Surviving H1N1

Where in the Hell have I been lately?

Well, Organic Chemistry is trying to kill me, I swear. And I have been working like a dog thanks to the pesky H1N1. I havemore updates later, but those will come unde separate cover...

What is it like to be a respiratory theapist in the throes of an early and horrendous flu season? "Suffocating" would be the first word I would choose. Everyone with a cough is in droplet precautions, which means I have to mask up before entering just about any room in the hospital. And we have gotten so out of hand with it! I had a vent patient who was known to have aspiration pneumonia. He had been on the vent for weeks when I went to treat him a few days ago. Imagine my surprise when I see a large "Droplet Precaution" sign on his door in the ICU. Why? Because he has pneumonia, we assume he has swine flu. Ridiculous.

Another example: I was working the ER the other night. The doctor was ordering my services for everyone. After about 5 unnecessary breathing treatments, I asked why a patient in with nausea/ vomiting with 100% clear lungs would need it. His response? Well, I think she has H1N1, so she may wheeze in the future. Again, ridiculous.

People are so panicked. Checking into the ER for sneezing, literally. Entire families checking in together. The ER's are clogged with this stuff, limiting access to care for people who need it most.

It irks me in a big way.

I know the flu sucks. I also know a new strain of anything is scary. But if you are healthy and just having manageable symptoms, there is nothing that can be done for you in the ER that cannot be done at home. So stay there. Tylenol works for fevers, Gatorade and Jell-O work for dehydration. And these are all infinitely cheaper than an ER bill.

Ha Ha

Just some RT humor.....

Sticky Situation I Found Myself In

A Patient is completely alert and oriented. She is intubated and has been on a ventilator for days, thought the initial problem had nothing to do with her lungs. Now she is awake and demanding to be extubated through hand gestures. Her vital signs look amazing. She has an order for a wean in the morning. But she insists on now. The family is called in to speak with her, and the family agrees with the idea of honoring her wishes. Her doctor, on the other hand, did not give the order, but did not tell us not to extubate, either, but simply made the statement that extubation would be at her wish and not his order. You put her on a t-piece and monitor her. There is absolutely no change in vital signs for 2 hours. You get a blood gas, and it is textbook-perfect. What do you do?

I'll tell you what I did. I pulled the damned tube, documenting heavily on her stability and the family and patient's wishes. Apparently, this has been the talk of the MICU. My director, critical care coordinator, and supervisor have commended my actions, saying I did exactly what I should have done in that situation. The director has even gone so far as to copy my charting to place in my personnel file along with a typed commendation from him. Only one pulmonologist has said anything. She wanted to know if it is "standard practice to extubate a patient in the middle of the night without a physician's order". Absolutely not. But to honor a patient's wishes while safely monitoring the patient's cardiopulmonary status...My intent throughout the whole ordeal was to watch for anything that would indicate that she would not be able to handle extubation. Had anything come up, I would have immediately had a discussion with the family regarding my concern. But nothing did. I could find no reason to leave her intubated against their wishes. And the outcome has been phenomenal. She hasn't needed so much as a breathing treatment since I did the deed.

So my Big Boss is recognizing me, stating that I have done a tremendous job for the hospital since I have been employed with them. Up until recently, I didn't even know if he knew that I work for him. But according to a phone conversation this morning, he has been getting a lot of positive feedback about me. Kind of makes my ears burn a little bit, wondering what has been said and when. But overall, it feels great to have your hard work recognized.

