Respiratory Therapy 101: Just Keep Breathing

I know this isn’t a political blog and as such I apologize for this, but the sad truth is that life in RT land has been unusually quiet lately. It’s creepy. I suspect that an entire busload of end-stage COPD patients is coming to town to have a tour of the methacholine factory or something…there’s no way that this sort of sustained un-busy-ness can last.

Anyway. I was reading The Dilbert Blog earlier and Scott Adams summed up our choices for the fall election very nicely:

When it comes to picking our next president, I can’t decide if I prefer the smooth-talking, inspirational candidate who promises to give my money to people who don’t work as hard as I do, or the old, short, ugly, angry guy with one good arm who graduated at the bottom of his class and somehow managed to shag a hot heiress and become a contender for president. It seems dangerous to underestimate that guy.

Yeah, I’m not thrilled. I guess all elections are the lesser of two evils, but this one is especially uninspiring.

It turns out that sometimes, fungi are extremely useful. First we had Penicillin; now we have Lodamin, which is a promising new cancer drug stemming from an accidentally discovered fungus and some nanotechnological manipulation. Reuters reports:

WASHINGTON (Reuters) - A drug developed using nanotechnology and a fungus that contaminated a lab experiment may be broadly effective against a range of cancers, U.S. researchers reported on Sunday.

The drug, called lodamin, was improved in one of the last experiments overseen by Dr. Judah Folkman, a cancer researcher who died in January. Folkman pioneered the idea of angiogenesis therapy — starving tumors by preventing them from growing blood supplies.

Lodamin is an angiogenesis inhibitor that Folkman’s team has been working to perfect for 20 years. Writing in the journal Nature Biotechnology, his colleagues say they developed a formulation that works as a pill, without side-effects.

How cool would it be if one of the most promising new cancer treatments in years came about as a result of a fungal mishap?

Things around here have been…dare I say it?…quiet lately. In fact, apart from an exponential worsening in hospital politics over the last three or four weeks, things have been disturbingly un-hectic. I have no new stories and no new thoughts to chew on. It’s sort of unsettling.

On another note, today’s Dilbert accurately sums up pretty much everything that’s been making hospital politics worse over the last couple of weeks:

Head on over to The Respiratory Therapy Cave to read about a great charity for sufferers of ChILD, Childhood Interstitial Lung Disease.

More later.

As part of this weeks Change of Shift I have been asked to assemble an article about RTs: what we do, how we think, and how we can improve our interactions with nursing. First: what RTs do!

Respiratory Therapists are usually responsible for all aspects of breathing-related care. In many different areas, we assess the respiration of patients with a variety of diagnostics and treat their disorders with a plethora of therapies. Among our arsenal of skills for assessment: auscultation of the lungs, examination of chest x-rays, sampling and interpretation of arterial blood gases, minor pulmonary function tests like vital capacities and peak flows, and full-blown pulmonary function tests in the laboratory. We also do homecare and work in sleep labs, two closely related aspects of our field.

In addition to applying our crazy assessment skills, RTs are responsible for all kinds of therapies to assist respiration. We give patients bronchodilators, perform chest physiotherapy, and work with patients to train them with various breathing exercises. We run BiPAP machines, both as critical-care machines and as sleep-apnea management systems. We manage mechanical ventilators, the machines that breathe for people when they are incapable of breathing. We intubate patients to manage their airways. We perform CPR. We assist physicians with placement of tracheostomy tubes. If there is something we can do to make a patient breathe better, we will do it.

Moving to thought. To understand how us RTs think, it is important to remember that our job focuses on what we perceive to be the most important bodily function: respiration. It has been said that if you are not breathing then you are not going to be doing anything else, and this is very true. Breathing is one of the few body functions whose immediate cessation will lead to death.

