Respiratory Therapy 101: Just Keep Breathing

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.

“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.

A nurse and I were talking about a patient today. The patient is a young woman who was recently paralyzed. She has only just begun to understand that it’s not “paralyzed for now,” it’s “paralyzed for the rest of your life.” The horror and the enormity of being permanently paralyzed from the neck down has sunk in. She is quite understandably devastated.

“In fact,” I said to the nurse with whom I was conversing, “just the other day we were talking and she asked me to pull the plug and let her die. It was really sad. I really think she wishes she had died in the accident. She kept mouthing ‘pull the plug, pull the plug’ until I left.”

“Awww…that’s terrible. But doesn’t she have that right? I mean, if she’s competent and she can voice her wishes, don’t we have to honor them?”

“I think she does, absolutely. If she’s competent and she can tell us to stop*, I don’t know why we should keep going. I don’t know if I would want to live like that.”

There was a slight pause as the nurse and I pondered. What would it be like to have such a fate, conscious and aware but completely immobile forever? How do you deal with that, with the horror of never being able to do anything for yourself?

I was brought back to the moment as the nurse took a deep breath and spoke.

“I guess she’d probably have a hard time signing the consent to withdraw form, wouldn’t she?”

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I thought it was funny. But then I may be crazy.

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*Of course, it can be argued that anybody who is expressing suicidal ideation is incompetent by definition. This is a tricky argument and one I won’t get into for now.

(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.

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 just stumbled across the SICU Queen’s Blog. She has written an excellent piece about the day that they all smiled when he died:

Dear Loving Family Member (GAG),

You moron… he suffered for over FIVE months because you refused to follow his wishes and let him die. His body finally gave out… finally… and you have the nerve to wonder what you’re “going to do” now? How about you get your drama-craving, code blue dreamin’ ass out of my ICU and get the fuck down the road? You weren’t driving the nurses crazy with your stupid demands because you loved and cared about him, you only did it because you’re a control freak. You have an inconsequential level of self-esteem and for some freaky reason you feel like someone when you sit in the visitor’s lounge and ramble on ad nauseum about how long YOU’VE been here and what YOU’VE been through. You are beyond stupid.

I detect a note of frustration in her writing, but who can blame her? We’ve all had family members who thoroughly deserved to be slapped repeatedly in the face. Some people are all touchy-feely and “we have to understand what they are going through,” and to an extent that’s true. But the bottom line is this: many families cross the line from reasonable grieving to self-indulgent attention whoring, and I think that at that point they should be declared incompetent and expelled from the ICU.

But that’s just me.

Some time ago I promised you new features: the hopeless case of the week and the success of the week. These features were part of an effort to create interesting content and explore some of the dichotomies of medicine. But me being me, I forgot all about them until today. Today, working in the ER, I got a new Hopeless Case Of The Week!

The hopeless case came in this morning via ambulance. I was sitting in our RT cave in the ER when my “spectralink” phone rang.

“Respiratory.” I drew a deep breath and sighed. In this ER, they either need me for something critical or something asinine. Middle ground is hard to come by.

A tinny voice leapt from the earpiece. “Intubated patient coming to Intensive One. Six minutes.”I got to my feet.

“Right!” Hanging the phone up, I grabbed my stethoscope and strode out into the ER, walking past The Hallway Patients and The Security Guards and eventually winding up in Intensive One. I turned on the ventilator and waited. Moments later EMS lurched into view, tugging a stretcher with a pile of blankets on it.

On closer inspection, the pile of blankets was a cachectic middle-aged individual. Their blue eyes were open and staring off into space; their wasted limbs were splayed lifelessly across the stretcher. The paramedic began to rattle off report: the patient was a middle-aged man from a local nursing home, with a history of IV drug use, drug-resistant pseudomonas, C-Diff, MRSA, various chronic failures, enormous amounts of thick yellow secretions indicating a fulminant pneumonia—and full-blown AIDS.

He had been found unresponsive in his room at the home, probably when the one aide for 100 patients poked him with a stick and he didn’t move. He had no DNR. He had no family. He was unable to decide for himself what to do…so now he sits in an ICU bed, intubated and ventilated, being pumped full of drugs while microorganisms eat him alive from the inside. His mere presence in the ICU puts healthcare workers of all stripes at risk. His quality of life is minimal. He is not aware of his surroundings, and he…is…going…to…die.

Despite all this, he sits in a 3,000-dollar-a-day plus intensive care bed. We are keeping his body alive as long as we possibly can, but for what? This case is 100% hopeless. If we cure him, he will return to the nursing home and then either die or come back to the ER again. If we don’t “cure” him but simply prolong his life for a long time, he will linger in our ICU, acquiring rare and exotic infections until the day that he dies in a high-risk ID-nightmare code blue.

I am at a loss to explain why we are doing this to this man. The compassionate thing to do would be to make him comfortable until his inevitable demise. But the promise of modern medicine is immortality at the expense of quality, and so…until he has the audacity to defeat our machinations, he will remain alive.