Frailty of Life

So....I really want to blog about the experience I had this morning in a code. An experience so bad that it left me questioning if I want to stay in this world I have lived in for several years: The World of Medicine. A 36-year-old female with breast cancer suffering from complications from a lymphectomy. There were those of us on the ICU team that had been working on her for hours before one of us hit the blue button that would signal the hospital switchboard operator to make the overhead call of "Code Blue", then there was the general crowd that shows up when the code is called. Those of us that knew the story tried to resuscitate the young woman with faces that were streaked with tears. One of my colleagues came to check and see if I needed any help, and saw that I was crying, so he offered to relieve me. Her mother was already there, but we kept her alive until the "rest of her family" got there. When we realized our efforts were futile, the Nursing Supervisor went to get her family. Allowing the family at a resuscitation attempt is kind of controversial. Is it cruel? But studies have shown that families deal better when they see the effort we are putting in to save their loved one. So while I hate it because it does not always allow me the mental distance from the situation, if it helps them, so be it. But nothing prepared me for this. Her weeping husband. And her nine-year-old daughter who was wailing in pain and anguish. I tried to count the number of ceiling tiles in the room. I inspected my shoes. I didn't have to look. By now, my hands hold within them the rhythym of breathing and I can deliver breaths at a steady pulse while intentionally not looking. But this time that didn't stop the tears. This time it was my family I was seeing, no matter where my eyes tried to focus.

I could not get John's face out of my head. Or Evan's voice. My reasons for living. And undoubtably, the husband and daughter were hers. They were robbed by the intricacies and the mysteries of the human body. And like us, I am sure they had plans for their future. The husband had been out of town, and didn't know that he would never see his wife again. I still cannot get the image of his pained, tear-streaked face pressed to her cold, pale, lifeless one. The picture serving as a study in the contrast between death and life. And her death proved something to us all. She was in the MICU, the unit of the hospital to which I have been assigned for going on the past 2 months now. Our MICU is new. State-of-the-art facility and equipment. Staffed with the A-team of the medical world. Even we therapists are a select few. We are all oriented to the unit, but non-hackers weed themselves out. But this morning, nothing we had to offer could have been enough for her. Which is scarier than you could imagine, because it humbles all of us. It shows us that we cannot fix everything with almost unnecessary cruelty. And while we are all there, working our demanding schedules to pay for kids' tuitions or the new family minivan or the plasma tv that society tells us we need, we are forced to face the idea that we are away from the very ones we are doing it all for. That life is frail, and would it be better to be at home, snuggled in bed with our spouses or waking in the morning to sloppy kisses from our young children. Because as we were witnessing at that very moment, life could have other plans for us.

Failure

Sometimes I have the autonomy to override a doctor's orders. Sometimes I do not. This weekend was an example of a time when I did not. It was also an example of the concept that just because we can do something to prolong a life doesn't always translate to we should. A lesson in medical futility and ethics. I have been assigned to the MICU for the past 6 days. The sickest patients in the hospital were once again in my care, as is happening even more frequently now.

A patient was admitted on Wednesday night, and by Thursday, it was well-known that there was nothing we could do for him. The name was familiar to all of us, but none of us could place his face. Disease had ravaged his body until there was little with which to work. I am not going into detail about the disease process or any other fact that can be used to identify this patient because I want to protect him as I am legally obligated to. But he was very, very ill. I watched as a parade of specialists for just about every body system in a human organism came and went from his room, speaking with his family.

I'm sorry. There is nothing more we can do.

We will provide him with comfort while he makes this final journey.

We will allow him to die with dignity.

I made sure he had enough oxygen, then went on to other patients of mine. Patients who were not breathing on their own, hooked to my ventilators. Not much time passed before another specialist came to see the patient. The patient, on top of everything else, had a raging infection. Sepsis. He wanted me to suction the patient, something we don't usually do for the dying patient because it is so uncomfortable for them. I asked him to explain why. His follow-up was that we were going to suction him, and then intubate. Within 15 minutes, the family wants to do everything. Put him through the medical gauntlet. The doctor seeing the patient for his infection bypassed the cardiologists, nephrologist, pulmonologists, neurologist, and oncologist. Told the family we could fix him.

My experiences with family members facing the loss of a loved one have taught me something. You must be very careful when you walk into the room of a dying patient. Because any tiny word you utter can be misconstrued as hope. Hope where there is none. And they grab onto to that like a life preserver, and hang on to it. To the layperson, this would seem like a gift to them. Instead it makes it worse. The patient passes away anyhow, after they have thought it was not going to happen. From the minute we know that death is looming, our care shifts from the patient to the ones left to live. Every action becomes about them. Making it easier for them. Never more difficult. The have enough difficulty to face.

