Talking to people with hearing loss

So on Sunday I instructed my RT Cave Facebook Page followers to read the transcripts from the August 30, 2015, Rush Limbaugh show where Rush explains how it felt to go deaf. Trust me, folks, this has nothing to do with politics and everything to do with how to deal with deaf people or people with hearing loss, people we deal with on a daily basis and still have to communicate with.  

Basically, what I wanted people to read was the following.

I was playing golf one day, and I ran into a guy I didn't even know. It was up at Jupiter Hills and I ran into a guy. I was coming off the practice range. The guy came up to me and said, "You know, I really admire what you're doing."

I had no idea what he was talking about. I said, "Why?"

"I don't know how you're still working. You're deaf, for crying out loud! You're deaf!"
I said, "Well, implants, this, that," explained to him.

He said -- and I've never forgotten this. He said, "Hearing loss, deafness is the only disability where the victim is blamed. Have you found that?"

I said, "What do you mean?"

"Do people get mad at you for not being able to hear them?"

I laughed. "All the time."

He said, "That's what I mean. You're the one that can't hear; they get mad at you. Because they can't relate to not being able to hear. And when they're around you and you're wearing your implant, you can hear them, so they think you can hear them all the time. They do not get it. They just don't," and he was right. He was dead-on right. And the way it manifests itself is... Well, let's say I'm on the golf course. I'm on the driver's side. Let's say before I got the implant on my right ear, so I can only hear out of my left.

I can't tell you how many times I have witnessed nurses or doctors get irritated with a person who can't hear because they can't hear.  Heck, I know that I have myself gotten annoyed from time to time. And this is what Rush is describing: the frustration of the deaf person because they are treated as the victim when the real victim is not them but you.  You are the victim because you don't know what it's like to be deaf, and you don't know how to communicate with deaf people.

The reminds me of when I was 15 and had a friend named Julie who was deaf.  She kept telling me over and over not to shout.  To me it made sense to shout what I said, thinking she'd be able to hear me better with the hearing aide and all.  But she would get irritated with me and tell me just to talk normal.  The reason she said this was because she was trying to read my lips and when I talked loud she couldn't read my lips.

I'll be honest with you: she corrected me a lot.  I remember many times she would touch the side of my head and aim it so that I was looking at her.  She would look annoyed or irritated, she would just just calmly give some kind of hint, or touch, indicating that I needed to look at her and talk normal.  She knew that I didn't know.  She had experienced this many times, and simply decided, at some point, that if a person is not deaf this is how they acted, and this is what needed to be done.

She was trying to help me understand what it was like to be deaf.  Then I would talk normal for a while, concentrating on making sure she was looking at me when I talked.  But then I would forget, and the next time we were having a conversation I would find myself shouting again.

I can't tell you how many times I have had to remind myself not to shout in a patient's room.  I can picture Julie as she constantly reminded me not to shout, that there was no need for me to shout.  But I still have to stop myself.  I can't tell you how many times I've told nurses or doctors not to shout.  But they just look at me annoyed.

Rush continued.

I'm on the driver's side (of a golf cart). My good buddy, whoever it is sitting on my right talking to me in a normal tone of voice as we're motoring along and the golf clubs are rattling and making noise and the wind is going through the microphone. I can't understand a single word. Two years later, same circumstance. The guy still doesn't speak up, doesn't aim for my left ear, just keeps talking. It's just... I don't know how to explain it.

As I say, it's been fascinating to study it and try to understand it, and I don't complain about it. You know, I just I'll stop the cart and I'll turn my head and get three inches from them and say, "Could you say that again," and it'll happen after I do that. Five minutes later they'll try to talk to me with all the racket again, and I'll stop the cart, and I'll turn my head and get three inches. They don't learn. And that has been the fascinating thing about it.

And this is not a criticism. It's human nature. It's just the way... I think it's all rooted in the fact that people simply can't relate to it, even people I've explained it to in great detail -- and I can't explain the acoustics.

You see, we don't know what it is like to be deaf, so we don't learn how to talk to deaf people even when they tell us.  We don't learn to get their attention and to make sure they know we are talking to them. We do not learn to be patient with them.  If we gain their attention, if they see us talk, they can, if they have hearing aides or know how to read lips, hear us.

But we forget.  We should not forget, but we do.  It's human nature.

The interesting alzheimers and dementia patients

Alzheimer's and dementia patients can be quite interesting, as you well know if you've ever met one.  They tend to gradually lose their short term memory, yet my experience is that they tend to hold on to their long term memory, something many people seem to not know, or forget.

The personality the develop is, in my opinion, their basic personality: phlegmatic (laid back and easy going), melancholy (neat, organized and whiny), choleric (bossy and meticulous), or sanguine (loud, outgoing, and talkative).  One of those personalities will shine. 

I find that no matter what personality the patient has, the way to get to that person you have to ask them about their past:

• What did you do for a living?
• Where did you live?
• Do you have kids?
• How many kids do you have?
• What do your kids do?
• Did you like to cook? If so, what were you best at?
• Did you draw? Did you have a hobby? What was it?
• Do you read the Bible? If so, what's your favorite story?

I find that these patients will sit and talk to you about their past, and sometimes they go on and on.  Even in the later stages of the disease, I find that they remember their past quite well. 

Surely you will have to reintroduce yourself with every visit, and the patient may shake your hand, or touch your shoulder, as though this is your first encounter.  Yet form your previous visits, by enquiring about their past, you can have a little more insight as to how to communicate with this patient. You know who they are, even though they probably don't know who you are.  And, many times, they DO remember you too, because you have made an impact on their long term memory too.

And I write this not having studied dementia and Alzheimers. I did not need to read a study to learn this. I say this as a person who has directly worked with many of them during the course of my many years as a respiratory therapist. 

You'd be amazed at what you can learn from a person with no short term memory.  You should try it sometime. 

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"I feel like such a baby!"

Yes she was agitated, sweating profusely, and complaining of agonizing stomach, chest and back pain.  She was so uncomfortable she could barely sit still.  She was uncharacteristically complaining.  She said, "I feel like such a baby!"

Yet she wasn't being a baby at all.  In some cases I'd say, "Yes!  You are being a baby."  But in her case, she was being a hero to herself.  She was biting the bullet and seeking help. Even if she gets a clean bill of health, at least she'll know she's okay and the pain is just superficial.

