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.

No One is Perfect

...but it's important to remember that we're all just human. We're all in this for the same reasons. Epijunky has always reminded us of that, but her latest post really struck a nerve.

Go check it out and send some kind words her way.

For All of My Fellow Students

School is stressful. School is hard. If it wasn't worth doing, it would be easy. We all know this. We remind ourselves of this every day. So what do you do when you reach your breaking point? What do you do when you feel like there is nothing you can do but cry or give up?

Keep on going. Hang in there. A year from now, or two years from now, it will all pay off. If there is a concept you can't seem to grasp, or something you can't figure out how to learn, experiment with different methods. Keep on trying.

Remember that there are a lot of people out there willing to help you succeed. Don't ever forget that there are a lot of people rooting for you, a lot of people who have been there before, and a lot of people who just want what is best for you. They're here for you.

Do them proud. Do yourself proud.

When you get to a point that you feel like you can't possibly study anymore in one day, stop. But pick it up again first chance you have the next day. Studying is never easy-- it comes easier for some than others-- but it is never truly easy. As you progress through school, you will find ways to make it a bit easier, or figure out what works for you. But don't ever think you don't know anything. You're brilliant. All of you.

If you're the student who is going to school with no kids and no job, and living off of loan money and your parents, consider yourself fortunate. Don't take advantage of it.

If you're the student who has kids and a full-time job, hang in there. You will make it if you believe in yourself. You will figure out when you can study, when you can read, and when you can spend time with your children. This will come to you along the way.

For some of you, this is a second career choice. Some of you, your first. Either way, be passionate about it in all aspects of your daily life. The passion that you have for what you do will help you to move through the obstacles.

When life with school becomes too much, don't be afraid to take the time to chill out and relax. It won't hurt anything, just keep school in the back of your mind. If anything, remember all the good experiences you've had thus far-- that first time you intubated a patient, the first test you passed, etc. Remembering the good experiences and knowing that you will have many more in the future will help you out greatly.

You never know what life will bring you, but you can know that you are making a positive choice.

Keep your chin up.