We failed that family. We didn't do what we should have done for the patient.

We intubated. I hooked him up to the machine that would breathe for him. I stood at the bedside and cleared mucus from his chin and smoothed down his hair while the ventilator hissed and puffed behind me. In that instant, I realized who he was. One of our regulars, I would always save his breathing treatment for last because we would always end up talking about his military service and kids. Through all of his admissions, he never forgot that my son's name is Evan. He would always light up and ask me if my Evan was still driving me crazy. He always called me his "Breathing Angel" because he said I always seemed to show up in the same instant he was thinking about calling for a PRN treatment. I tried on several occasions to explain to him that it was probably due to the fact that he was due for his medication and less about me. "In fact," I would tell him, "I'm actually really mean in real life." He would always giggle and shake his head, telling me he couldn't believe it.

I almost didn't recognize him through all of the tubes and lines.

Within 5 minutes of intubating him, he tried to go into cardiac arrest. We brought him back. I heard his ribs crack during CPR.

By the time I had reported for the next day, he was on continuous dialysis. We had given him the maximum amout of medication allowed to maintain his blood pressure. Dopamine. Levophed. Vasopressin. I was no longer able to maintain any sort of oxygen saturation on him. We had to insert an arterial line in his femoral artery, in his groin. His body temperatre was 88 degrees. We had him wrapped in heated blankets and a warming system so that only his face was visible. He had a rectal tube inserted that was draining blood. 10 IV pumps going. About the only drug category we didn't have covered was sedation. Through all of it, he didn't need any.

The family still was clinging to the hope that we could fix him. Despite the fact that we told them repeatedly that it was gettting worse. They held fast to that life preserver. I left my shift praying for his death.

By the time I reported for my shift the next day, he had died on his own. It took 6 nurses and me to remove all of the lines and tubes. His body released every fluid in it. There was a piece of tissue that I assumed to be a part of his trachea that came out when I removed the endotracheal tube.

I didn't cry. Instead I hated my job. I was upset that I didn't put my foot down for him and advocate for him. I realize that even if I had, and refused to participate, they would have just called another of the therapists. This was one of those that I could not override.

I still feel like I failed my patient. I wasn't his Breathing Angel anymore.

Tales from Behind The Mist....Of Albuterol

From the "Are You Serious?!" File....

Some true stories from work this weekend.

Phone rings and it is Nurse X: "Andrea, can you come and give the patient in room XXX a breathing treatment?"

Me: "Sure. Whats going on with the patient?"

Nurse X: "I don't know. He wants a Coke. Can you just give him a treatment so he will shut up about the Coke?"


Phone rings and it is Nurse Y: "Andrea, my patient's sat is 85 on 2 liters. Can you come see him?"

Me: "Did you turn up his oxygen?"

Nurse Y: "Yep. To 5 liters." (sounding very proud of herself)

Me: "What's his sat on 5 liters?"

Nurse Y: "I don't know. I left to call you."

Me: "Well, I am in the ER with a full arrest. Go and see what his sat is, and if it still low, put him on a venturi mask at 50% and 15 liters, and I will be there as soon as I can. Do you know how to do that?"

5 minutes later the phone rings. Nurse Y again: "Andrea, I think I broke the venturi mask."

Me: "Get another one and try again. I am still bagging this patient in the ER."

2 minutes later, Nurse Y, again.: "I don't think 50% is going to fix this. We need to go up on his oxygen, not down."

A few minutes later, I head to the room. The patient's sat was 100%. His heartrate was 85. I put him back on his 2 liters and went back to the critically ill patient I left in the ER to deal with this.


Later that night, a full arrest in the ER. We are intubating the patient and I have the nurse behind me at the crash cart hand me an en-tidal CO2 detector to verify proper tube placement.

Doctor X: "That won't work on this patient."
Me: "Well it is habit, so just humor me."
After a few breaths, we get the color change that shows the tube is indeed in the lungs and not the esophagus.
Me: "See, it worked."