Yet what if she stayed home and was having the big one?  What if she was having an aneurysm?  What if?  She couldn't take the chance.  In fact, chances are she already waited too long. She waited too long because she was a mom of five, a wife, and a tough woman. 

There are too many people in the world too modest to seek help when they should.  It's better to come in and be told you're fine than to stay home and risk dying.


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How to introduce yourself to a patient?

Your humble question:  What is the best way to introduce yourself to a patient and to identify the patient without breaking confidentiality rules?

My humble answer:  There really is no rule how to introduce yourself.  However, due to confidentiality laws (like HIPPA) I find it's best never to say the name of the patient.  My technique is to get the patient to say his or her name so I don't have to.  I usually do the following:

1. I pick up the written (printed) order and take it with me to the room
2. I always introduce myself as I enter the room:  "Hi, I'm Rick from respiratory therapy."
3. Then I say something like, "Will you please say your last name?" 
4. I confirm the last name with the order and I say the first name of the patient.  Or, if I'm in a humorous mood, I'll say something like, "Yeah, you're right?"  Or I say something like, "Yep, you're the right patient."  You can get creative once you know you have the right patient.
5. Or... if the patient is unable to communicate you can always check the wrist band, or follow the above procedure with the family member or guardian.

Obviously there's more than one best way to introduce yourself to the patient.  As with anything, every person has his own best practice.

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The God fearing patient

I met him three days ago for the first time. He had an amalgamate of health issues -- heart failure, kidney failure, fluid on the lungs, possible heart attack, pneumonia, poor ventilation (high CO2 and low pH) -- yet he was in good spirits.

He was doing so much better yesterday, even to the point I felt comfortable letting him stay off his BiPAP. He was so happy, because the mask was causing his facial skin to break down, and his mouth was dry, and the seal was tight and uncomfortable.

He didn't even have to ask what day it was today. Yesterday he said he felt a little disorientated. I confirmed to him that after what he went through a little disorientation was completely normal. Yet there was none of that today. He was awake, alert and completely orientated.

Yesterday a five minute breathing treatment with him took a minimum of 35 minutes each time. And considering he received a treatment every three hours, I spent quality time with him. Yet he wasn't like most patients. Mr. Sower and I clicked.

First we talked about the Bible. I started the conversation by placing my hand on his Bible and asking? "So, you a diligent reader of this?" I could see a sparkle in his eyes. A conversation took off.

During a later visit he was watching a Fox News report about the new Congress, and he said, "So, what do you think of all this?" I had a feeling what his political affiliation was after our discussion yesterday, yet I didn't know for sure.

So I almost jokingly set the table, "So do you want me to tell you what I think you want to hear, or do you want me to tell you the truth?" I have to ask this because I know some people get angry when their political views differ from yours. Normally I'm not so blunt, yet I knew his personality.

"Nothing but the truth in here," he said.

So I relayed to him what I think about the goings ons. A brilliant conversation ensued.

Today his blood gas values were worse. His pH had not gotten over 7.3 the three days he had been admitted, and it's supposed to be at least 7.35. And yesterday it was 7.2. Today, however, it was 7.1. The problem was that he acknowledged to feeling great. "They say I'm getting worse, but I feel so good."

So I had to make him put on the BiPAP mask he hated so much. Yet he was wise enough to know the machine was his only chance to live another day. Due to his poor health he had made a declaration he didn't want life saving measures, and he didn't want a tube in his throat. So that left us with BiPAP.

Yet he wanted to eat first.

So just as he was getting ready to eat he asked me to tell him the truth about his condition. He said, "Dr. Kick is a good doctor -- I think. Yet he doesn't communicate well. In fact, I don't think he's sure enough of himself to be straight."

I was honest with him. That's all he wanted. His problem was not oxygenation, it was that he wasn't taking deep enough breaths. I encouraged him to focus on his breathing especially when he was off the BiPAP. I encouraged him to focus on his breathing even when he was on the BiPAP.

And, most important, I encouraged him to stay on the BiPAP as often as possible until he was better. "If you don't stay on the BiPAP, and if you don't continue to take deep breaths, your numbers will continue to go down and you'll peter out. I know you feel good right now, you'll just have to put up with us until you get better."

I laid it straight, yet I didn't take his HOPE away. Yet Dr. Kick wasn't as faithful.

"Thanks, Rick," he said. And just then Dr. Kick came in and laid the cards on the table. When Mr Sower asked, Dr. Kick said, "It's not good. You're going in the wrong direction. There's a good chance you're going to die." He laid all the cards on the table, from the pneumonia to the heart failure, to rising cardiac enzymes (indicators of cardiac bruising). "And there's nothing I can give you for the heart failure," the doc said, "because I'm afraid your kidneys will completely shut down."

I could see the life fall from the patient's face. I thought it was good Dr. Kick played it straight with the patient, yet he could have had more tact. He could have done more to give the patient hope. For even if the hope was bleak, hope can keep a person ALIVE.

"Put the mask back on him," the doctor said.

"I hate to do this," I said. I set the mask on his face, it automatically gave the patient a high pressure breath, and I secured the straps. I felt bad that I had spent Mr. Sowers time in conversation, because he could have been eating. Now he wasn't allowed to eat.

The doctor left the room. The patient was looking at his feet with a dreamy stare. He did this, and I almost thought I should leave the room so he could have a moment. Just at that moment he looked at me, and his eyes lit up.

Right then I was reminded of a discussion I had once, a post I wrote once, about how patient's who believe in God may be depressed, yet they aren't gloomy. Patients who don't believe take you into their dark world. Mr. Sowers was a believer.

I went to the nurses station and checked the chart. Mr. Kick wrote an order so the patient was no longer allowed to eat. "What a fool that doctor is," I said to the nurse. "How can a patient keep up what little strength he has if he's not allowed to eat?

"Don't lecture me," the nurse said, smiling. "I didn't write the order."

"I'll have to call Dr. Kick and be firm," I said. Yet I knew I wasn't aggressive that way with doctors, so the nurse said she would do it. "Just make sure he gets some food."

An hour later Dr. Kick was in the RT cave reading EKGs. I said to him, "So, that guy in ICU 34 is a challenge for you, hey?"

"No, he's no challenge," he said, "He's losing the fight."

What a frickin pessimist, I wanted to say to him. I'm glad I didn't choose this bastard as my doctor.

