A good feeling for a humble RT

On the technical side of being an RT, one of the greatest joys is when you intubate a patient, and set up a vent based on your protocol and experience and common sense, and then you tell the doctor what you did and why.

"That sounds great," the doctor says. "Just try to keep the EtCO2 around 30."

Awesome, I think. So I titrate the rate and title volume a bit until that EtCO2 is just where the doctor wants it, and then turn down the FiO2 until the SpO2 is no longer 100%.

This is how it should be. This is awesome.

Tonight when I learned that a bad baby was coming to our ER, and the nurse told me how much the baby weighed, I grabbed my little cheat sheet and knew, based on our protocol, that I needed a 3.5 ETT and that it should be positioned approximately about 9-10 at the lip.

Once the doctor was done intubating, I said, "I think it should be 9-10 at the lip."

"No, I want it at 12," she said.

I listened for lung sounds and told her lung sounds were diminished on the left. She pulled it back to 11. "I don't want to pull out any further," she said. "Let's secure it right here."

Later, after we had secured that little tube with tons of sticky tape, the doc looked at the x-ray results. "Well, I think we need to pull it back to 9 or 10," she said.

I couldn't help but smile. She knew I was right.

A good feeling for a humble RT.

She slipped and dropped her baby

Somewhere I read that one of the biggest fears of a parent is accidentally dropping a baby. Unfortunately, that fear sometimes becomes reality, as I learned tonight.

It was difficult to get all the details from the upset mother, but she said she fell and her 2-month-old baby was tossed into the air, landing on his head. CPR was started and the baby was rushed to the hospital.

By the time the baby was in the ER, it was breathing fine, but it had occasional episodes of apnea. And it was relatively limp, and occasionally it would let out a cry. It would also cry to painful stimuli, but it did not fight otherwise. It was pale and just didn't look good.

I already had a #3.5 ETT ready to go, but the baby WAS breathing with an SpO2 of 100% on room air, so I just stood by. I humbly watched as the nurses and the DR. struggled to put in an IV, and then I watched as the doctor screwed in the inner-osseous port. I had learned about this in ACLS last fall, but had never seen it done.

The baby needed an airway, so we intubated. It was a very smooth operation, considering none of us work with baby's as often as we work with adults. But thankfully we have our bi-annual check offs and reviews of such a situation JUST IN CASE.

Today, the JUST IN CASE became real. It was really sad when the mom came in. She was a wreck, and understandably so. I have no idea how I would react if I would have dropped my baby. I might just be a wreck too.

But, as a member of the medical team, we couldn't let emotion effect us. It's neat how cool and calm we can be while we work on someone's limp baby. It was sad. But we had a job to do, and we did a great job.

We stabilized the baby, and within 45 minutes he was on his way to Big City hospital. That's what we do here. We stabilize and ship. We do whatever we can to give a sick baby a chance.

We never had time to do a cat scan. Perhaps a head bleed?

Because of Hippa, though, we may never get an update.

I'm not in the business of criticizing a young mother, especially because this very easily could happen to anyone.

Still, this is a reminder that we should never take these fears of dropping a baby for granted.

The saga of the 99-year-old man: part 2

I thought I'd take a moment finish my saga of the 99-year-old man I started last Friday. Of course you guessed correctly that he got admitted and was ordered on Q4 breathing treatments. You know the rule: being over 90 is an indication for bronchodilator.

But he was so combative it took four or five of us staffers to hold him down. We are no longer allowed to use restraints because someone decided it's inhumane (even though the patient has no clue where he is), so we had to do this often during the course of the night.

So, I had to give him a treatment. I didn't want to, nor did I think it was indicated, but to be politically correct, I had to at least try to do it. So, while the patient was sleeping, I snuck up from behind him and plucked out the bag part from the mask and...

... it woke up with a vengeance. He leaned forward and clenched the corner of the mask in between his yellow dentures and growled at the full force of his lungs. He made me think of a Lion at full charge. I came within a millimeter of him actually biting my finger off, which I think this man was fully capable of doing.

And his arm flailed up and barely missed my head, and the only reason he missed was because he was swinging blindly, because he was not of his right mind. Well, I suppose he was probably blind to boot. But that's beside the point. I had to use all my muscles to hold this man down, and as I held his hand, he squeezed with the might of a 24-year-old athlete.

He tried to dig his long fingernails into my flesh, and I did everything in my power to prevent this. I even tried to escape his grasp, but I couldn't. I tried as hard as I could, but this 99-year-old out to lunch man had the strength of a bull, and now had me trapped.

However, moments later, while he was still screaming at the top of his lungs, he forgot about me and let go long enough for me to slip the neb into his mask and then he fell asleep. So, after all of that, after showing all of us in the room how strong his lungs were, he still got his full dose of Ventolin whether he needed it or not.