Seeing things through this lens helps us to arrange our priorities. At the top of the list are people who honestly, genuinely can not breathe. A 55-year-old patient having a severe COPD exacerbation will require our immediate attention, while a 22-year-old in for a bunionectomy who “needs incentive spirometry” will be at the very bottom of our lists. In short: the greater the likelihood of a severe derangement in respiration, the higher the priority on our lists. RTs typically take much higher patient loads than nurses, anywhere from eight or ten ICU patients to twenty or thirty medical patients on the floor. Balancing the demands of caring for so many people appropriately keeps us busy.

Now: how can RTs and nurses better relate?

I think that the first part of this is understanding one another. Too often, nurses will become irate with RTs for various reasons: the RT was “slow,” they were argumentative, or perhaps they were just blunt. RTs become irritated with nurses for similar reasons: the nurse won’t leave me alone, the nurse wants something pointless, the nurse is just demanding and rude. If not resolved this kind of acrimony leads to bad teamwork and affects patient care.

The key to getting around this is to consider the viewpoint from the other side. RTs, remember that when a nurse calls you, nine times out of ten they are calling because they feel you can do something good for their patients. Sure, there are nuisance calls (stat incentive spirometry or albuterol treatments on a fluid-overloaded patient, for instance) but most of the time when you are being called there is a reason or a way you can be of assistance. Take a deep breath, smile, and focus on assessing the patient.

And nurses, consider the RT. When you call the RT and they’re blunt, perhaps they are simply harried and being pulled in a hundred directions at once. When the RT is arguing with you, listen: we will not withhold care we feel is neccesary, but we also do not want to perform unindicated therapy because it usually means that the therapy the patient really needs will be delayed. If the RT is slow, remember: you feel busy with five patients and we often carry twenty or more on the medical floor. The bottom line is communication: speak clearly, politely, and concisely and actually listen to the other party. It is amazing how much better things run when people communicate.

So that concludes the Nurses Guide to RTs. We RTs provide valuable care to patients through our superior knowledge of cardiopulmonary function and our ability to treat pulmonary dysfunction. We aim to be a “breath of fresh air” and I think we do an excellent job. The bottom line is that nurses need RTs just as much as RTs need nurses, and if we all make an effort to cooperate and communicate we can improve lives and help people breathe. And really, that’s what it’s all about.

Question: How do we know what we know?

Answer: We don’t. In fact, we’re not even sure that we know we don’t know. But we don’t know what we don’t know, and we often know a lot less than we think we know about things we think we’re pretty sure of. In other words, realistically speaking, we’ve just been living based on a lengthy series of lucky guesses that have informed a whole set of habits that have been subject to heavy scrutiny but which nevertheless will almost certainly be proven wrong within a few short years. But I really have no way of knowing that.

Epistemology. This is the kind of crap I think about when I’m not at work or otherwise occupied. I don’t know about you, but I take a certain amount of comfort from knowing that within 100 years more or less everything I know will be wrong. Taking the long-term view like that sort of removes the pressure and helps me move contentedly along.

Recently my hospital experienced a flood of gunshot victims in the ER. Apparently, one gangster approached another and made some unkind statements about his mother and his old lady. Gangster II apparently was not interested in verbal confrontations, whipped out a pistol, and shot Gangster I. In broad daylight in public with no fear.

This of course set off a spiral of gunshot victims, people run over by cars, and other gang-related violence. Our ER was flooded by these ignorant piles of wasted carbon; we got four or five gangsters in the ER in about forty minutes.

I don’t know if it’s just me or what, but I have zero sympathy for these people. If you make the decision to go into the gang lifestyle, if you make the decision to become a part of that violent and lawless society, you need to pay the price. I understand that sometimes people see no other option than to join up with the gangs, but that is a problem for the police and the social workers to solve, not the ER. And when somebody is injured in the pursuit of lawlessness I fail to see why the hospital should be forced to treat them for problems that are essentially their fault and eat the bill for it.

I mean, really. These gangsters are 100% worthless. What we need to do is to stop saving their useless asses and let them die. Treating them is futile. One of the GSW victims that we got was combative and threatening to the ER staff who were trying to prevent him from dying. I ask you: why should we bother? Why fight with him when he’s going to be a total asshole to everybody, a potentially violent asshole to boot? Every now and then you’ll hear some inspiring tale of how a gangster turns their life around and does something useful, but that’s the exception more than the rule.