Yet before I had a chance to say anything my beeper sounded off. I clicked the button on it and the LED lit up. The message was for me to return to the unit, "Mr. Sowers wants to talk with YOU."

I knew what he wanted. I knew what he wanted to tell me just like I knew what my Christmas present was going to be every time my 7 year old asked me, "So, daddy, what do you think is in this box." Yet I pretended not to know.

I stood beside his bed. I saw he was trying to hold back the tears. His wife, a good friend and coworker, was beside the bed. She too was trying to hold back her tears. He said to me:

"I wanted to talk to you..." his words were choppy and muffled through the BiPAP mask. I knew what he was going to say. I just knew." There's something I wanted to say...," a long pause as he tried to collect himself. "Please bare with me...you'll just have to bare with me here."

I looked at his wife, a lady I had worked with for several years, and she too had tears in the corners of her eyes. They were both trying to be strong. Why do we always have to try to be strong? Why can't we just cry when the urge hits? That would be the more natural, healthy, way to do it. Yet he was strong, and she was strong for him.

"I know we just met and all... yet there's something about that conversation we had yesterday -- all the conversations we had -- that made me think we shared a common bond. It made me feel a warmth -- a special warmth -- inside.

"It's not often you find that kind of person -- someone you click with. You and I share the same interests. We're passionate about the same things. We talked about politics. We talked about God. Most important, we talked about God on the same level. It makes me feel like I have something more to offer... I wasn't prepared for that shocker this morning..."

"I can understand that completely," I said.

"I don't really feel like it's my time. I just feel like I have more to offer. I understand if HE wants someone with my gifts, yet if he has one more miracle, one more effort, I would really appreciate it right now. I just... I know we just met...It's very rare that you find someone you really click with..."

"I know," I said, "It's very rare to find someone you really click with. It's rare to find someone who has an interest in the wisdom you have to offer."

I really didn't know what to say. I tried not to say anything. I tried to say something. I didn't know what I was supposed to say. Yet I found myself talking. It was a rare event for me to feel like I had the right words.

Before we got married my wife and I had to visit a priest once a week for a couple months. The first thing he helped us do was determine our personalities. My wife determined hers in one session. It took the priest five sessions to determine my personality.

The reason it took so long is because, as the priest described it to me, was, "You are a special blend of personalities. You are all personalities. You have this rare personality where you blend with everyone. You are a combination of all personalities."

In fact, the priest then said that my personality is "so rare, that you are so peaceful and so phlegmatic, that your interested in nearly everything. Yet you are less interested in trivial talk, and more interested in in depth material such as politics, philosophy, and even faith."

The priest himself had a sparkle in his eyes as he realized my personality. I believe the reason was because of what he said next, "When I took the personality test, the same thing happened to me. It took me days to decide my personality."

The priest said, "When you were a kid you probably had trouble finding friends, because you were searching for someone to share your wisdom with. Chances are, you were a loner as a friend. You had friends, but no one you really clicked with. The reason is because few share the same interests as you do. And, chances are, based on your personality, you will meet five people (he showed me his five fingers) with your same interests, your same personality, in your entire life. And they will all be in your adult hood."

After a brief pause, he said, "And chances are also that you'll never meet someone your same age. There are so few people your same age with your personality that you will probably never meet a person your same age with your personality. Chances are you'll meet people older than you. Or when you are old, you'll meet someone younger than you that you'll completely click with. You'll feel a warmth."

I didn't want to say anything, so I sat in my chair next to my wife back then hoping the priest would go on. I wanted more of his wisdom; needed more. He said, "Not only that, yet you will never get to spend quality time with any of these people you click with. Chances are your encounters will be in passing. Yet you'll still want to share your wisdom. You'll probably have the urge to teach, or to write."

I think that priest was the first, my co-worker Jane Sage was the second, and now Mr. Sowers was the third.

So when Mr. Sowers said, "I felt a special warmth" during our discussions, I knew exactly what he meant.

"I don't mean to sound...", he said,

"I completely understand," I said.

"You can understand why I don't think it's my time to leave. I feel I have more to offer. I'd like to meet with you again and have another discussion. Many discussions perhaps."

"I'll pray for you," I said. He offered his hand. I shook it firmly. His grip was stronger than mine. His smile sincere.

He closed his eyes. His hand went limp. I placed my left hand on his chest. I close his eyes.

Mr. Sowers was 54.

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She gave me the bird

I walked into her room and she showed her utter respect for me by placing her hand up in front of her face, and then, slowly, purposefully, and with a big smile on her face, she fully extended her arm high up over her head, and extended her middle finger.

Believe it or not, that was her way of showing respect for me. I worked damn hard the other day to get her off the vent, and she passed the weaning screen with flying colors, was awake and alert, and chomping at the bit to get off the vent. Then the doctor came in and basically gave me the big, "Rick, she's not coming off the vent."

Ahhhhhhhhhhhh!!!!! That was the first time I ever begged to extubate. "RICK! I am NOT EXTUBATING that lady today!!!!!"

So she needlessly stayed on the vent an extra day. She was awake and alert, able to read a newspaper, sit on the edge of the bed, watch TV, write notes on her sheet of paper, and the doctor refused to extubate.

She was one of my favorite patients ever. She showed her appreciation for my friendship and my hard work with the bird. Yep, that one event made me proud to be an RT. I smiled and had a nice long discussion with her about books.

RT Supermarket

I remember as a kid visiting my aunt who owned a mom and pop grocery store out by the state park. I always thought it was cool that my aunt would cheerfully greet every customer as though they were all her best friends.

When I questioned her about this later she said, "Basically my business comes from the same people. If you're friendly, they just keep coming back for a sucker here and a beer here and a ham there. They're all regulars."

In a way, that's the general feeling I get as I'm working as an RT. Even today we have eight patients on our list, and every single one of them is a regular. I know them all by name, and they know about as much about me as I know about them.

Earlier today I was called to the emergency room, and we were waiting for the ambulance to arrive. "So, I wonder what regular it is this time," one of the nurses said.

"Well, the call was out by Cracker Road," another nurse said, "so maybe it's Mr. Wilcox. He's a wildly old coot. A sick guy, but fun to take care of."

As a matter of fact that's who it was. Since it was relatively slow that night (low patient census) I ended up talking to him for over an hour after giving him his usual concoction of Albuterol and Ventolin.

He ended up going home, the old coot.

What we have here is an RT Supermarket, full of a bunch of regulars. In fact, this might be one of the advantages of working for a smaller hospital like Shoreline.

