On RT School and Hitting a Plateau

I apologize for the serious lack of quality posts lately. It appears that I haven't had much to say about "Surviving RT School," or anything in general, because quite frankly, nothing interesting has been going on in my life as far as school and work are concerned.

That's right. My kind readers, the Trauma Junkie has been nothing more than a neb jockey as of late. And let me tell you, that gets pretty boring at times. Those of you who are in RT school know what it's like to work with a bad therapist: you know, the ones who dump their assignment on you, don't take the time to answer your questions, rush you, and treat you more like a coworker who has been in the field for 10 years as opposed to someone who is working in the hospital for the learning experience.

This is only topped off by the fact that every patient I've been assigned lately wasn't very complex, medically. Don't get me wrong; I realize that a lot of the patients RTs see in the hospital aren't admitted for respiratory issues, but it's been week after week of caring for mom or dad with a GI bleed or broken arm who has a history of asthma and gets q4h treatments, like they take at home. Nothing out of the ordinary, nothing thought-provoking, nothing interesting. Until today...

The RT I was working with, off the bat, told me to sit down, catch my breath, and look through my patients chart. He actually took the time to assign me patients with serious respiratory issues, answer all of my questions, and he allowed me the time I needed to spent with my patients and their charts to really feel as if I accomplished something, instead of driving home and wondering what I forgot to do.

One patient in particular was quite interesting, a 34 year old male who had a grossly unremarkable medical and surgical history (despite diabetes and a cholecystectomy years ago). During my shift assessment, the patient was noted to have increased WOB via nasal flaring, retractions, and tachypneic at a rate of about 28 (labored). Nurse's notes showed the patient was febrile for the past few days. He reported to me a dry cough that was progressing to a productive cough with large amounts of blood-tinged sputum. He complained of chills, dyspnea on exertion, and night sweats.

On auscultation, the patient was diminished bilaterally in all lung lobes and bases. Heart rate and rhythm were regular. No clubbing or cyanosis, but there was +1 peripheral edema.

Okay...this is my type of patient. In case you were guessing pneumonia, you are correct. What's so interesting, you ask?

Well, this particular patient had Pneumocystitis jiroveci pneumonia.

PCJ Pneumonia is a rare strain of pneumonia, most typically seen in patients with AIDS. In fact, we were taught in school that we would probably never see it in a patient who didn't have AIDS or was HIV-positive.

Never say never. Per the pulmonologists' notes, the patient reports homosexual encounters but was negative for HIV, even with repeat testing. Socially, he works as a CNA and has for the past 16 years. He reports no contact with TB patients. He doesn't currently smoke or drink, but has a 10 pack year history and quit cocaine 3 months ago. Urine drug screens were negative for illicit drug use.

We know that PCJ Pneumonia also only occurs in patients who are severely immunodeficient, which is often why it is linked to AIDS. CD4 counts of 200 or lower are typical.

So that begs the question-- What is compromising Mr. Jones' immune system? Histoplasmosis.

Histoplasmosis is a disease caused by the fungus Histoplasma capsulatum. The patient reported no previous travels, with the exception of visiting some caves in a nearby town around just about a month ago today. Histoplasma capsulatum grows in soil and material contaminated with bird or bat droppings. When asked, he did recall seeing bats and large amounts of guano.

As far as respiratory is concerned, the patient was receiving DuoNeb (albuterol/atrovent) q6h and q2h PRN dyspnea. I can also now say that I've administered Pentamidine SVN (another one of those drugs we were taught to be familiar with but not memorize because we'd probably never see it given). Although Mr. Jones has never required supplemental oxygen to sustain life, he now wears BiPAP at night and is on 5L nasal cannula during waking hours. Any attempts to decrease the liter flow at this time have failed, as the patient desats rapidly within seconds.


I guess this is just further proof that disease can strike at any time, and the outcomes can be very severe. In the area where I live, there are quite a few caves nearby and I've visisted them on many occasions, as do hundreds of people each day.

And that, my friends, is where we come in. As RTs, take the time to review your patients' charts, talk with your patients, know every relevant detail, and study to learn, not to memorize.