After the code, Doctor X comes up to me, and in a gentle voice asks me if I understood why it would not work for that patient.
Me: "Well, it did work. Plus, It is an ACLS standard that tube placement be verified with an end-tidal CO2 detector, and therefore it is the policy of this hospital that we use it after an intubation."

Doctor X: "Well ACLS is wrong. I'm going to write them about that."


Seriously, people. Seriously.

Being Seen

I have had the most interesting weekend at work.

For the first two shifts of the weekend I had the ER, along with some general med-surg floors. I had to confront death head-on for a couple of patients. I lost one battle and am still in the process of losing another.

A 75-year-old man comes in as a full cardiopulmonary arrest. We are doing CPR, and they let the family back. I hate that. Hate it. I have to remain detached and professional to do my job effectively. But this little old lady comes limping back with her family, as we are doing CPR on her husband of over 50 years. They have had this life together, and I feel like we are taking that away from her when there is nothing we can do to save the man. As I watch her cry, I am finding it hard not to cry. The doctor calls time of death and I help her limp to the bedside, where she gives him a kiss on the cheek and crumbles with grief.

The next night, another full arrest comes in. That is what these patient's are to us. The full arrest in bed 18 or 8 or wherever they land. Not a name. She comes in already intubated, so the task of ventilating her falls to me. I am tweaking the vent to find a way to ventilate her that works best with her natural patterns of ventilation. I have my back turned to the door, turning knobs on the vent. I turn around for some unknown reason and see this sweet guy from housekeeping there behind me. In that instant I assume he is at work until my eyes take in his street clothes. He looks at me with these wide eyes, and I just know. I ask him if it is his mom, and he just nods. He stays in the room while we do all sorts of medical procedures to the woman. She is nude from the waist up for an EKG, and all I could think of was my relationship with my son, so I reach over and cover her breasts with a sheet. Later I go down to the smoking area for a much needed break for coffee and a Marlboro Light. He is down there smoking too. Before this, he and I would joke about college football. He would tease me about my hatred of Florida. He was always quick to offer a smile. Before that, I don't think either of us were very aware of what the other does in the hospital, other than these huge badges that go along with our picture badge that is designed to quickly reveal to patients just who we are. Mine says "Respiratory Therapist" in bright green. His says "housekeeping" in pale blue. But that night, in his grief, he saw firsthand what it is that I do. Never again in his eyes will I be the joking girl who loves Buckeye football.
We are sitting there talking. Once again, we are just two people down in the smoking area. There is no whoosh of a ventilator in the background or a beep of a monitor. He looks at me and gulps down tears as he thanks me for all of the hard work I do, not only for his mom, but for all of the other patients I see on a nightly basis. I get choked up by that. Because every night, I whisk in the room in response to a call that someone somewhere in the hospital has stopped breathing. I do my job and slip quietly away unnoticed by the patients' loved ones. I stay under the radar. They will never remember my name like they will the nurse who takes care of their loved ones. Or the doctor charged with their care. They don't know that I am the girl who stands over their family member, with my back breaking and the hot exam lights forming beads of sweat on my brow, breathing for them when they cannot. I am fine with that. I know what I do, and somewhere inside of me, despite self-criticism, I know I am good at my job. That has always been enough for me. It is okay to be the unseen. But that night, I was seen. And the reality of what it is that I do for a living settled with a big thunk somewhere inside of my soul. I see hundreds of patients nightly. I never remember names-- only faces. In that instant, a myriad of faces come back to me. I worry myself daily if I have been a success at the tasks I have undertaken. Did I do well on Exam X at school? Will I get into medical school? Does my time away from home to pursue these goals I have set for myself do harm to my husband and son? Am I truly making a contribution to this world in which we live? In that instant, the housekeeper from the hospital gave me my self-worth on a silver platter, showing me that this is who I am. That I have touched lives, even when I didn't realize I was doing anything more than earning money to support my family. And for some reason, at that point in time, my thoughts went to my mother. Is she watching me now? Does she see the hard work I do? Is she proud? What is this work I do really about? My confrontation with the housekeeper had such an impact on me. I am still the nineteen year old girl who lost her mom too soon to lung disease. And I have been battling lung disease ever since. It will not win. I am too tough to allow that to happen. It is like the housekeeper took a large mirror and held it to my face for me to see, saying "Here. Look at her. This woman, who works hard to fight for the lives of others. This woman who is capable and tough and smart, who can do whatever she deems fit in life, who will reach the dream she has set for herself, who is Pauline's daughter and John's wife and Evan's mom. She is you." I need to be thanking him.