All pateints deserve equal respect

She's a 66-year old end stage COPD patient and she's highly demanding. She doesn't mean to be annoying, she's just scared. So my advice is: Give her what she wants. Spoil her. Cater to her.

But, gosh darn it, stop getting irritated with her. If she wants those darn things over her ankles that vibrate the blood through her legs to prevent blood clots, dog gonnit put them on. If she wants a glass of water, go fetch it. If she wants to be tucked in, just do it. If she wants her oxygen on 3lpm instead of 2lpm, then dog gone it just do it.

She was so upset when I entered her room. I said, "What's wrong."

"I'm mad!" She said.

"At me?"

"No. At the nurse. I wanted those things on my legs and have asked four times and she refuses. She also refused to tuck me in better, because I was highly uncomfortable. Finally I told her just to get out of my room."

"Is there anything you want me to get for you. I'll do anything you want," I said.

"No. I'm feeling pretty comfortably now," she said, and she looked it.

I understand completely how the nurse feels, because this patient is highly demanding. Then again, this lady becomes dyspneic every time she even moves in her bed. She is scared. She is dying. It just irritates me that someone wouldn't take an extra step to cater to this woman. Give her whatever she wants. Let's make her happy. Let's comfort her.

Isn't that our job? Isn't that what we're here to do? Even if it's not, I see no reason why this sweet old lady can't get what she wants, annoying or not.

Her treatments are ordered QID and Q2 prn. I see absolutely no reason why she needs a breathing treatment every hour. But she asked for one and I shall giveth. Inconvenient -- yes. The right thing to do is giveth -- absolutely.

And I shall sit in her room and visit with her because I have a feeling she likes the company. She smiles when I'm in the room, and perhaps she provides me a sense of I'm-doing-a-good-deed on an evening where I otherwise probably don't even need to be here.

The carbon copy blue bloater

Disclaimer: The following was written by an anonymous author. Any resemblance to any person living or dead is merely coincidental.

You'd think with only five patients on my clipboard I'd have an easy night, right? Wrong! I have five very highly demanding patients. And, the funny thing is, they are all exactly the same. In fact, they all seem to be carbon copies of the other.

Yeah! Tonight I have the carbon copy patients. They all have or are:

1. end stage COPD and lung cancer
2. blue bloaters
3. severe dyspnea with even minimal exertion
4. members of the 50/50 club (chronic po2 50 and co2 50)
5. basically bed bound or recliner bound
6. severe anxiety
7. severe restlessness
8. highly demanding
9. somewhat annoying after a while
10. challenging
11. enjoying to talk with
12. exceptionally cordial and pleasant underlying dispositions
13. insist you stay in the room until their treatment is done
14. want you to stay in room after the treatment is done ("Please, don't go!")
15. clock watchers
16. want their treatments every two hours
17. require BiPAP to catch their breath
18. refuse to wear their BiPAP most of the time
19. call to have BiPAP hooked up when they get panicked
20. demand you increase their nasal cannula liter flow at their request (one insists on the liter flow being 10 lpm even though he's wearing a nasal cannula)

Thank you for the opportunity to share my piece.

I love intelligent patients

I love intelligent patients. As I was performing an EKG, he asked, "Does that EKG measure voltage or resistance?"

"You got me," I said, "I know it measures voltage, but I'd guess both."

"It's kind of a complicated machine," he said, "but all such machines are pretty much the same."

"What did you do for a living," I asked, assuming he was retired.

"I was an engineer. I made products for NASA."

"Cool," I said, for lack of a better word. "Impressive."

"Yeah, it was a good career."

"I bet."

"Didn't mean to stump you, I was just curious."

"No. I love to be challenged. About 20 years ago we RTs knew all our equipment inside and out. But now with all the microprocessors inside them, we leave the "inside" part to the engineers like yourself."

"Yeah, it does get pretty challenging."

I said, "My grandpa was a mechanic, and I remember him telling me once that all engines were pretty much the same. By the time he retired, he told me once, all the machines were so different you had to grab a different manual for each car."

He rattled off the parts of an old car that were always the same. "Computers certainly complicate things. But the workings really are pretty much the same as they were 36 years ago."

I wouldn't know, but I'll take his word for it. I love intelligent patients. I love an intelligent discussion.

An editorial about soft floors in hospitals?

Yesterday when I arrived at the hospital I heard a code blue overhead, and arrived in a room of a patient who had fallen and banged his head. A CT determined the patient had a head bleed due to the fall, and the patient was helecoptered to a larger trauma center.

Since then I've been thinking a lot about patient's falling. It seems that there are a lot of frail, old and sick people in hospitals. Like little children, they are prone to falls. Yet, when young people fall they are a lot more flexible and less prone to break hips, smash heads, and end up with life threatening pneumonia or a swollen brain as a result.

If you travel to any playground you will find some kind of soft padding to protect kids in case of falls. This is a good thing. Yet, when we get into hosptitals, the floors are made of rock, hard tiles. Hard head on on tile makes for a high risk for intracranial injury, and maybe even death. Falls also equal broken wrists, legs and hips. Broken hips in old people increase the risk of developing pneumonia, which so happens to be the number one killer of the elderly.

So, after discussing this with my co-workers, I have decided that a worthy investment for hospitals would be to have padded flooring in patient rooms. Why not? If we are going to flip the bill to pad floors where our beloved children play, why can't we flip the bill for padded floors in the hospitals where falls are most likely to happen.

He knew no life without her

She was 91 year old mother, grandmother -- wife. Her hair was ruffled to a degree she never in her adult life ever let anyone see, yet I was seeing it. Her skin was pale, no makeup. Her kith and kin may not even recognize her.

She looked up over the BiPAP mask, the machine that was supposed to give her wet lungs time to heal. Her eyes were circled with signs of anxiety and sleeplessness. In her weary eyes I saw all the years of cooking apple pies, hugs and kisses, and love.

On the other side of the bed, holding her frail hand, was the great man she was married to for 75 years; the only man she had ever loved. If ever there was a sign of soul mates, this was it. A feeling of sorrow rushed through my veins as I couldn't help feeling sorry for him.

Although, in a discussion the day before with this man, he said, "Whatever happens it's what God intends. Whatever happens, we had 75 great years together." He smiled then. There was no smile now. He was somber. The decision was made.

