Lately...

I apologize for the lack of posts lately.

Life has been kinda hectic for me. A lot of it I can't go into for one reason or another, but just know that I've been stressed to the max most days.

Yep, that's right. To quote my best friend, "I'm fried." Crispy, even. It's a feeling I never really understood until I experienced it myself.

School is kicking my butt. As we're nearing the end of the semester, it's a little less challenging, but finals are coming up soon, and I fully intend on rocking them. It's just going to take a little work.

So what's been going on this semester? Well, as I posted a while back, it's the start of my second year of RT school. It's been pretty busy. We're building on concepts we learned first year, and learning a lot of interesting things.

Here are the classes that have been occupying my time:

1. Pulmonary Diagnostics
More than you could ever want to know about sleep studies, capnography, flow-volume loops, pulmonary function studies, bronchoscopies, lung/chest imaging techniques, and the like. Interesting stuff, folks. I'm slowly finding out that next to good assessment skils, diagnostic skills are key.

2. Advanced Respiratory Care Patient Assessment
By far, my favorite class. I may or may not have talked before about how much I enjoy using my assessment skills to troubleshoot and treat my patients. Without these skills, there wouldn't really be a need for respiratory therapists. It's this particular class that helps me realize that we truly are specialists in the health care field and that we have a lot of good knowledge we should put to use. EKG interpretation, analysis of serum and urine chemistry, auscultation of heart sounds, and so on and so forth. Fun times.

3. Mechanical Ventilation
VC/AC, PC/AC, SIMV, PRVC, bilevel, APRV, VC+...say whaaaa? That's right. Homeboy knows his way around a vent now. This was, without a doubt, the most difficult class I have ever taken in my entire college experience. And believe me, coming from the guy who didn't know what he wanted to do with his life and has all the pre-requisites finished for four different degrees, that speaks volumes (Volumes? Yeah, I guess I still have ventilators on my brain). I remember when we first started working with vented patients and I was so intimidated, but now I have the confidence I need to be able to perform my job well.

As far as reading material goes?

Waugh, et al. Rapid Interpretation of Ventilator Waveforms, 2^nd Ed.


Ruppel, Manual of Pulmonary Function Testing, 9^th Ed.


Cairo and Pillbeam, Mosby's Respiratory Care Equipment, 7^th Ed.


Wilkins, et al. Egan's Fundamentals of Respiratory Care, 9^th Ed.


Chang, Clinical Applications of Mechanical Ventilation, 3^rd Ed.

So, there you have it. Add a precious three-year-old into the mix and such has been my life for the past 4-5 months.

I promise I'm working on a few posts that I have saved in my drafts folder. Bare with me as I get through this (I *can* get through this, right?), and I promise great things will be coming soon.

How's your life been lately?

One Last Breath.

As RT students, we are always taught how important it is to maintain a patent airway. We are taught from the beginning of school how to treat shortness of breath, airway obstructions, hypoxemia, and respiratory failure. This is our job. It's what we do for a living.

Many of us pride ourselves on being in a profession where we help people breathe better. I can't imagine anything better than treating an asthmatic who comes in with a full-blown attack and seeing her get discharged from the ER with a respiratory rate of 12-20, non-labored. Or weaning a vent patient to nasal cannula successfully. As they say, if you aren't breathing, you aren't doing much else.

At the same time, sometimes we have to go against what we have learned, based on the patient's decision. And that can be both emotionally trying and somewhat difficult to do. But it's important to keep in mind that we're in this for the patients and for no other reason.

Yes, I did it. I finally had a time where I had to withdraw care from my ventilator patient. I was the one who had to go into the room full of crying family members and turn off the patient's vent, knowing there was basically no chance of him being able to breathe on his own. And let me tell you, that...was the most difficult thing I've ever done, next to coding a pre-schooler.

For the first time, instead of helping a patient breathe, I had to take their breath away.

Instead of using everything I've learned to make adjustments to the vent to help this patient breathe on their own, I had to put it all aside and D/C the ET tube.

It was no longer my job to notify the nurse when her patient started bradying down (50s, 40s, 30s, 20s).

I did not treat his shortness of breath. I watched as he went into respiratory arrest, followed by cardiac arrest.

But...

I held his hand and told him it would be okay.

I comforted his family members and reminded them we were carrying out his wishes.

I prayed with them when they asked if we could pray.

I did not become startled as he gasped for his last few breaths. I squeezed his hand tighter and told him it would be over soon.

And, as my patient took his last breath before my eyes, I didn't reach for the ambu bag. Not this time.


He's in a better place. There was no chance of recovery from his condition. I wondered how I would sleep that night, feeling like I was the one that caused him to die...

But then I realized something. We all love saving lives-- there isn't a better feeling in the entire world. And sometimes "saving a life" doesn't mean bringing a patient back after CPR. Sometimes, saving their life, involves putting them totally at ease. He can now breathe better. And, in a sense, so can I.

It's nice to be appreciated...

Keeping in mind that Respiratory Care week is just around the corner (Oct. 26th-31st), I came across an excellent post by a blog I've been following for a while.

When you get a second, head over to Nurse Jane's blog, See Jane Nurse, and read her feelings towards the respiratory department at her hospital.

Does that patient *really* need another neb?

(credit to KeepBreathing for the pic)

It's that time of year again. Everyone and their friend and brother is catching pneumonia, bronchitis, or even...H1N1. Which means, for some reason which is beyond the RT (or RT student), 99.999% of all patients in the hospital and emergency department will be given SVN treatments. Okay, so maybe that's a slight exaggeration. But not really.

Due to the seasons changing (or God smiting the lowly RTs-- one of those), everyone's asthma also starts to act up. This, in turn, means that we get to give a lot of nebs. (It's what we do, ya know.)

