For Respiratory Care Week this year, our department head got us a poster that says “Happy RT week. Now get back to work, you ingrateful bastards.”

No! I jest. Our department may be badly run, but the management is at least making an honest and heavy effort to recognize us for RT week. There is a CEU blitz, a few free lunches, a few fun and festive moments, and generally a good time. RT week is the one time of the year where everyone in the hospital is made aware of our department and the work we do, and I’m glad we get the recognition and credit at least once.

New (but not “new” any more) Nurse Jane has written a lovely tribute to RTs everywhere. Thank you, Jane, for the kind words and the affection!

And, to all RT and non-RT readers, happy respiratory care week!

A commenter who is a veterinarian has made some intriguing and well-thought out comments lately, and it reminded me of a story from the vet that happened to me not too long ago.

We took our cat to the veterinarian recently because he has been scooting his ass across the floor and we were worried he might have worms, or possibly some sort of anal gland blockage. We corralled him into the kitty carrier, sprinted to the car before he shredded the carrier from the inside, and then drove to the vet, accompanied by the melodic and high-volume protest singings of our feline friend.

We got to the office, got into the exam room, and produced the cat. Our vet, a kindly older man who walks with a cane, ambled into the room, glanced at the chart and then looked at our cat.

“Well, there’s the problem, right there. Your cat’s a fatty. He’s too fat to lick his butt, so he scoots on the floor. He needs to lose some weight…that’s diabetes waiting to happen. Is he lazy? Looks like a couch potato…most fat cats are. You need to put him on a diet and get him some exercise.”

I was stunned, then awed by our veterinarian’s honesty. Instead of hemming and hawing, he was direct and to the point. I half expected him to get a megaphone and say “YO! GIVE THE DAMN CAT LESS FOOD!”

He took the time to explain to us that not only was our cat way too fat at 18 pounds, but that being fat can cause the full range of illnesses in cats that it can in humans, from vascular problems to diabetes. He told us that since we can’t really let him be an outside cat, we should play with him more, feed him less, and look into some sort of diet food.

The whole time we were at the vet I was struck by how direct and honest this man was. It got me to thinking: why aren’t human doctors like this?

I mean, I can’t tell you how many times I’ve seen doctors let people slide on things. Instead of telling people that they will die if they don’t stop smoking and drinking heavily, they chicken out and avoid discussions about that lifestyle. Instead of telling people that living an inactive life will clog their arteries and lead to stroke and heart failure, they ignore these facts and simply avoid the unpleasant confrontation about defective lifestyles. Where is the candor? Where is the honesty? If my veterinarian can have an honest and frank discussion about the way we care for our animal, why can’t the pediatricians at work tell parents that their kids are fatties and they should avoid Burger King? Instead of “Oh, he’s a husky boy!” we need to hear “Sweet Jesus that kid is fat! What are you feeding him? How about you put down the fucking fork, madam, and get involved in your childs health instead of blaming everybody else for your failed parenting? Society didn’t buy him that cheeseburger…”

It seems to me that the medical establishment is unwilling to be honest with people about the way that their choices affect their health. Maybe if human physicians could take a cue from their veterinary cousins, modern medicine would work a little better. I know if I could find a human doctor who was as honest and frank as our vet, I’d see him until he retired.

The death of a loved one can be hard to accept. Watching a family try to deal with an unexpected death is not one of my favorite things in this job.

The patient in room 12 had been here for weeks. After an unfortunate cardiac event on the medical floor, he went from being a “walkie-talkie*” to being totally sedated, on the ventilator, on continuous dialysis, with a host of a dozen IV pumps whiling away at his side.

His poor wife was unprepared for this. What she had assumed would be a routine hospital stay had turned into a nightmare of epic proportions; machines, tubes, hoses, swelling, bleeding, oozing discomfort in the 24-hour maelstrom of our busy ICU.

Today, after a long and difficult discussion with one of our ICU specialists, she decided to let her husband go. She had given him a fair chance but it was the end of the road for him, and she knew it. We waited until she and her friend were ready, and then extubated him and D/Ced his pressors, dialysis, and all IV meds but Morphine for comfort. We swept the equipment from the room and rushed the family back inside so they could be with their dying loved one. Watching from the monitor, it took about two minutes for his heart to stop beating; I never did see any independent breaths. I took a deep breath and walked away to clean the ventilator from his room, and didn’t give it too much thought.

An hour and a half later, I happened to walk past the room and an odd sight was before me. The wife and her friend were seated next to the bed, wife holding the dead mans hand, coffee cups out on a small bedside table between the two ladies. They were chatting and laughing and reminiscing, and they were speaking to the dead man as if he were present. The nurse saw me staring and we watched these old ladies from a distance for a moment.

“Oh my god!” the nurse said. “Look at the monitor!” On the bottom of the heart monitor was a rhythm strip, beating away. She had forgotten to unset the remote monitoring for her other patients, and the family–seeing the heart beating on the screen–believed that the dead man was not, in fact, dead.