Me Blogging about A Pic of Me Blogging

I had the night from Hades last night at work. 13 vents in just one unit, and I had multiple units. Here in a half an hour, I have to get ready to go back. So yep, I look like ass. No makeup, pillow creases on my face. I am dog-tired. I get my butt kicked just about every night at work. But tonight, I know I will. There is just something about the possibility of having an easy night that makes it much easier to go in in the first place. But for some reason, when you know the mountain of work will be insurmountable and there will be just some patients you cannot physically get to because you are so busy, followed by the realization that instead of being off in the morning, it is the start of your school day....Well it is enough to make you want to stay home.
But alas the time has come for my shower to get ready. I have to do my job.

I think I am running out of steam.

Do Not Touch the Feet

Ask any of us in health care and we will tell you that we have had some strange encounters with patients or their family members. I have a favorite...

I was called to the bedside of a very unfortunate patient in his early thirties with a head bleed. The man needed surgical intervention beyond the scope of the tiny rural facility in which I was employed at the time. Air transport had arrived to take him to the nearest trauma center, and I was standing at his head, bagging. I couldn't step away, as I was literally breathing for the guy. We call the wife in to say whatever she needed to say to him as we were pushing the stretcher out to the helo pad. I hate this part. Usually, it makes me tear up. Not this time. It was all I could do to remain professional and not crack. This woman actually walked up to her husband and said the following. "Nothing better happen to you, because you know what will happen, don't you? I'll have you stuffed and sit you in the corner. Taxidermy is cheaper than a funeral!" She proceeded to smack him on the forehead and tell him she would see him when she gets there.

Well, the other night, I had another strange encounter. There was a very young child who had assessments and treatments ordered every 3 hours. When this is the case, I try to be quiet as I walk in the room, hoping I can observe the child and possibly give a treatment without ever having to wake the family or the kid. This little boy's oximeter probe had fallen off of his finger, and was sort of stretched out. i figured I would put the probe on his big toe, and started to do so...

All hell unleashed. The dad started screaming at me, "Dud, what the F### are you doing??? Don't touch his F###ing feet, man. Who the F### do you think you are??? Why the F### would you do that???" Those are actual words, without the censorship. Seriously. This is a sample of what I endure at work. Really. For 12 hours a night.

Respiratory Distress

...Is in the eye of the beholder. Seriously.
I get a call from a nurse. We will call her RN. I like RN. RN and I have never had a problem. She is telling me that my patient is in respiratory distress and would like a PRN treatment. I respond.

RN is sitting at a desk when I get to the unit of the hospital. My first thought is : "If the patient is in such distress, why is she not at the bedside?" Realizing that crazier things have happened, I go to the patient's room. The door is closed. I knock lightly, then enter. The room is dark, but in the glow of the bathroom light, I can see it. The patient and her husband are both sound asleep. I tip-toe to the bedside and see that respirations are normal. Her breath sounds are clear, save for a few scattered crackles in the bases, which does not surprise me, considering the patient's diagnosis. I tiptoe out of the room, and as I pass the desk where RN is sitting, I give her that look and let her know that the patient is sleeping like a baby. I go back to my laundry list of tasks to complete.

30 minutes pass.
My phone rings again.

RN: "Andrea, she woke up and is breathing so badly that she is sobbing."
Me: "Sobbing????" (This isn't the usual presentation of respiratory distress.)
RN: "Yes, she says it hurts so bad...."
Me: "Wait a minute. Is pain her problem?"
RN: "Yep. She says it hurts in her side."
Me: "You know, albuterol won't fix that."
RN: "Well then, she's short of breath."