As part of the ongoing Respiratory Care Week festivities at Sunny Flats Medical Center, the RT department has been having free lunches sponsored by various people who give us CEU-worthy lunchtime speeches. Even though today was my day off, I went in to hear the speech and get my CEU–and some freebies.

You see, the lunch today was sponsored by A Major Pharmaceutical Company. Major Pharmaceutical Company manufactures a specialty respiratory drug that is used with varying degrees of frequency here, and in an effort to boost the usage of their product they treated us RTs to a phenomenal lunch of delicious Italian foods, gourmet brownies and gallons of Sweet Tea. To further curry favor with us respiratory types,  the rep from MPC brought us toys.

I snagged myself a sweet stethoscope cover, a notebook, half a dozen pens for MPC’s various products, a magnet and a little hand-sanitizer bottle holder thing. The talk was by one of our intensivists, who was speaking about the need for better communication in the ICU to improve outcomes. He made some excellent points as far as I could tell, although I was somewhat distracted by my bag of goodies and my delicious foods.

I know there are ethical concerns about drug-company sponsored events, but frankly I like the freebies too much to be strongly opposed to drug rep lunches. Besides, it’s a free market: why shouldn’t companies be able to aggressively advertise?

More wacky medical tales to come soon.

MonkeyGirl has succinctly summed up what I think all of us are feeling at some level. In regard to the typical elderly, demented DNR patients who come to the hospital from hellish nursing homes covered in bedsores and feces because the one nurse/CNA team for 100 patients couldn’t get to them for a week:

“It is my opinion that if you cause the absolutely miserable existence of another human being to be unnecessarily prolonged against their will, you should be prosecuted for cruel and unusual punishment and should go to jail.”

Thank you! How is it any less ethical to prolong the suffering of the elderly than to deliberately kill a young and vital patient? How is it ethical to bring a 95-year-old alzheimers DNR patient with one leg and gangrenous diabetic sores on their remaining toe and bedsore you could drive a truck through into the ICU and convince their family to intubate them and prolong their life? Haven’t these people suffered enough? What is so difficult to grasp about this?

When I worked at Our Lady of Immaculate Grace way up in the Great North Woods, we had this one pulmonologist who absolutely refused to let anybody die. He seemed to have forgotten that eventually everybody would. He would routinely attempt to talk DNR patients out of their wishes, upon which he would intubate them and they would languish in our ICU for several weeks before either dying a painful ICU death or going off to be neglected in a nursing home…until they were made a DNR, forgotten about and brought back to the ER, ad infinitum. It happens everywhere. If a patient does not wish to have their life prolonged…if, in a sound state of mind, they have decided that they do not want to be resuscitated or artificially prolonged, who are we to deny them their wishes? Why would you do that?

After all: death is simply a part of the process of living. 100% of our patients are going to die, and some of them have tried to exercise some degree of control over the circumstances of that event. Taking that away from them is one of the cruelest acts imaginable. I think that it would be healthy for some people to remember that.

First: I saw the best patient ever today. She was a young lady who needed a blood gas, and not only was she cheerful and cooperative, she was absolutely charming even with a needle stuck in her artery. I was totally impressed with her as a patient and left her room smiling and feeling satisfied, an unusual occurrence. Another patient of mine had a very curious family member who was considering a career in RT, and I spoke with him for a while and hopefully was able to sway him in the direction that’s best for him. Those are two really positive, awesome things that happened today that offset the sad case of Mr. Crusty.

Mr. Crusty was encrusted in weeks worth of filth. His disgustingly large omentum was covered in fungus and dried liquids, and his toenails appeared to require the services of a professional arborist. He was, in short, totally incapable of caring for himself in any meaningful way. This had not prevented him from living alone in his own filth, where he had apparently slipped on something abominable and landed on his head on a floor covered in effluvium.

Mr. Crusty was officially a DNR patient, until the physician called his family (Crusty Junior, a few towns over) and asked them if they were OK with Crusty Senior’s DNR status. Crusty Junior was in direct violation of Geraghty’s Law of Grieving (thanks PJ), which states that there is an inverse relationship between the volume and duration of grief and the amount of love and care demonstrated for relatives in the past. Needless to say, we intubated Crusty Senior and dragged his mostly-dead, filth-encrusted butt up to the ICU.

This is a perfect example of the Hopeless Case of the Week.

What we did was to take an 80-some year old man, who stated that he did not want life prolonging measures, and perform some of the most aggressive procedures we have on him to placate his yokel family. We spent a great deal of time, money and resources to “save” the life of a man who (a) has stated that he does not want to be saved in the presence of his physician, and who (b) has absolutely no quality of life outside of the hospital. We violated his wishes to make his family happy. Not only is this a really bad use of critical care resources, it’s a violation of the implied contract between patients and caregivers, and that disheartens me.  Why did we do this? What did we achieve? If nothing else we can ask these questions and maybe think a little bit about what it is that we sometimes do to people.

Mr. Crusty is this week’s best candidate for the Hopeless Case of the Week so far.