I listened to the sigh of the machine as it assisted her with a breath, and the hiss as she inhaled through the mask; the tubing, the machine's exhalation port. The cycle continued again and again. Yet it was my job now to end it. "It's time for her to go home," her husband said.

A vision of yesterday rocked in my head. Dr. Adams walked into the room, shook the old man's hand. I imagine Dr. Adams was thinking the same thing I was thinking now, that for a 93 year old he looks healthy, perhaps not a day over 80.

The husband said to Adams, "I promised her I wouldn't let her suffer, and she hates that thing. I think it's time to take it off. It's time to let her go."

Dr. Adams sighed, said, "With more time we might be able to nip this thing. We can give her body time to heal."

The old man said, "It's time. Let's just do it."

I unleashed the Velcro straps that supported the mask around her head and lifted the mask off her face. She sighed, smiled, looked up at me, took my hand, held it tight, and lipped, "Thank you."

I held her hand what seemed like five minutes, and then I left the room. It was time for her husband to say goodbye -- her best friend. He did not know life without her. What was he going to do. Would he be able to cope? Those thoughts rushed through my somber mind.

Outside the door I turned and looked back: he had his head on her chest, his hand gently caressing her face. They were together as one. Oblivious of the circumstances, they were happy.

I got busy and never saw him again. At around three in the morning I got a page to call critical care. Instead of calling I walked there, and as soon as I looked into her room I knew what the page was for.

The Ideal night at the RT Cave

I came to work today expecting 17 patients and the ventilator I had on Sunday night. Yet, when I was handed the sheet I noticed there were seven patients on treatments, two ventilators, and one patient on a BiPAP who, I was told, might be ventilator bait.

"You're going to have your hands full tonight," Jane said.

"Hey," I said, "This is the kind of work I love. When we're ventilator, BiPAP, and treatment for bronchospasm busy I love it. It's when you have a bunch of people on needless treatment busy I hate. This I love."

"It's funny you say that," Jane said, "'Cause when I got here this morning Paul said, 'Jane, you're gonna be mad at me. You now have three ventilators.' I said to him, 'Paul, this is the kind of work we went to RT school for. I love it.!'"

I said, "You hit the nail on the head. This is what we went to school for: to think."

A couple new diseases

Spending so much time with patients we tend to observe new diseases doctors and scientists never picked up on. See if you recognize some of these that were sent to me from a fellow RT in Kentucky:

1. Chronic bed syndrome: Here you have your typical chronically sick patients who are unable to get out of the bed. They usually present with some grumpiness and fear not bossing you around without saying thank you. They expect you to cater to their every need; to actually know what they need before they ask. They tend to fit into any or all of the following adjectives: grumpy, demanding, purposeful apathy, melancholy, bossy, condescension.

2. Whoa is me syndrome: Some diseases might be MS, ALS, MSA, trauma, rehabilitation, chronically ill, or any such disease where the patient slowly develops atrophy of muscles and possible paralysis. She needs constant assistance moving and perhaps even drinking. They constantly yearn empathy and can at times fall into the Chronic bed syndrome. Ultimately, they want you to feel sorry for them. Something you might hear from this patient is, "Oh, why did this happen to me."

Sweet lady in a confusing moment

She was out of it. When she fell into a deep sleep she went apneic and her spo2 dropped to 72%. The RN tried to awaken her, but she would not respond. And when she finally did respond, she had no clue who she was nor where.

The doctor, correctly, opted for BiPAP. I was a head of the game and already had the BiPAP ready to go. Keep in mind here this lady was completely either obtunded or out to lunch for over two and a half hours.

So, I go to put the mask on her and she wakes up and is completely defiant about putting "that damn mask on my face." She writhed her head this way and that, grasped with her hands. I had the RN hold her hands thinking she simply wasn't with it and was just reacting. But, as it turned out, she was as alert as my 3 month old in the middle of the night when you expect her to be sleeping.

I was surprised by her reaction here mainly because she was so OTL for so long. I tried to wake her up before I put the mask on, and she never even twitched. So I figured I'd put the mask on real quick and be done with it.

But, that's not how it went down. So here I'm standing watching this lady flail, and screaming how much she didn't want my BiPAP.

I was thinking, "It's amazing what a little scare with the BiPAP mask can do to a person. It can wake up a person, change her mental status."

I pulled back the BiPAP mask; no point in forcing it on someone who is fully awake and defiant. I certainly don't want to traumatize the lady any further. I don't want to be inhumane. I shut off the machine and listen to the discussion between RN and patient.

"We need to put you on the machine because you stopped breathing when you slept," the RN said.

"No I didn't," the patient said.

"Yes you did."

"No. I'm just fine."

"No you are not. You need help with your breathing."

"Well, I'm fine now."

"Yeah, you're fine now, but when you sleep you have trouble breathing."

"So, I'm fine now, so leave me alone."

"So," the RN says, "When you stop breathing again, can we put the mask on you then?"

"Only if I stop breathing for two hours again."

"Well, it doesn't work that way."

"Why not."

"We can't let you go 2 hours without braething."

"Well, I don't want that mask."

"Okay, well, if your heart stops beating, do you want us to put a tube in your throat to help you breath then."

"Why don't you try it now so I can see if I like it or not."

That's where I had to leave the room.

It was a sweet old lady and she was so cute. And she had no clue. The sad part about it is that she had no family, no person to help her make decisions. She should have been a DNR patient I thought. It should have been discussed before now. It may have been. I highly doubt even under the sanest of moments this lady may not have a clue about what we are referring to in an attempt to help her survive another day.

Or are we only seeing a lady in her weakest moments. Perhaps on a normal day she's sharp as a whip. That's the thing about working in the medical field, sometimes we only know what's right before us, yet we have to consider everything -- including that of which we have no clue.

Then again, it may have been the hypoxia talking. Or, better yet (and this is why I backed off instead of forcing it upon her as some might have done), perhaps she was simply overwhelmed by the moment. I mean, what would you think if you suddenly woke up to a huge mask blowing air in your face?

As, an hour later, she let me put the BiPAP on her and hence it is still on with the patient who is sleeping comfortably. It's amazing what a little TLC can do -- and the help of a wonderful nurses assistant.

Sometimes you know what's best for the patient, yet you have to become creative in how best to take the next step.

A dose of normal patients tonight

I don't know if I'm just in a good mood or what, but my patients are actually really interesting to talk to tonight. I had five 10 p.m. breathing treatments, and I got into a lengthy discussion with each one.