The nurse went in, pushed some buttons, and removed the strip. She explained to the family that the patient was in actual fact deceased, and had been for some time. The wife continued holding her dead man’s hand, sipping coffee all the while, and told the nurse

“I know he’s gone. But I need to talk to him some more…I just need to talk to him.”

Out of some weird compassion we let them stay and chat. They were in there with him for two more hours, reminiscing and talking, before they left and we took him to the morgue. They’d have stayed longer, but all the coffee they had been drinking had made one of the old ladies crap in her pants.

Elderly women drinking coffee with a dead man and then leaving his side only when forced to by an unfortunate loss of bowel control. I hope there’s more to getting old than this.

Such is life and death in the ICU. So much for dignity, so much for pathos.

*Able to walk and talk

Holy Cow, I haven’t posted here in a long-ass time. Sorry, loyal readers; many things have been afoot here on the other side of the internet.

I have a few fun things to write about, which I’ll try to post over the next few days. It’s the usual assortment: tragicomic moments in the ICU, issues with death and dying, rants and raves about things that infuriate me.

I’ll try not to leave y’all hanging for another month. More to follow soon.

All these are things that have been said to me on the medical floors within the last week:

“Jesus fucking Christ, another breathing treatment? I don’t even take these at home. My doctor ordered it? Why would he do that? If you don’t know, why are you even giving it to me?” I have to give props, this is an excellent question.

“Why do you need MORE blood from me? The nurse just took eight vials! It’s the same blood in my veins and arteries, I know it is, there’s no difference! You can’t fool me, I went to nursing school for a semester last year…you just want to run medical experiments on me!”

“No, I don’t want a breathing treatment. Have you lost your fucking mind?”

“So, what are you, some kind of candystriper? What’s that? You went to school for this? Wow…why?”

“Man, I never even seen the dude. I don’ even know who he was. He jus’ come up to me and stab me, jus’ like that!”

“No, no, I don’t think I need any breathing exercises. I haven’t even picked up that sucking tube there. You should check with my Doctor first. …What do you mean, he ordered it? No, he didn’t. I don’t believe you. Can’t it wait until after Jeopardy?”

“Breathing treatment? Oh, that thing? Yeah, I guess I’m supposed to take them at home…I do it maybe a few times a day if I feel like it…yeah, about two packs a day, but that’s not why I’m sick! I’m sick because of that H-A-1-1 thing…yeah, the flu. Naw, smokin’s not bad for you. I guess I’ll take your dumb treatment if it’ll make you happy.”

One thing patients never say:

“Gosh, thanks for doing your best to help me feel better.”

I have to tell you, I love what this job could be. The idea of making people’s lives better by making it easier for them to breathe is awesome. But in reality, we waste a lot of time dealing with treatments that are not indicated. We waste a lot of time trying to convince noncompliant patients that they need their therapy, which they will refuse to take. Sometimes, this burns…me…out.

Tomorrow: Things Family Members In The ICU Say!

I was working in one of our ICUs last week. One of my patients was a kindly little old lady of 96 years. She was a soft-spoken, tiny, shriveled little thing, but she was sweet and alert and fully capable of interacting with the staff beyond the usual condescenscions of “Awww she’s so CUTE.” If one were to actually talk to her like a human being instead of talking down to her like so many healthcare providers do, she was just the coolest person in the ICU. A youngun’ like me can learn from a soul of 96.

At 96 years old, she was ready and prepared to pass away. “I don’t want to live forever,” she told me. “I’ve done what I needed to do.” She had a fully signed and witnessed DNR/DNI form and wanted no aggressive care.

Her family, a staunchly religious group of people, would hear nothing of it. They demanded that we do everything for their mother. They wanted ABGS, they wanted full-blown diagnostics, they wanted a dramatic full-on assault. Despite their mothers pleas that she wanted to be left alone to live out her final days in peace, they talked over her and demanded that she rescind her DNR, which she refused to do.

The attending physician agreed with them, talked with the patient, and ignored her. The nurse and I were at the bedside when he was trying to talk this awake, alert, competent, and reasonable 96-year-old woman out of her DNR. Her nurse couldn’t take it any more.

“Do you want all of this, or do you want to go home?” she asked the patient.

“I want to go home. I want to go to heaven. I don’t want any of this.”  The doctor, not one of my favorite clinicians, stared at her in disbelief.

“Get me a psyche consult, and an ABG.”  I was dumbfounded. The nurse got red in the face and raised her voice.

“A PSYCHE consult? You’re the one who needs a psyche consult! This lady is perfectly capable of making her own decisions!”

“It’s not normal to want to die! Just because she wants to go doesn’t mean we can push her off the cliff!”

At this point I interjected.

“We’re hardly pushing her off a cliff. Everybody has to die sometime. She’s 96. She’s a grown-up. She can make her own decisions.”

“Well, I don’t think it’s normal. I want a psyche consult. And an ABG. She must be hypoxic or something.” I stared at him, amazed. My fists clenched. I wanted to punch him in the face. “I’ll be sure to get right on that,” I told him, and then I walked away.