I go to the room. Again, RN is sitting at the desk and the patient's door is closed. I enter to find her awake this time. I ask what the problem is and she says that it hurts to breath. I ask her to describe her pain, and she clutches at the right lower rib cage, explaining that it hurts to take a deep breath. I observe her and notice her wincing with each breath. I ask her if she is short of breath. "NoNotReallyItJustHurtsWhenITakeADeepBreathCanPneumoniaDoThatIDidn'tKnowPneumoniaCouldDoThat."
Long run-on sentences. Normal respiratory pattern (rate and depth). SPO2 is 98% on 1 liter of O2. Heart rate is 86. Breath sounds completely clear. I know that nothing I can do is going to help her. She needs her pain meds, which come from RN. I explain to her that we can try the treatment, but that it really won't help if her problem is pain. She is too vague, so I give the med. After the treatment, she insists she is cured. There is no more pain. (!!!!!) I am convinced she needs a psych consult. I leave the floor, but not before letting RN know that while I did treat the patient, she was not in respiratory distress. That while I would love to run around the hospital appeasing patients and nurses all night, I truly have patients who need me.

As I am walking out, I think I should stop and see the patient on Q4 treatments. She is due for the next one in 15 minutes. I walk in her room. She is sound asleep. I gently wake her and let her know it is time for her treatment. She blatantly tells me she doesn't want it, doesn't need it, and rolls over and goes back to sleep. I chart the refusal and go on about my business.

45 minutes pass. It's RN again.

RN: "Andrea, our patient in room xxxx is feeling short of breath and would like a breathing treatment."
Me: "Seriously???? I was just in there less than an hour ago and woke her up. She refused. What changed?"
RN: "She refused??? (soft giggle) Well she wants one now, says she is short of breath. She just got back from being downstairs smoking."
Me: "Let me get this straight: she wouldn't let me treat her 45 minutes ago, but then went down and smoked and wants me to make a trip up there to treat her because she is short of breath after her trip to the smoking area?"
RN: "Yep (louder giggle now)." Shall I tell her she's on your 'list'?"
Me: "Yes, thank you."

"Respiratory distress" and "dyspnea" and "shortness of breath" are all subjective terms that are used too loosely in a hospital at night. They know I have to respond to a call that uses those words. I trust that the nurses have used their assessment skills, that they know I am busy, and have filtered through some of the BS. This is not always the case. I got calls like these all night last night. All 12 hours. A lot of them weren't even from my assigned units of the hospital. They were from other nurses who didn't feel like they got a quick enough response from their therapist and started dialing random respiratory extensions until they get me. In a respiratory eutopia, we would have the staff to run around and do this random crap. At my place of employment, we do not. At 11 PM, the respiratory staff cuts down from 8 therapists and/or techs to about 4 therapists (no techs at night because we have to be able to handle it when we are called). I am one of the lucky 4. And if you divide the hospital into 4 equal sets of work units, you wind up with therapists who have anywhere from 5 to 8 units of the hospital. I had the entire 2nd floor of the hospital last night, plus NICU and pediatrics, for a grand total of 9 units of the hospital. I do not have time for bullsh*t calls like this. And with assignments like this, if there is a code at night, all of us respond because you are never assumed to be able to go to a code on your own floor. I have been known to have simultaneous codes going on at multiple units to which I was assigned. So in the middle of all of this, I had to respond to a code, which resulted in my brand new shoes getting doused with so much vomit that it soaked through to my socks. In the middle of it all, I have to call the supply people and have them deliver to me a fresh set of scrubs, shoe covers and a jug of hydrogen peroxide. I got the puke out of my shoe, but only by pouring the entire bottle inside and outside of it, then having my toes squish around in the peroxide-soaked shoe for the remaining 5 hours of my shift. Fun.

God, I hate being a "floor whore". Send me back to the ICUs or the ER. Please!

Don't Watch

Yep, I stole that pic from the internet. But notice the lovely PB 840 Ventilator in the lower left corner??? By far my fave!