I guess what I got tonight was a dose of normalcy. I had some normal patients as opposed to a bunch of dementia patients or people so sick they don't want to communicate.

Tonight, however, my patients were intelligent and interesting:

Patient #1 was watching the Tigers and we got into a neat discussion about what the Tigers need to do to be an improved team next year.

Patient #2 was a police officer who simply had the bum luck to get pneumonia. He was watching a show where people were tasing each other. He told me that as part of police training the officers have to be shocked with a taser.

He said, "It's something you never want to have done twice. When you get hit with the prongs you go down like a falling rock. It's not fun."

He said he has rarely used one, but there are a few losers who leave you no choice but to use it. Some officers, he said, use it way too much.

Patient #3 was an asthmatic, and he talked about what a bad asthmatic he was when he was a kid. He said it wasn't until he "cured myself from myself that I got my asthma under control."

Being an asthmatic myself, I had trouble removing myself from that room.

So, all my patients are normal tonight. It's a wonderful break for the RT Cave RT.

Two very interesting patients

Here is something interesting that I doubt happens very often.

It started out as just your typical breathing treatment. She was a 66-year-old end-stage COPD patient who was a regular. I knocked and entered the room.

In bed #1 was her room mate, a lady who looked younger and healthier than my patient. Since she was new to me, and since I was going to be in and out of the room all night, I introduced myself. "Hey, I'm Rick from RT. I'm here to annoy your room mate."

"She's a pretty nice person," the lady in bed #1 said, smiling.

I approached the more sickly looking patient in bed #2. "Hey, Mrs. Lunger, it's time for your before bed peace pipe."

"I'm ready," she said.

Banter ensued between the two very pleasant patients and myself. But that's not what made this encounter so interesting. My patient kept referring to the lady in bed one as "Mommy."

At first I never thought anything of it, just thought these two ladies just got along very well as room mates.

Later, however, as I was wrapping up the treatment and stuffing it into the bag, my patient said, "So, what do you think of my mommy. She looks pretty good, hey."

They both giggled.

I never would have guessed.

No Vent, DNR, or full code: what's your choice?

The decision of whether or not you want to be placed on a ventilator, or whether or not you want to make a decision for your loved one, is one of the most difficult decisions one can make. In fact, this is the basis of some very deep ethical discussions, and one of which may never be answered by society, only by the person who has to actually make that decision.

First let us note here that a majority of patients who go on a ventilator do so only for temporary purposes. If you have surgery, if you have severe asthma, pneumonia, or failing heart, you may need to be placed on a ventilator short term, just to get over the hump, per se. If a person is involved in a trauma, or if CPR is performed, then a person may be intubated and placed on a ventilator.

Those are easy decisions, especially when we are in emergent situations and are trying to save a life. However, there are also times when the decision to intubate or not to intubate can be complicated as complicated can get, and very stressful, and often disappointing if not discouraging.

In some cases you can plan ahead and write in your advanced directives that you do not want to be placed on a vent.  However, sometimes I have seen this declaration over-ruled at the point of impact when a person is in the emergency room and the person has to decide, "Do I want to risk dying now, or do I want to let these good people here in the emergency room help me breathe by placing a tube into my airway and assisting me with my breathing? Do I want to do that?"  More than likely, it will be, "Do I want mom or dad or grandma to die?"

Here I will provide some examples for you. All of these come from real life examples as I have actually seen them in my eleven years as a registered respiratory therapist.

One of the most frustrating examples to me was when a person decided they did not want to be placed on life support because, "I don't want to spend the rest of my life on one of those things," or "because I don't want to become a vegetable." In thinking this way, many people choose the following in their advanced directives: Full Code, Do Not Vent, or Do Not Intubate.

I have to cringe when I see that. I cannot believe any lawyer or doctor -- or advisor -- would recommend that option, because when a person's heart stops, and we have to do CPR on the patient, we also have to pump in quite a bit of medicine, and 99.9% of the time the patient does not survive a code breathing on his own: he has to be intubated and placed on a ventilator. Thus, if we do CPR, we have to put you on a vent -- there is no other option.

What might confuse people is what you see in the movies. There was one episode of "Walker, Texas Ranger," where Chuck Norris's character was having chest compressions performed on him, and his friend who broke his arm was watching on. Then Chuck woke up, the ambulance arrived, and the person who was taken away on the ambulance was not Chuck, but Chuck's friend with the broken arm.

It does not work this way in real life. The majority of the time when CPR is done on a person, that person buys himself a ventilator. That is, unless you are a DNR. In short, DNR means Do Not Resuscitate. That means if your heart stops we will not try to restart it. And, if you stop breathing, we will not place you on a ventilator. We will let nature take its course.

However, if the people working on you don't know you are a DNR, you will end up on a vent regardless. Not only is that the ethical thing to do, it's the law. If you're going to err, you err on the side of life.

However, I do think the decision not to become a vegetable on a vent is a valid issue for most people. Yet, one also has to consider the definition of a vegetable. Are you a vegetable when you have no body, but your brain is fully functional (as would be the case Lou Gehrig's Disease).  Or are you considered a vegetable when your brain if officially declared dead but your body continues to life?

Some people value life so much that they would want to live so long as they have control of their brain. That was my grandmas wishes when she was diagnosed with multi system atrophy, a disease similar to Lou Gehrig's Disease.  As a pro-life advocate, I totally supported her decision.

However, there was also the issue of depression and humiliation as you are fully aware that you have a tube up every orifice, and some strange person wiping you every time you have a bowel movement. Not only that, but you have to have someone assist you every time you move anywhere. Basically, you are a mind without a body. Do you want to live like that? Do you value life that much? Some people do. And we medical workers respect that.

Then you have the people who have Alzheimer's. These people will have fully functioning bodies but no mind. No mind no matter, no matter no mind. I would imagine that this might be the best way to end your life on a ventilator, if one had to choose between the two.

If I were an elderly person diagnosed with Alzheimer's, I would simply make a wish to be a DNR just so that I wouldn't become a ward of the state, a useless blob of skin on a bed taking up space and absorbing taxpayers money.

However, that would be my decision. I have to respect the wishes of others who think otherwise. Thus, life is very precious no matter how fragile, and each individual has to decide for himself. Grandma should be allowed to  choose for herself how she wants to die. This is why it is so important for physicians to be honest with their patients and talk to them about end of life options.