Now, let us fast forward two hours. The patient's nurse asked me and the other nurse in the CCU to assist him in repositioning the patient. We all knew this was not going to be easy. The patient, every time he had been awake all night, screamed at the top of his lungs, keeping all the other patients awake.

So, when I walked into the room, and this 99-year-old man put his arm out in my direction, I flinched. My co-workers laughed at me, but I was very leery of this old man. But brave as I was, I took his grip and, instead of digging into my palm with his nails, he provided a firm grip and he smiled at me.

Then he appeared to pucker his lips and was saying something I couldn't understand.

"He wants to kiss you," the patient's nurse said.

He was right. So, what was I to do? I provided him my hand to kiss. I touched the back of the mask with the back of my hand. "No. No," he chanted, as he made a feeble effort to pull the mask off.

It occurred to me then that he wanted more than just the back of my hand through on the mask, he wanted to kiss my hand. So I offered him my hand to kiss, which he did. But he wanted more than just my hand, he wanted to kiss me on the lips. So I pressed my cheek up to the mask. But he was not satisfied with that, he wanted to kiss me on the lips.

"Ativan does wonders," the nurse said. "It's the true miracle drug."

"Yeah, I see," I said.

"Well, we're done. While you had him side tracked, we did our job. So, now you have to make him happy and just let him kiss you on the lips."

I looked at the man, wondering what his life was like. I will never know what he did during the course of his life, whether he was married, happy, or whatever, but I do know that he did something physical, and was very fit.

And he was a fighter at times, and a lover at times.

The saga of the 99-year-old man: part 1

I gave treatment before I went home Thursday morning to an obtunded 99 year old patient who was wheeled into the emergency room with a non-rebreather plastered to his face. I was informed by the nurse the patient was from a local nursing home and was having trouble breathing.

"We are definitely going to need a breathing treatment on him, Rick," Julie, the patient's nurse told me, "he already had a Duoneb in route." They gave this guy a treatment enroute? Why?

Exhausted after perhaps one of the worst nights on recorded memory, one where I did 12 breathing treatments in the emergency room (two of which were indicated) and 12 EKGs in one four hour span while having a nursing student at the same time, I had long lost my ability to just keep my mouth shut and do what I was told.

So I let the nurse know what I thought about giving a treatment to this guy: "Looks more to me like he's in renal failure or is septic or something like that," I said. "More than likely he's probably wet."

I did an EKG, assessed the patient, and decided the patient did have no signs of bronchospasm. More than anything, he looked like a strong 99-year-old who had had a fulfilling life and was now ready to cross through the pearly gates to meet his maker.

So, after doing the EKG, I went upstairs. "Screw that nurse and her breathing stupid treatment," I thought to myself as I exited through the double doors and out of the emergency room. "I have patients upstairs who actually need treatments."

You guessed it, I as much as made it to the patient floors and was called back to do the treatment. What the, "I wanted to say hell here, but somehow managed to refrain myself as the doctor was standing right next to me, "the heck does he need a breathing treatment for," I grumbled. Honestly, though, I didn't mean to sound grumpy, but the exhaustion and burnout had raped me of my ability to control my cadence.

"Well," the all knowing nurse said, "He's short of breath."

You see, this is what's wrong with the medical field. Instead of actually assessing the patient, and knowing the indications for bronchodilators (for which all my blog readers know I am sure), some nurses think every patient who's short-of-breath needs a breathing treatment, including those patients, like this 99-year-old, who are in respiratory failure secondary to a metabolic problem.

I just want you guys to know that most of the time I an equanimitous guy who does what he's told and keeps his mouth shut and feigns a smile and grumbles to himself instead of verbally releasing into the atmosphere his frustration about an unnecessarily ordered procedure. For the most part, I have a mission to be happy and get along with everyone.

The nurse, who more than likely knew full well how miserable of a night I had (because her night was equally miserable) did not say anything back to me like, "This treatment is too indicated you stupid useless RT who thinks he knows everything." Nope, she did not say that.

And I'm glad she didn't, because I just wanted to go home, refuel and collapse. And, after I finished doing that breathing treatment, the nurse was preparing to insert a syringe into the patients newly inserted IV. I smiled and said, "Well, you don't have to give that," Julie.

"Why would that be?" She looked up at me and smiled. She knew what was coming.

"Because my Allbetterol mist just cured him of all his ailments."

She proceeded to smile and pushed her med.

I didn't tell her this, but also tossed into this mixture some Reserectolin to ease this patients transfer across the pearly gates, and some Waytoolateolin to ease the suffering of the nurse.

For more information on Waytoolateolin or Toolateolin check out this link. If you want to know more about Resurectolin, check out my list of 'olins at the bottom of this blog, of which I will update right now.

Oh, and I forgot to inform you guys that this patient was also a full code. Perhaps that will help you to understand my RT frustration a bit more.

(Note: I will continue the saga of the 99-year-old full code tomorrow.)