Your assessment skills, interviewing abilities, and being to recall what you were taught regarding both disease processes and pharmacology are undoubtedly the most important assets we possess.

Every now and then, you get to be more than a neb jockey. Hold on to those opportunities to use everything you've learned, and really, this career won't be too bad.

Challenge yourself. Often.

A Fight for Lives

Photo credit

Teamwork is definitely the greatest asset to any ER, as is proved by this story. People who have never worked in the emergency room on a busy night have no idea what it can be like when the traumas are coming in back to back.

Seriously, given the situation, I salute these guys. They are heroes in ways they don't even know. I only hope that I can emulate their abilities one day.

H/T WhiteCoat for linking me to this article.

From the Archives...

I realize that some of you have just came to my blog in the past few months, weeks, or even days (Thanks again, David!) I've had a bad case of writer's block lately, so in the mean time, here's something from the archives for your enjoyment:

YOU MIGHT BE AN RRT/RT STUDENT IF:
1. You spend so much time studying patient assessments, that you're aware of lung sounds in the checkout line.
2. Terms like "ASSS," "PISS," "DISS," and "clubbing," take on a new meaning.
3. You go to work and consider it a nice break from school.
4. Even if you have a job outside of school, when people ask what you do, you tell them, "I'm a student."
5. When you tell people your major, they say, "What's that?"
6. You know the significance of the phrase "Ninety-nine."
7. You've auscultated lung sounds on your mom, dad, kid, spouse, grandfather, grandmother, and so on...
8. You love the high amounts of caffeine in Starbucks coffee (great for late night study sessions), and you also know the affect of caffeine on the respiratory system.
9. You've considered intubating someone around you who just won't shut up.
10. You have started realizing that medical dramas/sitcoms aren't anything like the real world (What?! You mean the doctor doesn't bag the patient during CPR?)
11. You realize that a jaw thrust isn't just something that happens in a bar fight
12. You can look at and comment on the shape of someone's curves without getting slapped for it
13. You know and fully understand the dangers of uncovered trach, and you avoid standing directly in front of one at all costs (You probably learned this one the hard way)
14. You know what the Sputum Bowl is and have even considered participating in it
15. Your Lego skills as a kid have come into play when trying to put together two things that don't want to go together
16. Watching a doc shove a camera down someone's throat isn't just part of the job or something you have to do in school, it's cool as hell
17. You curse the operator at the mall or the grocery store for starting her announcements with "Attention please..."
18. You see someone smoking and think of it as "job security"
19. At least a couple of times a day you explain that you have to suck, not blow, to make the balls go up
20. You can guess a saturation pretty accurately just by looking at the blood, or the patient
21. Your day (or night) doesn't begin until you've had your first, or second, or third cup of coffee
22. You've learned that 90-something year old FULL CODES really exist
23. You've pulled the family into the room during a code to get them to tell the doctor to switch mom or dad back to DNR status
24. You know that tripodding is not just something you see in gymnastics
25. You know that "PEEP" is no longer a sound made by a chicken
26. You believe that unspeakable evils will befall you if anyone says, "Boy, it sure is quiet around here."
27. You hate working on nights with a full moon
28. Terms like "sympathomimetic adrenergic beta-2 agonists," "anticholinergic parasympatholytic bronchodilators," and, "hydropneumothorax," all make sense to you.
29. A nurse pisses you off, and you kindly tell your patient, "If you need anything, and I mean anything at all, don't hesitate to use your call light," knowing that you will be in the RT department for most of the shift.
30. In the RT program, a study group for you involves/involved Egan's Fundamentals of Respiratory Care, a Red Bull (or two), and your class notes.
31. You either work night shift or want to work night shift to avoid all of the daily, BID, TID, and QID breathing treatments.
32. You know that an SpO2 of 100% does not rule out hypoxemia
33. You have no problem discussing sputum over lunch.
34. You've ever had a nurse call you about an alarming vent or BiPAP, asked them what the alarm sounded like, and were able to tell them how to fix it over the phone.
35. You've found yourself saying, "Good cough!" to complete strangers.
36. Not only are you familiar with the terms "blue bloater" and a "pink puffer," but you can probably tell which one a COPD pt is just by looking at them from across the room
37. You coworker can tell you that they just spent 45 minutes on pulmonary toilet and both of you know that it has nothing to do with the restroom
38. You know that wheezing after a bronchodilator SVN is sometimes okay
39. You spent a ton of time learning about Heli-Ox in school and have maybe seen it used one time in your career
40. Dalton's Law of Partial Pressures, Law of LaPlace, Frank-Starling Law, Boyle's Law, the Ideal Gas Law, and Law of Avogadro: you know these inside and out, as well as their practical application
41. You've found yourself telling others that "COPD isn't a disease. It's a group of diseases."
42. You hear vent alarms on your day off
43. You have avoided people in stores who are SOB
44. You're tempted to carry a pocket mask on dates (or to the store)
45. You've ever heard "Code Blue" in your sleep
46. You know your ABG's to the point that you can interpret them in your sleep (and probably have at some point)
47. You have ever said or overheard the following conversation between an RT and a nurse: "You deal with the stuff below the waist, and I'll deal with the stuff above the waist."
48. You've had days where all you do is sit around and wait for someone to code
49. You've had more days in which you never get to sit down and people are coding left and right.
50. You have calculated the pack year history of all your relatives and friends who smoke