Then, let us consider the COPD patient who decides that he does not want to be placed on a ventilator. He is not necessarily end stage, but he is to the point that he cannot go without using his oxygen. However, he has a quality life to the extent that he is not one of those people who simply sits around and feels sorry for himself. He loves life. He loves living.  Yet he was also scared by the prospect that he might be placed on a ventilator and have to stay on it the rest of his life. So he makes the decision one day that he will make himself a dd not vent patient.

Then one day he is having trouble breathing. His wife drives him to the hospital and by the time he arrives there he is severely short-of-breath; his work of breathing is labored. The doctor looked the patient straight in the eyes and asked the question no one wants to ever hear: "If something happens to you, do you want to be placed on a ventilator?"

Of course now the patient is not in the planning stages. He is actually miserable, gasping for every breath. His oxygen levels are falling. His CO2 levels are rising. He is pooping out. He has a feeling of impending doom. He, however, does not want to die; he is not quite ready.

Then again, he does not want to go on one of those things either; he does not want to be intubated.

So, he asks the naive question that is really not so naive because the only people who truly knew the answer were standing in the bright room around him. Of course there were other COPD patients who knew the answer, but they were not in the room. His life, his destiny, was in the hands of the fine medical workers in the room.

"So," he says, huffing and puffing, barely able to get the words out, "How long would I have to be intubated for?"

"Well, the goal would be a day or two, but we really can't guarantee," the doctor explained. Of course she doesn't want to give false hope, but she also doesn't want the patient to simply give up hope at the same time. This is the ironic twist that we often face in the emergency room. She continued: "The goal is basically to rest your lungs and allow them a chance to heal. That's the goal. I can't guarantee anything, but that's the goal."

I stand there thinking, as I am getting my intubation equipment ready just in case the patient makes the decision, that the doctor made a good presentation. In fact, I couldn't have worded it better myself. The key words there were help you get over the hump and I can't guarantee anything.

By these short phrases the doctor threw the ball completely in the patient's corner. And, if the patient were to pass out, into the wife's corner. And if the wife were not there, the medical staff would have no choice but to make the patient a full code and do everything for the patient, unless they were 100% positive the patient was a DNR.

Another case I've seen is the elderly man with a chronically failing heart come into the hospital in respiratory failure secondary to the failing heart. The patient is non-responsive, and he is also not a declared DNR. The wife now is forced to make the decision of whether or not to allow nature to take its course, or to allow the medical staff to intubate her husband and place him on a vent.

"What should I do?" the patient's wife asks the Doctor.

"Well," the doctor says, "I know this is a difficult decision. Since you are in a very stressful situation right now and you want to make sure you don't make the wrong decision, perhaps it would be best to let us intubate your dad, and you can see how things progress, allowing yourself some time to spend with your family and to think. Then, in 24 hours or so, you can see how things are going with your dad. Either way, I can't make any promises. It's your decision."

The doctor pauses, allowing the patient time to think.  He then says, "Technically speaking, the goal of going on a vent is short term therapy to allow your husband's heart and lungs to rest. If things work out, he might come off in a day or two. However, I can't honestly say those odds are very likely right now. But, if things don't work out, he very well could be dependent, that's always a possibility. But if it comes to that, you can make a decision to terminate the vent if you wish."

After another pause, the doctor solemnly states, "However, if he doesn't go on a vent now, there is very little chance he will survive this."

Yes!  That was so true. The doctor was very honest with the patient.  He did was was necessary.

In this case, the wife decided to place her husband on the vent and the patient came off two days later with full mental capacity. Of course he was limited in what he could do, and had to go home with oxygen. And while his heart remained severely fragile, he was able to spend another two years with his family.

Thus going on a vent to get over the hump bought this man two years to say good-bye to those he loved, and allowed those he loved to say good-bye to him.

I talked to the wife a year after he died, she told me she was very pleased with her decision to place her husband on the vent. She said her dad was also very pleased.

One time we had a lady on a ventilator with ARDS, and as she was on the vent for the fourth week. It was becoming evident that she wasn't going to make it. The patient had already been given a slim 10-20% chance of surviving by the doctor.

But the family stood firm with their hope, and prayed the patient would not only come off the vent but have some quality of life thereafter. Even the family was starting to give up hope after a while, though. Then one day, as though by some miracle, the patient woke up and was eventually discharged.

I know that's a rare instance, but patients with grim chances of survival can survive. And while it might be fine to say, "I've seen people like this survive before," you still don't want to give a family member false hope.

Likewise, I have seen many cases similar to my above examples go in different directions. In the medical field, you just never know what's going to happen. And, when you are making end of life decisions, you never know what the right answer is.

There are times, though, where I would definitely recommend a DNR status. These would be elderly people over 90, and any person who has a terminal end stage illness. If you have an 80 year old lady dying of cancer, it would be kind of foolish to place that person on a vent, when all the vent would do is delay the inevitable, and cost the family insurance and taxpayers thousands of dollars in the process. I'm not saying that money is more valuable than life, I'm not saying that at all.  What I'm saying is that sometimes it's just noble to let nature take its course.

Yet, I see these people going on ventilators all the time. In many cases it becomes quite frustrating to see these people on the vent for weeks on end. And, this can quite possibly be one of the most frustrating parts of the medical field. Sometimes I even feel sorry for these people, especially when it appears to me they are trying to die, and their family members keep pushing for them to live.

Recently I placed a cerebral palsy patient on a ventilator. He is off now and back at home in the care of his family. The quality of life for this person was already pretty low, but the family loved this young man and truly valued the sanctity of life. We had to respect those wishes, and we took care of him as we would any other patient.

So, if you are wondering whether or not you want to be a full code or DNR, or whether or not you want to go on a ventilator should your body start to fail you, you should take some time to consider the what ifs.
It might be a difficult thing to stop and think about, but it could save you and/or your family members a ton of grief and stress.  It would help you and your family prepare for the end.  It would help you die with grace and dignity.  It would let you decide how you want to die.

As you can see, this is not an easy subject matter for anyone, including us in the medical field. And this has been and will continue to be an important ethical discussion for years to come, especially as we live in a world where we have the means to prolong life.

We are all vulnerable

Today is my 8th day off in a row. It hasn't actually been the most ideal vacation since it took spending 3 nights in the hospital to get days off, but I'm feeling quite refreshed none-the-less.