Monday's class: My response to your queries

This post is my weekly attempt to answer Internet search engine queries that lead someone to clicking onto my medblog.

Of the 500 queries in my stat counter's memory, I have picked some of the most interesting queries. Keep in mind I do not answer queries if the page the person landed on would have provided them with an appropriate answer.

Yes, this is supposed to be my Monday feature. For now on it will be. We'll also have class on Tuesday and Wednesday as well starting next week.

Here we go:

1. copd patient with left side chest pain: The emergency room staff would treat this as cardiac related until test results show otherwise.
2. What year was Albuterol invented?: I had to look this up. According to Wikipedia, "Salbutamol became available in the United Kingdom in 1969 and in the United States in 1980 under the trade name Ventolin." I never knew about it until 1993.
3. what's it like to be a respiratory therapist? It's rewarding knowing that your skills saved a life or improved someones breathing. We also get to share our vast respiratory knowledge by educating our patients about their respective disease process, and how to live with their illness. We spend a lot of our time going room to room doing breathing treatments that help patients breathe better. I've met a lot of neat people and have had many great conversations doing this. Another part of the job is taking care of critical patients, maintaining their airway when needed and, if necessary, setting them up on life support. This, in my opinion, is the most rewarding and challenging part of the job.
4. Duoneb croup: First of all, croup is caused by a virus, and typically only effects children. It causes swelling of the smooth muscles of the upper airway above the vocal chords, and, as the child is breathing in, you will hear a harsh sound we refer to as stridor. The child's cough may sound like a bark. Duoneb will not benefit croup. However, if there is an underlying bronchospasm component (asthma) along with the croup, Duoneb will relax the lung muscles and make it easier for the patient to breathe. Usually for croup we use a cool mist aerosol to try to relax the muscles of the throat, or, if necessary, we give a racemic epinepherine treatment. Sometimes this works, sometimes it doesn't. For the most part, whether this is used depends on the doctor's preference. The Racemic Epinepherine will relax the smooth muscles in the lungs, but theoretically it will also relax the smooth muscles in the throat, which is what is causing the croup, and is why this is usually the aerosol of choice for croup.
5. Albuterol potassium: Albuterol can lower potassium if it is given excessively. If you use it as prescribed it should not lower your potassium. This, however, is something that should be watched when a patient is receiving continuous breathing treatments in the hospital setting, and might be a good reason not to overuse your Ventolin inhaler at home.
6. nursing home respiratory therapist: Currently, Medicaid won't pay for an RT in the nursing home in Michigan, but I'm not sure about other states. However, before the law was changed, I did work in a nursing home for a while. It was a very slow paced job where pretty much all I did was breathing treatments and incentive spirometers -- lots of incentive spirometers. Occasionally I'd be called to assess a patient in distress, in which case I'd usually recommend sending the patient to the hospital.
7. still use mist tents: Not at my hospital. We hid them in the basement where they are currently collecting dust. We find that it is better for the patient, the parents and the hospital staff to simply use a pediatric nasal cannula if the patient needs oxygen. If a patient needs the mist, then we simply set up a cool mist aerosol. However, I've only done the later in the emergency room.
8. nebulizer for cough spasm: Sure. You can try it. If there is an underlying bronchospasm component, a nebulizer with Albuterol might help.
9. copd sucks: I imagine it does. However, there are many things you can do to help you cope with this illness. Click here for a good article on coping with COPD. Or click here to check out what the COPD doctors and scientists at National Jewish Medical and Research Center have to say about coping with COPD. And here is a good blog of a COPDer who has written many great posts on how to cope with breathing illnesses.
10. asthma attack every 2 weeks: If you are having an asthma attack every two weeks, then you should definitely be on some preventative medications, and you should learn what triggers your asthma and how to avoid them. There is no cure for asthma, but there is no reason why any person in today's world should'nt live a normal productive life. For more information you can check out this link. Another good link for asthma information I will link to right here. You should fully educate yourself about asthma and talk to your doctor about how best to manage it.
11. oxygen weaning protocol: I've never worked at a hospital that doesn't have one. We are allowed to wean oxygen to maintain an SpO2 of 92% or greater on any patient ordered on our oxygen protocol or ventilator protocol, which would include most of our patients. If the oxygen does not stay above 92%, we may increase oxygen to whatever the original order was. However, if a patient suddenly needs a lot more oxygen, say from room air to a 50% venti mask, common sense dictates that a doctor should be notified.
12. Respiratory therapy stories: This would be a good idea for a post. What is the most exciting thing that ever happened to you as an RT? Or what was the weirdest thing you ever saw? I had a an end stage COPD patient once who was extremely short of breath and she shouted, "I JUST WANT TO BE WITH THE LORD!" She did right then.

Keep in mind I receive hundreds of queries a week, and I am limited in space on this weekly column.

If you have a question I have not addressed here, or if you want an answer right now, feel free to contact us anytime and we'll get you an answer ASAP. You can contact us at Freadom1776@yahoo.com, or RTcave@yahoo.com.

