The best beverage to drink while roofing in the middle of the day in the middle of the summer is probably not beer. Especially not vast quantities of beer chugged on the roof of a three-story building while applying hot tar in the mid-day sun. Those falls from three stories can be killer, as no doubt you have recently learned.

Water might be a better beverage choice. At least until you’re on the ground again.

Maybe I am being judgmental, but it seems to me that when you revoke Grandpa’s recent, clearly worded, clearly signed and prominently posted DNR and ask us to intubate him and place him on heavy pressors and full-on life support in clear violation of his clearly stated desires, all because “we wanted him to live to 100,” you are being a total dipshit. In fact, I’d stab you in the eyeballs over and over with a cafeteria spork just to drive home the fact that there is a special place in hell for people who do things like this.

You know, I could understand this violation of the DNR if you didn’t know he had a DNR, or if you panicked and then asked us to make him CMO once the DNR was brought to light. I could understand violating it or temporarily rescinding it for minor surgery or other procedures. There are exceptions to rules, and there are occasionally solid reasons to violate a signed and clear-cut DNR. But “we wanted him to live longer” is nothing more than a selfish, terrible reason to put someone through the uncomfortable rigors of the ICU against their wishes. I wanted my grandfather to live longer too, but nobody in my family had the unmitigated audacity to rescind his DNR and violate his wishes. No, we made the hard choice and let him die peacefully, as he wanted it. I’m sad he’s gone but I’m glad he passed peacefully in his sleep, instead of horribly in an ICU somewhere.

Your grandfather wanted to die a peaceful, dignified death. Because of you he will linger in the ICU for a few weeks before he ultimately dies of something unpleasant, painful, and expensive. There is almost nothing worse you can do to someone than to remove whatever control they tried to exert over their own inevitable death. You have ruined the last few weeks of his life, and that is an awful thing to do to another human being.

I hope he haunts you. From the grave, I hope he haunts you.

*CMO = Comfort Measures Only

Michael Jackson is still dead!

Madness gets it right with the media circus surrounding this. The whole thing disgusts me.

I think the funniest thing I heard was somebody who was saying they hoped he popped out of the casket and started performing “Thriller.”  The best comeback ever? I think CNN would shit their collective pants if that happened.

Happy fourth of July!

Just remember: Jubilation good, severe ETOH abuse and fireworks bad.

Fingers good, explosives held at arms length bad.

Happy times good, ending up in the ER bad.

Have fun. Be safe. Happy 4th!

Before I saw the living dead man, I had been optimistic about the world of respiratory therapy. Academically it sounds great: you’re helping people to breathe, and breathing is a fundamental aspect of living. If one ceases to breathe, or ceases breathing as well as before, very few things have higher priority. We half-joked in school that if you are not breathing, you will not be doing anything else either. And what could be more satisfying than aiding people’s breathing? It is an important and vital job. That attitude colored most of my first clinical education day.

Cheerfully I made the rounds, following a real respiratory therapist around and passing out nebulizers to patients who needed close maintenance to keep their lungs functional. I listened to lung sounds and was happy to hear, for the first time, real wheezing in an asthmatic in the ER. I coached patients on breathing exercises designed to expand the lungs and prevent pneumonia. I felt ecstatic at the opportunity to help people, to really make a difference in their lives. On our first round, we passed out more than a dozen breathing treatments, and I studiously made note of each one in my clinical notebook. For a few high moments, I truly felt that I was living the dream. But there was an exception coming. One thing I have learned is that there is always an exception.

The exception, that pesky and bothersome exception, was the living dead man.

The first time I saw a living dead man was at a hospital in Southern Maine. I was following a respiratory therapist on one of the medical floors where chronic patients gradually erode away under time’s ceaseless waves. He was the final patient on our first round of therapy, sequestered away in a corner room at the end of a long hallway. An ominous smell, a mix of tube feeding and plastic and feces, filled the hallway near his room. A battered metal cart stacked with synthetic isolation gowns, gloves, and eye-shielded masks was parked next to the door. Bright orange signs reading CONTACT ISOLATION: NO ENTRY WITHOUT PROTECTION were tacked to the door. From inside the room came the frantic, gurgling sound of a tracheotomy full of slime. It sounded like a monster from my childhood nightmares, breathing hard and waiting to suck me in and devour me. GGHHRR-ghrrr….GGHHRR-ghrrr…

Following the therapist, I donned the protective outfit of gloves, gown, and mask. We knocked loudly and entered the room. The wall of smell hit my virgin nostrils hard and I blinked back tears and shock. An incongruous advertisement for Clorox played loudly on the television and I caught a glimpse of the unfortunate man before me. Contorted, skeletal limbs, coated with peeling and bruised skin, were folded over a large, puffy torso that was topped with a melon-like head. A pair of panicked and pained eyes peered at out us and I was reminded of the look I‘d seen on slaughtered livestock. The patient was breathing heavily, hacking yellow phlegm out from his tracheotomy, bubbles spewing from between his lips.