I have no problem with that. I love being busy. I love getting to use my assessment skills. I love being able to help people breathe better. But the problem comes into play when you have a particular doctor that overuses neb txs. You know what I'm talking about. Case in point:

I'm working ER yesterday at clinicals. A 5 year old male presents to us. No past medical history except asthma. On assessment, he is in distress. Intercostal retractions, tachypneic, coarse rales on inspiration and expiration. Auditory wheezes. Okay, this kid needs a neb.

Doctor orders 0.63 Xopenex (x2) and 0.5 Atrovent (x2). I don't really agree with this, but being the student, I give the treatment anyway. Post-tx, he has improved aeration and clear breath sounds, but he is still tachypneic and now slightly tachycardic (go figure, right?). It's not rocket science to figure out that the kiddo needs some steroids. Maybe Solumedrol IV?

An hour later, I'm called back to the ER. Xopenex .63 (x2) and Atrovent .5 (x2). Yes, an hour later. BBS are clear pre-tx. I give it anyway. My kid's HR increases from 136 to 180. I notify the ED MD and suggest politely that we hold off on more nebs or even consider a continuous neb, since they run at a lower flow and won't affect the HR as much. I also suggest we don't add Atrovent. He nods.

About an hour and 20 minutes later, ER is blowing up my phone again. Another Xopenex .63 x2. (Did I mention the kid took five albuterol treatments at home before coming to the ER? And yes, they're aware of this.) Again, HR goes through the roof. Now the kid is complaining of nausea. Instead of considering that maybe the SVNs are causing this, the doc orders some Phenergan IVP and orders another neb an hour later.

Seriously???

Don't get me wrong, I respect doctors to no end. But wow. How could this have been handled diferently? Just my suggestion:

1. Obtain a CXR

2. Draw an ABG to evaluate the patient's acid-base status (he was, after all, hyperventilating)

3. Steroids? Yes please.

4. Admit to inpatient for observation

Just sayin'.

Big Blue Eyes

My first day in the OR practicing intubations was something I had been looking forward to for a long time. The day was going well. I had seen several cases and successfully intubated four people. It was a typically busy Monday for the operating room staff.

Closer to the middle of the afternoon, things started to slow down. I made my way to the breakroom to eat lunch-- leftovers from the night before-- as I heard the pagers go off.

"Prep OR 7 for a trauma!" My anesthesiologist for the day said to one of the scrub techs. "We may get this one. I hope like Hell they make it to OR."

Making it to the OR would mean the patient was still alive. With traumas, it can go either way.

I glanced down at my pager, reading the words on the screen:

911: Level 1 Response-- 4 y/o female, cardiac arrest. CPR in progress. ETA 5 min.

I felt a huge lump form in my throat. My stomach sank. My palms became sweaty.

I made way to the ER, praying the entire time that she would be saved before I got there. Praying the page was somehow a mistake. Hoping, wishing, pleaing, bargaining... anything to save her life.

*********

As the body of a 4-year-old lay limp and lifeless there before me, I'd like to be able to say I was totally caught up in the moment. I'd love...to be able to say that, while performing CPR, I knew nothing but the objective data: Pulseless, apneic, and cool to touch. Asystole without compressions. Cyanotic. Two IV lines established. Size 4.0 ETT, 22 at the lips. Five doses of Epi in. Flail-chest.

But the truth is, when working on a kid, I learned this isn't the case. As much as I'd like to be able to say I was strong and my sole focus were the numbers, the drugs, the vitals, and how many cycles of CPR were given, I made a mistake that day that I always try not to make.

I looked at her innocent face. Her eyes, which were wide open during the entire code, started into me like the deep blue eyes of my own little one who is the same age. For just a brief second, I saw our patient outside at daycare, playing on the playground, laughing and running around freely like kids do so well-- exactly what she was doing shortly before she went down.

I wanted to be able to bring her back more than I've ever wanted to save anyone. I fought like Hell, trying to defy all odds. I begged silently. I prayed. I made amends with God in hopes that this innocent little girl would live to see another day.

I pictured myself in her parent's shoes, and the thought was absolutely horrifying. Just then, they came running down the brightly lit hallway of the emergency department. Security wouldn't let them in the room.

Her young mother was shouting, "Save my baby! Work harder!! Keep trying!" She could barely get a word in without sobbing hysterically. Her husband was trying so hard to console her-- holding her tightly in his arms, whispering something in her ear.

"Janet, let them DO this!" His voice was firm and commanding, but I could hear the pain. He was doing what he knew a husband and father should do. He was trying to stay strong.

I will never forget the screams from the parents or the little one we fought so hard to save. I did compressions for an entire hour, not wanting to let anyone take over.

I reached the point of shear exhaustion. My entire body was sore. I could feel my muscles aching, joints popping. None of that mattered. Eventually, someone grabbed my by the arm and took over. I was too tired to fight them, as much as I wanted to.

I stood in the back of the room and watched them continue to work on her for about another hour. It felt like minutes.

The trauma doc looked up at the clock, and I about wanted to collapse. I knew what was coming. He ordered us to stop CPR and stated the time of death.

Godspeed, little angel. You will be missed.

It wasn't supposed to happen. Her mom and dad kissed her goodbye before she left for school, like any parent would do. It was a normal day, in a normal town, and she was a healthy kid. She didn't deserve to die. It has been on my mind, even weeks later.

I know we did all we could. I do. And pedi codes are never easy. The next one...will be just as bad, just as trying, just as hard. I'll think about it for weeks like I have this one. It's a part of what we do.

We couldn't save her. It was beyond our control. And, as much as we wish she had made it out alive, it doesn't always happen that way.

RIP, babydoll. My heart is with you.