That concludes today's class.

The student who was told he would fail as an RT

There was a RT student about 13 years ago who was told he wasn't going to make it as a respiratory therapist. What made this particularly distressing to the student was that the person telling him this was one of his RT teachers

The incident that lead up to this encounter with his teacher occurred during his first clinical rotation as a student. This was actually supposed to by his oxygen rotation where he was to learn about oxygen and oxygen rounds, but was also allowed to do treatments if his preceptor felt he was ready.

After he had followed his preceptor, an elderly choleric lady named Ellen, around for two rotations, he was finally given his own assignment of doing oxygen rounds on his own, and one patient to give a breathing treatment to.

This seems like a simple assignment to any seasoned RT, but it could be quite daunting to new student. And, once he was set free by his preceptor, he set out to do his oxygen rounds. He was so determined to do a good job, and so intense in concentration, that he forgot about the treatment.

Several hours later he was feeling pretty good about another good clinical day's work. He listened as Ellen gave report on her patients, and thought nothing of it at first when she paused and looked at him.

"You give report on this person." Ellen pointed at the student.

"Who?"

"You were supposed to do a treatment on this person right?"

"ummm... Gulp!

The next day Ellen watched the student like a hound as he did his oxygen rounds, and later as he did ALL of her breathing treatments. She stood behind him so close as he put together the nebulizer that he felt faint by the rancid odor of her breath, and this made him nervous, and he fumbled immensely.

It's not that he couldn't do treatments either, because he had asthma his entire life and gave himself treatments at his home when he needed them. Such a choleric person might have caused stress on a seasoned RT, let alone a new student.

And, after he finished doing ALL of her treatments and had returned to the RT Cave at this hospital, the RT student felt a sense of joy as he knew he would be going home soon. He actually felt good about what he had accomplished. He was bound and determined not to be swayed in his desire to be an RT by this evil woman.

Yet, just as he thought things were starting to go well, and just as he thought he was going to be able to rest a bit, Ellen plopped an oxygen tank in front of the RT student and gave the student a petulant glare that would have caused an experienced RT to stay away. But this student had no such option.

"Turn that on and off and on and off again," she growled. The student looked at her. Are you joking?

She did not blink. The corners of her lips moved just slightly, and he thought for a moment her face might crack. He thought he might turn to stone by her wicked glance, but unfortunately he didn't.

Instead, he plucked the key off the top of the tank and fumbled terribly in his attempt to do this simple task. It was as though that cantankerous old RT had a spell on him.

The next morning at school the RT Student was called to his teacher/clinical coordinator's office. Oh, boy, he thought, Here we go.

"Student, grades aside, I'm not sure you have the personality to make it as an RT. You just don't have the bubbly, outgoing personality like the other people in this class."

His heart skipped a beat. Okay, what's coming next? I can take it. I'm out of the program aren't I?

"The people you worked with at Happy don't think you are capable of being an RT. I know you're new at this, so we're gonna give you some time. But, I'm not quite sure about you at this point." He paused and stared at the paperwork on his desk, then looked at the student. "We'll see."

Fortunately, that RT student never had to follow that witchy preceptor again, probably more so because she refused to work with him than anything else. But the other preceptors weren't any better the rest of that six week clinical.

And, likewise fortunate, every six week rotation was at a different hospital, so he was exceptionally happy that his next assignment was far, far away from the wicked withch of the west. And everything went perfect from then on, well, aside from the few bumps in the road.

And, a year later when he applied at the hospital of his choice, one of the RT's from the hospital, we'l call her Tara, where he did his first clinical just happened to work there. And she was not nice to him. Right off the bat she put in a bad word about him, and she recommended he not be hired because "he's incompetent."

Fortunately, he had made a far better impression at his later clinicals, and had made some great friends along the way. And, despite the bad word from that one RT, he was hired.

And while all the other RTs at this new hospital were great, that one lady was just as bitchy as Ellen. This student love his new place of employment. But Tara continued to bad mouth him. It got so that the now former student was only scheduled to work when Tara wasn't working.

Then one day Tara quit because she couldn't handle the workload of working at a small town hospital. Things get pretty hectic sometimes.

You see,he was bound and determined not to let one stupid mistake, two cows and one teacher's comments stand between him and success. If anything, these people lit a fire under his butt.

That was more than ten years ago, and now I'm still here working as one member of an elite RT staff. That's right: I am the student who was told he would never make it as an RT.

Now you know the rest of the story.

A world where doctors are trained by RTs

I wonder sometimes what the job of RT would be like today if doctors were required to work a day as an RT as part of their doctor training.

If we had RT doctor students, then we'd most definitely need a doctor RT student lounge, and in that lounge we'd have to have a bed and a TV for the doctor students to enjoy between passing out peace pipes.

BEEP.

Knock-knock.