I know that some whiny person out there will hit me with but every human life is precious blah blah blah, but I don’t buy that argument. Most lives are precious, sure; but the life of somebody who is willing to kill somebody simply for wearing the wrong color bandana is neither precious nor worth the financial resources it takes to care for them. These people are violent, dangerous, felonious thugs who not only harm other gangsters but who occasionally harm innocent human beings for no reason. Why would you even want to save them? I know that I don’t. I treat them like any other patient because I have to, but if I was allowed to choose, I would outright refuse to do anything for them. Heartless? Maybe, but sometimes you need to fight fire with fire. Showing compassion or anything other than contempt for their existence is only going to mark you as someone they can exploit.

I say, leave the gang-bangers in the street. Let them kill each other, and maybe when they see that we’re not going to resuce their worthless asses, they’ll either shape up or die out. Either outcome is fine with me.

My apologies to those of you who work in the wonderful world of Anesthesia, but this is just too funny not to post. To give credit where it’s due I come by this originally over at Ambulance Driver’s Place. Watch and enjoy!

I deal with a lot of head and brain injuries at work. They are many-faceted creatures. They intrigue and terrify mt all at once. The intrigue lies in the fact that one never knows exactly what to expect of a head injury; the terror lies in the fact that I see myself as one firm whack to the noggin away from being the drooling vegetative empty shell of a human being in the bed.

Lately I have been wondering, what do people do after a severe head injury? I mean, the patient usually go to rehab and sort of try to work back into reality, but what do the families do?

Recently we had a case involving a newlywed couple. They had been married for all of three months when they went out one evening to a club. On returning home the wife realized she had forgotten something at the club and the husband gallantly dashed off up the road to get it on his motorbike.

When he pulled out of the club, he lost control and was thrown from his bike. He whacked his noggin pretty good and got some severe lung damage in the process. He was in the ICU in a drug-induced coma for almost eight weeks before he was well enough for us to wake him.

When he awoke he was…different. The anoxia, the drugs, the trauma to his brain; all of them had combined to alter him in significant ways. He lost a lot of emotional control and a fair bit of cognitive function. He became a frightened child in a thirty-year-old body. In short, he was no longer the same man he had been. He could no longer joke around with people, understand complex things, solve complex problems. He could no longer control or damp his emotions when he needed to.

He was a very different man from the man that his wife married. How far does “better or worse” go? How do you react when someone you love is no longer the same in such significant ways?

Eventually the patient moved back to his homestate with his parents. I don’t know and I probably never will know what became of his wife. But I wonder…what do you do? If my wife was involved in a serious head trauma and was totally different when she awoke, what would I do? Would I be strong enough to stick it out through the rehab and the misery and the change?

Somehow I doubt it.

We recently had a young girl in our ICU. She had been involved in a terrible motor vehicle collision and she was mangled beyond belief. Her skull was partially removed to let the brain swell, giving her head a grotesque misshapen look. Her head was shaved and her face was lacerated from windshield glass. Her body was wasted from weeks and weeks in our ICU; her eyes were shut and had not opened since her arrival at the hospital. She was clenched up in a bizarre pseudo-decorticate posture, arms and legs stiff and clenched in between our rumpled ICU blankets, head slumped in a too-big Aspen collar full of neurological drool. Looking at her was unpleasant at best and horrifying at worst. She was destroyed.

Her family brought in a photo of her and pinned it to the wall over her bed. It was a headshot, presumably a senior portrait for her high school yearbook. In the photo she was beautiful: long hair, a nice smile, eyes bright and full of life.

One day I found one of our ICU nurses staring at the picture crying. Seeing an ICU nurse cry is like seeing Rambo picking flowers. I stopped and asked her what was wrong.

She took a deep breath and sighed.

“I hate it when they bring in pictures,” she told me, ” because it makes them seem more human.”