked at the patient as they maneuvered the stretcher into the room.

The patient was a middle-aged man, flat on his back with an enormous cardiac scar on his chest. His head was cocked to one side, and his eyes were wide open and focused at a point in the middle distance. I watched him as he went by and became concerned when I noticed that he didn’t seem to be breathing.

I jumped as my co-worker returned behind me. “He’s got the whole ‘Come-To-Jesus’ look going on, don’t he?” she said to me. “Is he even breathing?”

“I’m not really sure. He could be.” I followed the stretcher into a room, my co-worker just behind me. While the nurses made the bed ready and prepared to slide the patient over, I walked up and stood next to the stretcher. I placed my hand on his chest and looked at him for a moment. He was breathing; I could feel some excursion with my hands. But it was shallow and not sufficient. Better get the airway box, I thought.

The nurse had other plans.  He came up behind me and leaned in close to the patient. With a colossal breath in, he bellowed:

“HEY! HEY! YOU GOTTA WAKE UP NOW, MISTER! WAKE UP!”

With a jerk and a jump the patient lifted out of the bed and snapped out of his trance. His wide-open eyes found the nurse, and he screamed back:

“WHY?”

A snappy comeback, and one that made me a little more confident that this patient would be alive for a little while yet.

Wow. I have been beaten in every aspect by The Happy Hospitalist’s Frequent Flyer Club. It is a total, comprehensive guide to all of the chronic patients that we have to deal with. I am impressed!

Hat tip to Shadowfax at Movin’ Meat who originally posted this awesome link.

Another article in my series on the Rules of the House of God is coming up, but in the meantime, why not enjoy some  other blogs?

Freadom over in the RT Cave has written a good Q-and-A about rescue bronchodilators, those wonderfully abused but mostly harmless drugs.  He’s hinting at a crucial point, which is that physicians tell patients that Albuterol will prevent them from developing an asthma exacerbation because they’re too lazy to write prescriptions for real control meds like Flovent, Advair or even Singulair. Go on over and read the Q/A, it’s interesting.

Meanwhile, GruntDoc has been making lawyers crap their pants in the ER. There are very few things that make seasoned ER personnel nervous, but the phrase “I’m a lawyer” is enough to give just about anybody pause. However, the tables turn when the lawyer is on the table, as we can see here.

Moving out of medicine and into Politics, we can see that there’s an initiative coming up to repeal the income tax in Massachusetts. Having previously lived, worked, paid taxes and driven (”Spirit of America”apparently refers to passing on the right with extended middle digits–and that’s just the cops) in Massachusetts I am intrigued by this. The state doesn’t exactly have a reputation for this sort of tax-repealing small-government movement, at least not since we threw all the tea into the harbor, but maybe some of the libertarians from New Hampshire have been creeping across the state line.

Further updates as events warrant.

Well, it’s Monday and I am far too lazy to actually make any content today. So for your amusement, I present to you some links!

First, Julia at Snotjockeys Revisited has written an informative and fascinating piece about resistance to change. She explores some of the reasons behind the resistance to changes in the medical field, and her analysis seems spot-on to me.

Second, an anonymous medblog troll named Linda has apparently decided that MonkeyGirl is an evil evil nurse. Now, we all know that this isn’t true: indeed, MG is a footsoldier on the front lines of the endless battle with Sumdood and his pill-popping legions. Now, Linda claims not to be a member of Sumdood’s endless legion of narc-abusing pain-fakers, but someone with a reaction this visceral to what is clearly a humorous jab at some of the most frustrating and obnoxious patients we deal with is probably compensating for something.

More links as I stumble across intriguing things.

Despite my recent raving about Gomers and the frustrations that they bring to the healthcare world, I honestly feel a lot of sympathy for them. They’re feeble old people who should have been allowed to die with dignity, but who we are keeping alive for reasons I am unable to discern.  Terry over at Counting Sheep has made this point much more eloquently than I have. The last line here is exactly what I have been trying to say:

These are the lost people of our society, and they cannot speak for themselves: the crowning culmination of a life. lived. long. They come to our ORs to have feeding tubes inserted into their abdominal wall; to have their bedsores scraped and excavated; to have their broken bones repaired; to have months and sometimes years of neglect “fixed” so that they may return to exist. In a life without hope or happiness, only today, over and over again.

“Where do they all belong?”

This old, edentulous woman, this shriveled shadow of a man in the bed. Surely he once laughed, and dated; she married and bore children. She cooked; he worried about his family. She did the ironing and darned the family’s socks. He had opinions; he balanced the checkbook. She felt the hot sun on her head; the icy winter blast of wind braised his cheek. She lost her husband too soon; his children all moved away.

There is nothing we can do to save them from us.

How very true.