"Wake up, you doctor student," Larry the RT said, "we gotta give another neb to Mr. Edgington."

"Wha...hugh..." The doctor smacked his lips together, rolled over, and snuggled back up under the blankets.

"Come on!" A sound of knuckles rapping on a wooden door. "Get out of that bed; it was ordered stat. Doc. student, come on! we gotta--"

"All right, all right... I'm coming." The doc. student swung his feet from under the covers and sat on the edge of the bed. His eyes were still glued shut. "The nerve of them stupid bla bla ordering more stupid bla bla treatments. When I become a doctor--"

"Yeah, that's what the last generation said. Come on!" He held the door and motioned for the doc. student to follow. Very, very slowly the doc. student managed his way to his feet. He opened his eyes, blinked several times to get used to the light, and followed the RT.

"I just want you to know," the RT said as the duo rushed down the hall, "Is this is one of my favorite patients. He's one of the coolest guys I've ever met."

"Really," the doc. student said.

Upon entering the room the RT observed a patient sitting on the edge of the bed facing away from the door. On a table by the window he saw a comode, and he watched as an elderly nurse replaced the tray of the comode, and rushed past the doc. and RT, into the hall, disappearing around the corner. The smell of bowel was redolent in the room.

The RT walked around the bed and faced the patient.

"You got like this because you went to the comode, hey?"

"Yep," the patient ghasped. "The usual." He was leaning on an end table like short-of-breath COPD patient are famous for, and had his shoulders hunched. While he looked like a COPD patient, the RT knew this patient also had an extensive cardiac history. He was got this way, he knew from experience, not due to bronchospasm, but due to his heart.

"You're a little wet too, I bet," The RT said.

The patient coughed up some of the wet stuff from his lungs and swished it in his mouth. He grabbed a tissue with one hand from a small box and hacked up a good one, but the sloppy wet, white secretions was overwhelming for the cheap tissue paper, and dribbled down his chin and onto his gown. He made no effort to clean his mess.

The doctor student plucked a pair of rubber gloves from a box on the wall, and slid them with some difficulty onto his large hands which, the RT thought, were probably too big to perform small operations. But, then again, what do I know? The doc. plucked several tissues from the box, and cleaned the slobber from the patient's chin.

"Thanks," the patient snuffed between breaths.

"We're going to give you a breathing treatment," the doc. said. The RT observed a bit of sarcasm in the doctor-to-be's voice, but he ignored comment on that as he observed the subject, who was obviously pale, drenched in sweat, and had audible rhales that could be heard across the room. He was laboriously breathing for sure. "Go ahead and listen to him.

"What the heck do I need to listen to him for," the doc. student grumbled. "It's obvious he's wet. What he needs is some Lasix and to pee."

"Um," the RT patted the doctor-to-be on the shoulders. "Doc. student, just do as you're told. If the real doctor orders a treatment, then it's a treatment the patient needs. What's so hard to understand about that. What this patient needs is a breathing treatment. One vial of scrubbing bubbles and the patient will be cured in an hour."

"Oh, come on," the doc grumbled as he put together the neb and squeezed a vial of Scrubbing Bubbles into it. "We've done 20 treatments tonight, and about 5 of them have been indicated. I could be in dreamland right now, instead my feet are killing me."

"Did you look at that vial you just poured in. You certainly don't want to give Xoponex when Scrubbing Bubbles is the ordered medicine."

The doc. student rolled his eyes. "Yes! What do you think." He closed his lips tight and concentrated intently on his task. You're mad aren't you. This oughta teach you to order useless therapies when you grow up.

"I could be sleeping." The doctor placed a mask over the patient's face that was connected to some O2 tubing, which the doc. pluged into a flowmeter on the wall, and turned up the flow on the flowmeter. The nebulizer spun to life, hissing. The magic mist instantly filled the mask and billowed through the holes in the mask into the room. Heressed his fingers around the patients wrist and stared at his watch.

The Rt laughed to himself as he stepped around the bed and stood by the door. "Doc. student," he said, smiling, "There will be plenty of time for sleeping on the job when you become a real doctor. You should just be happy our bosses let you practice for that part of your job with that bed in the student doctor lounge. If it were up to me you'd have to stay suffer with staying awake like us RTs and RNs have to."

A fresh, sweet smelling breeze suddenly wafted over the RT as a pretty young dark haired nurse came into the room. The doctor let go of the patients wrist, stepped back and the RN gently positioned the syringe into the port on the patient's IV line. "I have something that will make you pee."

"Good," the patient said.

The RT sat in a chair by the door so he was facing the back of the patient, but could observe his student closely. He crossed his legs, and set his clipboard on his lap. He watched closely as the patient inhaled the magic mist. He knew the treatment wasn't the solution to the patient's ailments, but he enjoyed bossing the student around, because he also knew in a few years it would be the other way around.