The therapist, a pleasant and kind middle-aged woman, took a long suction catheter and advanced it into the trachea. A horrible slurping noise and a grimace from the patient followed, and then the plastic tubing attached to the catheter was suddenly full of yellow snot. The patient coughed one more time, my preceptor sucked the last bits of yellow from his trachea, and suddenly things were eerily quiet.

“What’s wrong with him?” I asked her as we set up for the man‘s therapy. We poured a vial of Albuterol into a nebulizer and hooked it into the man’s oxygen collar.

“He had a stroke…family wanted us to do everything, so here we are. He was in the ICU for months before he got the trache.”

“Will he get better?”

“Sometimes, stroke patients get better. This time probably not. It was a big stroke. He can’t do much.”

“What will happen to him?”

“He’ll probably go to a rehab center or a nursing home, but long-term, this is probably how he’ll be. Probably he’ll end up with a bad infection and then come back here and pass away.”

We finished our treatment, and the man stared off into the middle distance, the same look of horror on his face that he’d had when we came in. This was his life, day in and day out; tube feedings and colostomy bags and the endless fountain of mucous from his tracheotomy tube.

This whole scenario bothered me. What kind of cruel joke was this? Were we seriously going to prolong this man’s suffering, delay the inevitable? Was I actively participating in the extension of suffering? Our job as respiratory therapists is to help people, not to torture the dying and prolong the misery. I was confused. I was frightened. My head was spinning. I could not fathom a life in bed, a life without speaking, a life without moving, a life spent staring into the middle distance listening to Clorox commercials as clinicians tried to slow the inevitable decay of my body. Being alive but with no control and no voice seemed like a veritable hell on earth to me. I tried not to think about him much, but he haunted me and as the day wore on I kept seeing his horrified eyes staring out into space. I pondered his fate and asked myself what kind of people could put a man through that kind of suffering instead of letting him die.

Later that day, we encountered his family, a large group of old Maine Catholics. They seemed to be nice people, but I couldn‘t face them. All I could think was that his family either hated him or had advanced to a state of pure denial. It bothered me, and I couldn’t look at them. It was my first encounter with the dark side of modern medicine, and it was the first time that I ever asked myself: is our help just hurting this man?

If only the Iranian police had killed Michael Jackson, maybe the world would pay more attention to the travesties going on in that formerly great nation.

That is all.

“I’d be really happy that we made so much progress on this guy today if it weren’t for the fact that, when he does get better, he’s just going to go out and fuck himself up again.”

Sometimes, it seems like we’re more in the business of prolonging the inevitable than in the business of saving lives. All the albuterol in the universe won’t cure someone who has a 180 pack-year smoking history. The most amazing ventilator in the world won’t cure cancer. And all the respiratory care in the world won’t cure stupid.

What really gets me is the absurdity of what we are often asked to do. Many times physicians have said things to me such as, “This man has lung cancer. I’m going to start him on Q4 albuterol.” I have some terrible news for these optimistic physicians, but albuterol does not have tumor-shrinking properties, and all the bronchodilation on earth won’t shrink the baseball-size mass that’s crushing this poor patient’s airway. To even order such a ridiculous treatment is totally absurd. It does nothing to treat the root cause of the problem, and will do nothing to alleviate the symptoms of lung cancer. Don’t get me wrong, I feel bad for the patients, I really do. But these treatments are useless.

Another absurdly overused therapy, at least where I work, is volume expansion. “Give everybody a therapep and an EZ-PAP!” is the mantra here. Giving a COPD exacerbation an EZ-PAP seems sort of silly to me. Most of them tell me it makes them feel worse, and they can’t take the treatment as well. We’re losing ground. Fools!

Ah, well. It pays the bills. Off to revel in the absurdity for a weekend.

Headline 1: MICHAEL JACKSON DIES OMG

Headline 2: N. Korea says will nuke US if provoked

Good to know where our priorities are.

Got a patient in the ICU from the nursing home the other day. One leg, out of her mind, decrepit, pitiable…as are many of the unfortunate patients we receive from the homes.

But this one was different. She was only 45.

She was also positive for benzos, cocaine, and marijuana.

I don’t know what nursing home she came from, but damn, I hope I can get that kind of hookup if I ever have to go to the home. I imagine the ol’ nursing home routine is a lot more exciting when you’re jacked up on coke or tripped out on acid.

“Some people may call me a bad parent for not having my children vaccinated. Other people may call me an irresponsible asshole. But personally, I don’t see why I can’t be both.”

The Onion on anti-vaccinators.