Even though I wasn't even close to deathly ill, I came home last Thursday and appreciated my wife and children more so than I normally might. My job allows me to spend quality time with my family, but I spent even more quality time with them.

I suppose I came home with a growing appreciation for what little I have. Not that I didn't appreciate it before, but I appreciate it more so now -- at least for a while.

I also feel vulnerable. I think that's a normal feeling people get after spending a few nights in the hospital. By vulnerable I mean not feeling as though I'm going to live forever, and I need to take care of myself so I'm still around when my kids have kids and their kids have kids.

Perhaps all people who work in a hospital have some sense of vulnerability, since we see what happens to people when they don't take care of themselves on a daily basis. Despite this, however, we still tend to turn a blind eye to this. For lack of a better word, we become numb to it.

We become numb to it despite all the people who tell us, "If I'd have known I was going to live this long I would have taken better care of myself."

Yet, how many among us still continue to smoke, to drink on a regular basis, or eat excessively? How many among us are going to fill up on all that candy sitting around the nurses stations this year? How many among us are still going to pig out at all those Christmas parties until we are bloated?

The truth is, most of us will. And even while I had been working out in an attempt to get in better shape before becoming an in-patient last week, I had been slacking to some extent. Yes, I am in better shape than most people my age, but I am still overweight. I am still vulnerable.

We all can think of many among us who smoke, drink and eat and be merry all day long or at least "socially" and never seem to have any consequences to this. While I do all of these (except smoke) on occasion, I have learned I have bad genes that won't allow me to not suffer any consequences.

Not that this would have prevented my most recent hospital visit, because my doctor said it was simply, "luck of the draw" that I got H. Pylori in my small intestine. But still, people with good genes would not have been hit this hard.

There is no way anyone of us can be perfect. There is no way to avoid all the temptations proffered to us this time of year, so long as we are aware of what we are doing; so long as we are aware of our vulnerability.

I think it's this vulnerability that we feed when we educate our patients on what they need to do to improve their lives. While most of these people will follow what we say to a tee while they are still feeling "vulnerable" after their release from the hospital, they will soon forget, as most of us forget too as time passes by.

They will forget until they get sick again. They will forget until they get so sick they are forced to change their lifestyle, because their disease process will no longer allow them to smoke, or to drink, or to eat excessively.

It is important to enjoy life. It is also important to at least be aware that we are also not impervious. We are all vulnerable.

Click here for my experience with vulnerable.

Here's my advice for hospital patients

Based on my own experience as an in-patient earlier this week, I've come up with a few bits of good advice for anyone going to the Emergency Room, or who might be a potential hospital in-patient.

1. Know your rights as a patient
2. Make sure you have someone with you.
3. If you think a therapy might be ridiculous, you may be right
4. Know you have a right to refuse therapy.

As you know from reading earlier posts on my blog, there are a lot of frivolous doctor orders pertaining to respiratory therapy. Knowing this, I ask nurses all the time if they get stupid orders, and usually they tell me they do, but can never think of anything off hand.

With no disrespect to doctors, I know they have a tendency to write orders out of habit and not necessarily because they are all necessary. Now that I've been that patient, I saw first hand what some of these frivolous orders are.

After I was told I was going to be admitted, and after I was stoned on phenergin, my ER nurse approached me carrying a foley kit. "The bad news is we don't have a male working who can put this in."

"I...don...crrrr..." slipped from my lips. I was trying to tell her that I didn't care who put the damn thing in, it wasn't going to happen.

Thank God I followed patient rule #1, because my wife was sitting right there and refused for me. She made sure the nurse was aware that we had a pact that the only time anyone would stick a foley in me is if I end up on a vent.

I like to call it a DNC order: DO NOT CATH.

"Why do you need to put a foley in him," my wife asked. "He can get up and pee."

"I don't know," the nurse said, and tossed it aside.

My wife added, "Just make sure you keep good track of your pee."

That was the end of that. In retrospect, I think this RN wanted me to refuse; that she knew it was a dumb order, but out of respect for the doctor she couldn't come right out and say it. I suppose this was not unlike me when I know a patient doesn't need a treatment.

Later that night, after I was admitted to the floor, a nurse woke me from a sound sleep. "I have to put these on you."

"What?" I said, groggily.

The RN said, "Sequential compression devices (SCS) to prevent you from getting clots."

"What do I need those for?" I know what they are for, but why do I need them?

"It's protocol to prevent clots." Clots? I can flip myself over no problem. And I didn't get clots when I slept in my own bed just last night.

"Okay," I said, "I'll try it." Why the hell am I agreeing to this? This is ridiculous.

Those damn things made my legs sweat, were excessively loud, and were extremely annoying. Not only that, but they made it nearly imposible for me to sleep on my side, which is how I like to sleep. These are coming off as soon as that nurse gets back in here.

"Why do I need these things again?" I said when she checked on me a half hour later with a syringe in her grasp. I proffered my arm.

"We have a standing protocol that all patients have to get these to prevent clots." She inserted the syringe into the IV.

"Every patient has to have these?"

"Yes."

"Well, that's ridiculous.

"I know." She's agreeing with me. That's it. She knows it's a stupid order.

"I thought it was just respiratory therapy that got stupid orders." Okay, shut up man; you're crossing into grumpy patient category.

She didn't say anything, finished her work on my IV. The machine beeped momentarily as she pressed a few buttons, and then she stood by the side of the bed.

What? Are you waiting for my order. "Then take these things off. I'm a young guy and I don't think I have a problem with clots."

"Okay," she said, and pulled the blankets from over my feet without hesitation. She's not argueing with me. That's reassurance enough. I heard the rip of the valcro as she stipped those things I couldn't remember the name of off.

I felt fresh air upon my ankles. Ah, that feels good. I rolled over and within a few moments was having pleasant dreams again.

"Do you think I need those things," I said to my wife when she arrived after breakfast the next morning.

"No," she said, "but I know sometimes doctors write orders just out of habit."

"I kind of figured that."

"You know you almost agreed to a foley last night? You were lucky I was here."

"Thank God for you."

She told me she remembered a time when she was working in OB when the doctor ordered a cath on a lady. She approached the doctor. "Why does this patient need a foley?"

"Oh," the doctor said, "I just wrote it out of habit. I'll DC it."

Dr. Tree said nothing about me not having a foley when he checked on me that morning. I wondered if he even knew he ordered it.