"You know what," the RT said on a whim and looking over at the doc. student. "When you are a real doc., you'll get paid $200,000 more a year than me, and you'll get the privelage of us catering to your every whim. And , when your work is done, you'll be allowed to sleep all you want, while we lowly RTs will have to stay awake no matter how slow or tired we are."

The doctor looked at the RT with deep, dark glaring eyes. His eyebrows curved inward so they were snug over the base of his long, narrow nose. Then he relaxed his face, plucked the nebulizer cup from the mask, tapped it a few times, and pressed it back into place. More mist sputtered another moment, then the mist was gone.

All the RT could hear now was the familiar hiss of oxygen, and of course the patient's harsh, gurgling breathing. "It's done."

"I know," the doc said. He removed the mask from the patient, stuffed it into its bag, and set tossed it onto the windowsill. He listened to the patient with his stethescope.

"Do I sound better," the patient said, with a choppy breath between every second word. "Because I sure don't feel better."

"We're working on that," the nurse said, and left the room.

"You guys... are... pretty funny," the patient said, smiling despite his predicament. "You are... a pretty... good duo. Lasix works far better for me that that treatment."

"We'll come back and check on you in about ten minutes," the RT said.

"Ten minutes," the doctor on the way back to the RT cave. "So, after we get him fixed, how long before the next scheduled procedure."

"Three hours," the RT said. "Time to get some charting done."

"Well, I'm going to take a nap first."

BEEP

The doctor jumped at the sound. The RT observed the swear word that crossed the doctor's lips.

"Well, let's see what that is." The RT nonchalantly reached into his pocket and pulled out his pager. "Ah," he said, "Another ABG in ER. Well, how about that."

"ANOTHER ABG" "I hope it's not the same as the last ABG, where the patient was NOT labored, and had a sat of 98 percent on room air."

"Look doc. student, it doesn't matter. Our job is to do what we're told."

"Well, that's gonna end when I'm a real doc here."

The RT rolled his eyes. "Yep, I've heard that one before."

Fast forward two hours.

The doctor student grabbed a donut from a stash of treats provided complimentary by the hospital cafeteria for doctor students only to ingest and not for RTs to enjoy (however they've been known to sneak one from time to time), slammed the door to the RT Cave doctor student lounge, and flopped onto the bed. He groped blindly to one side of the bed for the remote control. When he failed to find it, he stuffed the donut into his mouth.

Through the door he heard a muffled beeeeep, followed by a knock on the door. "Come on, doc, time to go do another ABG."

"Argh."

Ventolin is the medicine used by Angels

"You're my little Angel." She was a middle-aged, dark-haired lady sort of stocky but not really fat. "You're my little Angel. You saved my life." Who in the world are you, I thought as she proceeded to give me a big hug. "I thought I would never see you again, my little Angel."

"Well, uh, hi," I said, "Nice to see you again.

She stepped back and proceeded to peer at me with a big gaping smile. "You probably don't remember me, but I had surgery. I thought I was going to die. When I woke up yours was the first face I saw."

She was right, I had no clue who she was. "Yeah, I remember."

Church was about to begin, so we both took our seats.
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Work has picked up tremendously in the past three days. We now have 13 patients on the board, and 2 of them are indicated. That aside, I was sitting in my office in the middle of the night, my feet up on the desk, peering out at the parking lot with its dull orange halo of light set against a pitch black background. The window was open and a cool, refreshing breeze was wafting through the room. It was awesome.

We probably have one of the best respiratory therapy caves in the world, with ours having a huge window with an excellent view. In fact, probably 95 percent of the office and patient rooms in this hospital have views of hospital additions. Otherwise called walls.

That was the best part of the night. It lasted about five minutes. My pager went off. "Need a treatment in 206." He was watching TV. He was "a little" short of breath and I could hear audible stridor.

"He's wet," I said to the nurse.

"How do you know without listening to him, " she asked.

"He just looks wet to me." I had the patient sit up and listened to his backside. No wheezes, but the patient did sound coarse throughout. Then I listened to the neck: It was coarse up there. "And 80% of wet patients have that upper airway congestion you hear."

"Really?"

"The noise you hear in his chest is not a wheeze, it's upper airway congestion you hear radiating throughout the lung fields. Here, listen to his neck."

She did. "Oh."

"What are his I&Os?" I started a treatment just just in case, and we preceded to the nurses station to check out the chart. The patient was 2000cc over in the past 24 hours.

As I was finishing up the treatment she gave Lasix.
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Overhead page: "Respiratory Stat to 244."

Upon entering the room the lady was standing aside the bed leaning on the bedside table, naked but for a gown flowing freely in front of her. "I can't take it much longer," she said.

I could hear audible, bubbly crackles, "She's wet."

"You think so."

"I know so." I listened to verify. "I'm positive. Have you called the doctor."

"I already did." I was impressed. "I have Lasix to give her. I don't know why, but Dr. Brave ordered a treatment too."