Here is the deal, peeps. We do some things that are uncomfortable for a patient when in an ICU. The list is numerous: chest tubes and a-lines and don't forget intubation. A tube made of polyvinylchloride is not a pleasant thing to have jammed into your airway. But we do it out of necessity. Not rosey and cute. But required. Then occasionally we have the patient who is having trouble breathing and we try to intervene on their behalf to actually avoid intubation. Whatever unpleasantness I could be up to is nothing compared to days of mechanical ventilation, I assure you. What am I getting at? Well here it is:

I know the patient I am taking care of may be your sweet mother. I completely understand that. I had a mother once before. I know you do not want to leave her side. Your presence at her bedside 24/7 is as much your way of ensuring we are giving her adequate attention as it is for tou to assure her with your presence. But when I come into an intensive care room, it is a sign that sweet Mom is just not breathing so well on her own. She needs some sort of help, whether that be in the form of aerosolized meds or oxygen, bronchial hygiene or mechanical ventilation. But please know that I am good at my job, even if that job is not all sunshine.

So you are at Mom's side. Great! But when I tell you I am about to do something unpleasant and encourage you to leave the room, please follow my advice. The most recent situation was the nasotracheal suctioning of an elderly lady unable to speak, and unable to adequately clear her airway with cough. DO NOT insist on watching me thread a catheter up her nostril, through the pharynx and into her trachea. She is not going to like it. She will cough and gag, and naturally try to fight me, at which point I will have to firmly insist she stop. I need to do this. I do not want the process to take so long that she becomes hypoxic or starts to brady down. That would be bad ju-ju. What I can say is that, while unpleasant, she will feel better when I am finished and have removed the nastiness from her. She may hate me, but she will feel better.

Please do not watch me, then get angry because I upset dear Mom. I am not concerned with Mom being upset with me at all. My job isn't to have tea with her or to convince her that I am worthy of her adoration. My job is to ensure that her respiratory function is intact. Making her mad is just a side effect.

If you can't handle the heat, stay out of the kitchen? More like if you cannot handle the unpleasantness, stay out of the ICU (other than for standard visiting hours, of course.)

Seriously? Not the ER?

I knew it. Just knew it. I am at work the other night, working with S (name withheld to protect the innocent), and he laughs and tells me that every night he is working, I am The ER Therapist. Fine by me. I really do, though I gripe about it, love the ER. That is the only place in the hospital where I actually get to see my patients, use my full assessment skills (yes, I have those), and actually, at some point, come across everything within my scope of practice. The part I do not like about being assigned to the ER for a shift comes in the middle of the night. From 2100-2300, you have just the ER. But at 2300, all of the 1100-2300 people leave and the hospital's arsenal of RT's whittles down from 7 or 8 to about 4. Your assignment changes and you usually, on average, have about 4 other units of the hospital along with the ER. This can be okay, on nights that are not so busy. But during Respiratory Season (Haha! November through March when flu/ RSV hits!) this is not the case. You could be clear across the hospital and be paged to the ER to meet a full arrest. You have to break out in a run to get there in time. ER patients always come first. This may be to the dismay of a nurse on a med-surg floor who thinks her patient is your only patient, but is still the case nonetheless. I am always the ER therapist. It's fine. They know me down there, and I like to think that they like me.

I was very shocked this past week. I worked 6 12's in a row, only to find that I was not assigned to the ER for a single one of them. For the past 3 work nights, I had the SICU and Cardiac Surgery Recovery (CSR) Unit. I would run into people from the ER as I made my way around the building, and they actually had thought I had taken a vacation because they had not seen my face around. Ha! No asthmatic kids. No croup or RSV. My patients were intubated and silent, other than the occasional vent alarm or monitor beep. It was actually kind of nice.

Dog-Tired

I have finally experienced the ultimate level of tiredness. An exhaustion you can feel in your bones, your teeth, your hair.

I go to work Wednesday night. It is not the typical work night, as I usually work weekend nights, so I am already out of sorts. I do my twelve hours, not assigned to the ER, but instead to the Surgical Intensive Care unit. I have vent patients in 3 different units of the hospital and spend the night shuffling from one unit to the next, all while weaning a patient in the Post-Anesthesia Care Unit (PACU). Weaning is rather labor-intensive. As in turn down the FIO2, check a blood gas. Turn down the rate, check a blood gas. Turn down the PEEP, check a blood gas. When you get the settings so low that the vent is doing virtually nothing for the patient, you turn the vent to a mode of spontaneous ventilation and let the patient cruise for a bit. Order another blood gas. Looks good? Extubate. So I do all of this. And once 02:00 rolls around, and I am starting to hit my wall, as I do every night, I start counting down the hours until the day shift people come in and I can go home.