0327

"What time is it? I'm calling it."

The physician was sweating, and his voice was faint as he spoke the words that every doctor hates to say.

From across the room, the charge nurse spoke up, "O three twenty-seven, Doctor Jameson*." She scribbled the time down on her records.

And with that, the entire room was clear. Members of the code team dispersed back to their respective departments. Floor staff resumed care of their own patients. And it was almost like it never happened, like Mr. Smith never even arrested, because there were still other patients who had to be taken care of.

********

James Smith, Sr., was well-known to the staff at Memorial Hospital. You could say he was what is colloquially known by nurses and doctors alike as a "frequent flier." Just about once every month or two, Mr. Smith would return with a different medical issue than he present with before. He always ended up being admitted, and for some reason, he was always placed on Unit 3B.

Aside from being about the nicest man you could ever know, Mr. Smith was a man of God and man of the service. He was a captain the United States Air Force, attended church twice a week, and would be more than happy to tell you about the time he spent in a church or overseas.

It was fascinating just to hear him talk about any of it. He had been places that no one could imagine, from Paris to Germany to a makeshift prison where he thought he was going to meet his end many nights during World War II. He'd tell you that he never figured he would live to tell about any of it.

Mr. Smith never smoked, never drank, and never did illicit drugs. When asked, he would tell you he was, "As straight as an arrow..." So, needless to say, it was hard for Mr. Smith to understand why he developed so many health problems later in life. And to be quite honest, I don't think anyone else knew the answer either.

This particular time, however, he was in with community acquired Pneumonia.

*****

I just finished rounds at 0300. All of my patients were resting in bed, with no complaints. I headed back to the nurses' station to begin documenting from earlier in the night.

As I began to circle various things and check boxes on the documentation flowsheet, I start to get an uneasy feeling.

Something was out of place. Something wasn't right.

I had only been a CNA for two days at this point, and this was my first time working in a hospital. It could have been anything.

But something told me it wasn't a mistake in charting or something as simple as forgetting to move the patient's bedside table within their reach.

I couldn't quite put my finger on it, so I decided I would start vital signs a little early. I knew that Mr. Smith wouldn't be asleep yet, so I went to his room first.

There, laying before me, was the body of Mr. Smith. There was no smile, his eyes were closed, and he was cocked off to one side, almost like he was stuck in that position.

You don't have to be a CNA for long to realize that something was wrong with this picture. This wasn't Mr. Smith-- not how we knew him.

Ten seconds. You can do it. Look, listen, feel.

The CPR class I took for the first time two days ago was playing in my head.

No pulse. No spontaneous respirations. I called the code.

I pulled the ambu bag from behind the bed, hooked it up, and gave two rescue breaths.

Where the HELL is the code team? (It had only been 20 seconds at this point.)

Still no pulse. Start compressions, I thought to myself.