"That's okay, I have no problem with trying a treatment." Not like it's hard putting a pipe in someones mouth, or in this case a mask over it. Then again, nothing like putting an extra 8cc of fluid into an already wet lung.
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I was trying my best to get my 2:00 breathing treatment done when I was called to ER to do a breathing treatment.

"Why does this patient need a treatment," I asked RN Sarah.

"Because she has pneumonia."

By this time I'm exhausted from running around ragged all night, and have had enough of doing senseless therapy when I have two critical patients upstairs. "Pneumonia isn't an indication for a breathing treatment," I grumbled.

"Yes it is!"

"No it isn't."

"Breathing treatments are for short of breath."

"Breathing treatments are for bronchospasm. Ventolin doesn't even get down to the alveoli where the pneumonia is. It's particle size fits in the bronchioles to open up the bronchioles and resolve bronchospasm."

"Ventolin is for shortness of breath."

"Do you ever give Lasix for bronchospasm."

"Just give the treatment, Rick," she said smiling. She obviously knew I was swamped. That's one of the nice things about working in a close nit hospital like this is we usually don't hold grudges when one of us has a bad moment.

I gave the treatment.

"Do you feel any better after this treatment?" I asked the patient.

"No."
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Finally I got out of ER back up to the floors to check on my patients. The man I described earlier had already peed out 500cc. The lady was back in bed and "much more comfortable." By morning they were both fine.

"You are my hero," the lady said when I entered her room in the morning. Her nurse was at the bedside checking her sugar. "You gave me that treatment and now I feel so good. That stuff you give is a gift from God."

"Thank you." I said. "It's so nice getting a compliment. I really appreciate it."

"Well, you can give me a treatment anytime you want."

"You'll be getting them every four hours." Whether you're short of breath or not for now on.

I checked, and the patient had peed out over 2 liters during the night, and started to return to the room when the nurse met me in the hallway.

I said, "Did you see I got credit for her breathing better."

She said, "Yeah, you prick, my Lasix had nothing to do with it."

We laughed.

Accidental Extubation and spontaneous ARDS

I was having a wonderful conversation with one of my favorite patients when my beeper sounded: "We need you stat in ER."

"Shit!" I said ruefully, "You're breathing okay right now, right?" She looked fine, but I had to be sure.

"Yes, you go right ahead." She was such a great patient and, unlike some patients, I trusted her judgement.

I stopped the treatment and rushed to ER. I busted through the double doors, a strong horrible stench hit me, and Bee the nurse shouted from across the room:

"They need you in Cat Scan!"

"Cat Scan?"

"Yes. Cat Scan. A lady is coding."

"Oh, shit!" Not knowing for sure an airway box was in CT, I grabbed one and busted back through the double doors and started walking fast. Ahead, a skinny man in surgery scrubs burst from the CT room.

"Oh, RT, get me a size 8," he shouts. "Now!" I realize now it's Bob the acerbic anesthesiologist.

"Okay, just a minute."

"No, I need it now!"

"Hugh!" I busted open the box and started shuffling through it looking for the tube while still walking. This is ridiculous, I thought. "You'll have to wait till I get in there."

"No we need it now."

"What's going on here," I said as I enter the room with Dr. Bob breathing down my neck. He was standing beside me now like a little kid, panting for his ETT. I handed it to him.

"We extubated her," one of the surgery nurses said. She was bagging. What in the hell? I thought. How could somebody be extubated in CT when I didn't even know there was an intubated patient. Hello, I'm the lone RT working, I'm supposed to know this kind of stuff. And there's no code, as Bee told me.

Bob crouches by the head of the patient on the CT table, shouts for the nurse to stop bagging, and easily slides the tube in.

I secure the ETT with an ETT holder. "So, what happened again."

"We brought her from surgery. She started wriggling, seizing, and, well, you know."

Then it clicked. I thought this was an ER patient. I thought this was a patient they were working on and didn't tell me about for some inexplicable reason. Why an intubated patient from surgery would need a CT I had no clue. I did not inquire. Then I noticed the old gooey ETT lying askew on the side of the patients head: it had tape on it. Aha.

"So, Bob, maybe next time you'll put one of these in before you transport your patient," I joked, pointing at the ETT holder. To my amazement he smiled.

The excitement was over, and I was starving. I had lunch on my mind. The beeper went off: "Need you in ER."

"Shit!"

I stumbled through the ER doors, grabbed my sheet, grabbed my EKG machine, and headed for my patient. On the way, however, I was overcome again my a horrible stench. I looked into a room and saw a thin, scraggly bearded man sitting up on his bed. He literally looked like something that was scraped off the street. Turned out he was.

I pray to God I don't have to do an EKG on that guy, I thought, and proceeded to my patient. I did a quick EKG and, back at the nurses station, hand it to the doctor. He reads it. "Hey, Rick, could you do an EKG in room four?" He said, kindly, and with a smile.