But then I remember. Mandatory Inservice. 6 stations of things we do in our scope of practice, but we do so rarely that it is difficult to stay fresh. This is the hospital's way of ensuring that when I have that rare patient who must go to MRI in the middle of the night, I know how to use the primitive ventilator with no metal in it. This wouldn't seem like a big deal to someone who knows nothing about mechanical ventilators. But a vent is not necessarily a vent. The big microprocessor vents are awesome. User friendly. Easy-peasy. And we are all spoiled with those. We forget the fundamentals of ventialtion. How do you dial in a rate if there is no specific way to set a rate? You want the rate to be 12. That means a breath every 5 seconds. In order to get the tidal volume you want, you had to set the flow and inspiratory time. So I-Time can't be changed or you will mess up your volume. I-Time is 0.75 seconds. So to get a total cycle time of 5 seconds, you need to set expiratory time at 4.25. Because TI+TE=TCT=5. Lovely.

But the primitive ventilator is not the only issue. How do you ventilate (safely, without barotrauma) the 1 lb. preemie? What is the best way to complete a protocol on the acute vs. the chronic illness upon admission into the hospital. There is a difference.

So the inservice is mandatory and only being offered on two days. Wednesday and Thursday morning. I intentionally skipped Wednesday's because why would I drive an hour and a half for that? So I planned to go Thursday morning when leaving from my Wednesday-night shift. Completely forgot all about that.

But wait! That isn't it! I also have to do my anual fit testing to ensure that the disposible mask I wear upon entering a TB patient's room will fit me adequately enough to keep me from bringing home the present of tuberculosis to my family and friends. Keep in mind that I failed this fit testing last time. I just do not have much of a nose, and when I would nod my head, as the tester made me, it would create this enormous air leak. Did that mean I got out of seeing TB patients??? Hells to the nah! I am a respiratory therapist! Instead, I had to wear this hood looking thingy. Ridiculous. And it had this fan that worked with it, to circulate the air, so it made this woosh-swoosh sound. I looked like the Ku-Klux-Klan Grand Wizard meets Darth Vader. I refuse to miss the chance to test again, to get the chance to just wear the disposable N-95 mask and not the crazy hood. So I am tired, but I go. And when it gets to the part of moving my head up and down, as in an exaggerated nod, I keep falling asleep with my head in the leaning-back position. Thank God the tester was the mother of one of the other RT's who works night shift. She brought me a very caffeinated a beverage as I was walking out the door. But I Passed.

So I have maneuvered all of the little inservice stations. I have completed the fit testing that is to free me from the Dork-Hood for at least the next year. Now I have to drive home. One and a half hours.

So I know tired now. The tired in your bones, your hair, you teeth. By the time I arrived in my house yesterday morning (I think it was yesterday!) I had been gone for over 20 hours. Blah.

Huh?

So I had the ER again last night. Busy, busy, busy. There are significantly fewer therapists at night than during any other time period throughout the day, and last night we were ever shorter staffed. Lovely. Crazy-busy. And I am running all over the hospital, and one of the seasoned nurses asks me if they were to create a full-time ER RT position, where I would exlusively work nothing but the emergency department on the weekends, would I consider accepting. I said I would. Actually, my exact response was "Sure!". But as the clock was approaching go-home time and we were intubating yet another end-stage COPD patient, I was left wondering wtf I was thinking. My status as an adrenaline junkie and my gluttony for punishment momentarily overcame my rationale. And I think I was just basking in the compliment. I mean, when I started there, I was told the ER RNs would run me over until they were convinced that I knew my stuff. Now their faces light with smiles when, at the beginning of my shift, I walk through those ER doors. I guess I have proved my worth.