—-

I  never did get the ABG on that patient. Psyche came to see her, declared her competent to make her own decisions, and left. Last time I saw her, her family was still trying to weasel us into doing drastic measures for their mother. They called in their priest to try and guilt her into rescinding her DNR. They prayed over her bed and asked God to expel the demons from her that were possessing her. I believe in God but I don’t believe in the kind of religion that warps a mind that badly; there’s nothing holy about what those people were doing.

I hope to God we didn’t do anything drastic after I left my shift. That lady was ready to go, and if her time was up, I hope we let her go in peace instead of subjecting her to the horrors of the modern ICU that she explicitly stated she did not want.

Why is it so hard for people? Why is it so hard for Doctors of all people? Somewhere I heard the phrase “All that lives is born to die,” and there’s a lot of truth to that. I know that it’s hard to say goodbye, but the fact is that nobody on the planet will live forever. Knowing that your loved one has to die, why would you deprive them of their autonomy in the last days of their life? Why would you inflict on them sufferings that they have specifically asked to avoid? Why would you do that to someone? There’s no going back from that, no time to heal those wounds. You put your loved one through something they didn’t want, and then they die, there’s no time for them to forgive you.

Sometimes, what we do in the ICU makes a world of difference and can recover someone, lead them along the first steps to the road of recovery. I’ve seen patients in the ICU do exceptionally well and come walking back in, months and months later, to say thank you. But there’s a dark side. I’ve seen us do a lot of painful, pointless things to people who will never recover. And thinking ahead to my own eventual demise, I can only hope that when the time comes for me, it’s a natural and peaceful end to a life well lived, not a chaotic and frantic death amid the insanity of the ICU.

While browsing Second Shift I found a link to an interesting USA Today article about 24 hours in the ER. Worth a quick read.

A friend of mine who works in financial services took a First Responders course some time ago. She was hoping never to need it, just took it as a curiosity. She wasn’t planning to go into any branch of medicine; she wasn’t planning to do any volunteer EMS, or anything like that.

A few days ago, she was in traffic when the car in front of her was struck head-on by another vehicle. She stopped to render aid. The other driver was a foreign woman who could speak no English. Her son, in the back seat, was screaming and kept lunging for his mother. For someone with no medical experience, no experience in EMS or the ER or even the hospital, this was immensely traumatic. But she did the best she could. Where others might have frozen, she moved and did what she knew to do.

With her first responders training my friend was unable to do much other than to stabilize the victim to the best of her abilities, and then sit and hold her hand and wait while EMS arrived. The accident happened in a rural part of the state, and it was 20 minutes before the ambulance came. It was another 20 before the helicopter landed to whisk the victim away. My friend was shaken up badly by this, by the trauma of seeing the accident and seeing the victim. Today, she found that the woman she aided died overnight.

Though she felt that she couldn’t do much, what my friend did was provide a human presence in the last moments of wakefulness in this poor woman’s life. She sat with her, held her hand, gave her what comfort she could. That is something that does not often happen in the mechanical and high-stress world of the ER and the ICU.

My sympathies to the deceased, and my best comforts to my friend. You did all you could. And in the end it may have been the best thing any of us could have done.

Charles Krauthammer weighs in on the healthcare debate and the discussions about end of life care:

Well, as pain and diminishment enter your life as you age, your calculations change and your tolerance for suffering increases. In the ICU, you might have a new way of looking at things.

My own living will, which I have always considered more a literary than a legal document, basically says: “I’ve had some good innings, thank you. If I have anything so much as a hangnail, pull the plug.” I’ve never taken it terribly seriously because unless I’m comatose or demented, they’re going to ask me at the time whether or not I want to be resuscitated if I go into cardiac arrest. The paper I signed years ago will mean nothing.

And if I’m totally out of it, my family will decide, with little or no reference to my living will. Why? I’ll give you an example. When my father was dying, my mother and brother and I had to decide how much treatment to pursue. What was a better way to ascertain my father’s wishes: What he checked off on a form one fine summer’s day years before being stricken; or what we, who had known him intimately for decades, thought he would want? The answer is obvious.

Go look.

Angry rant coming:

Nurses, enlighten me: how does one make it all the way through nursing school without knowing what a tracheostomy is? I mean, REALLY? When a nurse–a registered nurse–asks me “what is that white thing sticking out of Mr. Jones’ neck?” there is a SERIOUS DEFICIENCY in nursing education. I mean, what do you even say to that? I just walked away and shook my head and died a little more on the inside. If I ever get sick, I’ll stay home and die before I subject myself to the half-baked whims of Albuteholic physicians and undereducated nurses. Who is she sleeping with to get a job taking care of patients, because there is no WAY somebody THAT STUPID could possibly get a job in any legitimate way. Unless the government has made it “discrimination” to not hire dumbasses…

I mean, I always feel sort of bad for my patients, but I spent some extra time that day checking on that nurses patients. That genuinely frightened me, that an RN would actually not know what a tracheostomy was. At least she asked, I guess; I could see her hooking the tube feeding up to the trache and the trache collar up to the PEG tube or something.