"Oh sure." I grab the machine and start for room four when it hits me: it's that guy. Why is it every time there's a gross patient they always seem to find a way to get RT involved. I suppose if he's homeless he could be malnourished. His electrolytes could be off, which equals indication for EKG.

"Could you tell me about this patient?" I ask the nurse out of range of the patient.

"Well, we just plucked maggots off him," she whispers.

"Maggots?"

"Yeah, he had poor circulation in his legs. About two or three months ago he went to a doctor and the doctor had his feet wrapped. When he came in, he had garbage bags wrapped over the bandages," she made as though she were going to puke, "It was awful."

"I'd hate to have your job."

"So did I." She smiled.

"So now you want me to get involved." I took a deep breath, and proceeded to do the EKG.

An hour later I was upstairs because Dr. Young ordered a STAT BATH. I reluctantly volunteered. Mickey, a former EMT of 30 plus years and who was now an ER assistant, also volunteered. He had a good idea that we place a sheet in the tub so we could use it to get him out and into the wheel chair. It turned out to be a great idea. It was a horrible job, but a great idea.

I digress though. I was off the next week. When I came back, almost immediately after I received report, I was called stat to room 208.

"What's going on?" The patient was in low fowlers, obtunded and appeared to be laboring. He was gray. I checked his sat, it wouldn't pick up. Of course this was before the rapid response team was in effect. "Does he have a pulse? Have you checked a pulse."

"Yes," the nurse assured me. "His pulse in 90 and his BP is 120/80."

"Does he always look this way, obtunded I mean."

"No. He was fine my last check." Mental note: acute mental change.

"Okay, well that's a good start. But he sure don't look good. Is he a DNR? Did you call the doctor?"

"He's not a DNR. We did call the doctor." I look at the patient again. Now I realize this was the guy with the maggots. I thought about asking if they checked his sugar, but second guessed myself. This would later come back to haunt me.

The patient looked like shit, so we all conclusively decided that I should place the patient on an NRB and do an EKG and a blood gas. What's the old saying, better to do now and apologize later. The patient bled so bad I had blood dripping on the floor. After holding it 5 minutes I gave the job to the nursing supervisor.

The ABG said: ph 6.98, PO2 45 (before NRB), CO2 35 and ? bicarb. The machine did not pick up the bacard, probably because it was so low. My initial conclusion, although I'm not the doctor I usually try to make an educated guess, was this man was in respiratory failure secondary to sepsis. Because he was leaking so bad I'm certain he's in DIC.

By now Dr. Young, our surgeon, was in the room. He's one of those quiet little guys with poor bedside manners. "That's a venous blood."

"No, it came out pretty good."

"It's venous blood. Look at that pH. It's venous blood."

"I'm quite sure it's not venous blood."

"It's venous blood." He looks at the patient. "Why did you call me? He's fine."

"He's not fine. He's labored," the RN says.

"He's fine. Why do you call me for this."

Now the Internist on call enters the room. He looks at the ABGs, "Those are venous."

No they are not, I think but do not say. "Look, even if it is venous blood the pH will still be similar to arterial blood. Look, this guy is in failure."

"He's fine." Both Doctors leave the room. Fine, the only reason they don't want to come in here is because this guy is homeless and he's gross, and they don't want to be bothered.

I never leave the room. The nursing supervisor and I discuss the patient, and we both agree something is obviously wrong. And, five minutes later, the patient codes. Both doctors come back into the room. And, guess who comes in to intubate? Dr. Bob.

He slides the ETT in easily and, before I have a chance to secure the ETT, the head nurse said, "We need to boost him down the bed: one, two, three...

"WAIT!" I shout as they scoot the patient away from me, as my hands and the ETT stay in the same place. The patient is now extubated.

"What the fuck!" Dr. Bob yells. He reintubates the patient in a swift moment. He holds the ETT while I secure it with an ETT holder. "Next time you intubate a patient, be sure to secure the ETT with one of these before you move him," he said, pointing at ETT holder.

He smiles and exits the room. He got me back.

I redrew the ABG. By the time I got back the patient was dead.

The second pH was 7.00. I was right. And, after reading the autopsy a few days later, I learned I was also right about the sepsis. The autopsy also identified ARDS. Oh, and his glucose was 18 which, I learned, if a patient is not on insulen means liver failure.

This was one of those cases I couldn't get out of my mind. What did we do wrong? I wished I had asked about the sugar check. I thought about labs. I checked, and the patient didn't have any labs ordered the day before, nor sugar checks, both of which would have set off alarms.

A week later I ran into Dr. Peterson, an Internist who came into the cave to read EKGs. After I explained the situation to him he said:

"Patients do not go into spontaneous DIC or ARDS. It simply does not happen. And this would never have happened with one of my patients. You don't simply send someone to the floor and not order any tests, regardless of who the patient is."

I never did get into trouble for drawing ABGs without an order. Perhaps because those two doctors knew I was right.