Somewhere during the first cycle of compressions, entered a large group of people to include nurses, doctors, and respiratory therapists. I don't even really remember them coming in, but I do remember making eye contact with the doctor, and he gave me an affirmative nod.

"Just keep doing what you're doing. Let's get him on the monitor." Dr. Jameson's voice was calming. When he spoke, the entire room became silent, awaiting his orders.

I watched the cardiac monitor as I circulated blood through Mr. Smith's body and I couldn't help but think that this man was talking to me not even thirty minutes ago. His heart was circulating its own blood. He was breathing. He was alert, awake, and oriented.

Don't you die on me, Mr. Smith. You've got grandchildren who love you. James...

I pretended for a second that he could hear what I was thinking as I pumped on his chest then I snapped back to reality. The room was loud again, full of people talking, everyone's eyes affixed on the monitor.

"Stop CPR. Let's see if we have a rhythm," piped up Dr. Jameson over all the commotion.

It was clear that when the compressions stopped, Mr. Smith was still asystole.

"One milligram of Epi in. Resume compressions."

And again, I began pounding away at his chest, pumping my arms up and down. I knew the compressions were truly effective at the point in which I was forcing blood into the syringe with each compressions as the respiratory therapist obtained an ABG from his femoral artery.
One...two...three...four...five...six...

I counted. I'd worked in health care for a long time before becoming a CNA and I had heard stories of people gasping violently for air and opening their eyes during CPR, only to return to this earth fully recovered and move on with their life. Part of me thought that would happen. Part of me wanted him to wake up and look at all of us.

Mr. Smith received two more doses of epinephrine just about five minutes apart.

Dr. Jameson spoke up, "How long was he down?"

Seven... eight... nine...

"Hard. To. Say. Ten minutes at most. I was just in here." I was out of breath at this point, but I didn't want to stop. I couldn't stop. I could feel my entire body aching.

"Are we still asystole?"

I stopped compressions long enough to glance at the monitor.

An ICU nurse spoke up, "Yes, still asystole."

"Let's get in one more set of compressions."

*****

On that particular morning, at 0327, CPR stopped. Mr. Smith's heart wasn't beating and he wasn't breathing on his own. I'd like to be able to say that we left the room for a few seconds and the monitor showed Sinus Brady with a rate of 20. I'd love to be able to say that Mr. Smith saw his grandkids again. I'd like to be able to say that Mr. Smith got a second chance at life. But you know I can't do that.

What I can say, however, is that he is in a better place. If I could talk to him now, he'd tell us he appreciated everything we did. Our perseverance, our determination, and our empathy.


This, my friends, is the day I became a trauma junkie. I'll never forget 0327.

The Things You DON'T Learn in School

Epijunky over at Pink Warm and Dry has written an excellent post titled, "A Blur of Pink." I won't give away too much, but here is an excerpt:

He was a large bear of a man, holding what looked like a blur of pink in his hands. A woman was shrieking inside the house, her screams a soul shaking guttural wail. All of a sudden things were becoming very clear to me.

This was not an old couple. There was no 80-year-old man laying on the floor of his kitchen waiting for me.

I didn’t even get two steps outside of the truck before the man practically heaved the Baby to me...

Can you imagine? What you assume is a fairly normal call, turns out to be an entirely different story. Some of us in healthcare thrive on the fact that we never know what is going to happen. It's safe to say that those of who are drawn to trauma love the challenge, the ability to apply our knowledge, and the use of our assessment skills and clinical knowledge that we use to treat the most severe patients at the worst time of their lives.

Most of that is learned in school. But what about the stuff you don't learn?

A friend of mine came up to me the other day and we were talking about our recent rotation through the emergency department in clinicals.

My friend says to me, "How do you not get attached?"

The most obvious answer that any EMT, Emergency Physician, or Nurse will tell you is that you never look the patient in the face. It's just as simple as not letting yourself get attached.

What no textbook or years of experience can prepare you for are those rare moments where you do, in fact, become attached.

There's going to be a time in all of our careers when we look at a patient who is crashing and think, for just a moment, that this could by my kid or my mom. How do you deal with it?

I don't know that there is a right or wrong answer, or if there even is an answer, but I'd definitely recommend that you take the time to read this post.