Alpha Centauri 2

Community => Recreation Commons => Topic started by: Elok on July 29, 2025, 01:14:04 am

Title: Healthcare junk w/Elok
Post by: Elok on July 29, 2025, 01:14:04 am

So, I'm a respiratory therapist.  Most people don't know what that is because medical shows on TV show nurses doing our job when they show it at all.  A respiratory therapist is someone who looks at a scene of someone on a mechanical ventilator ("life support") in what's supposed to be a dramatic scene in a movie, and snickers, because they put it together all wrong.  We do everything that involves helping someone breathe, that's more complicated than putting on basic oxygen through your nose.  Much of the time that involves breathing treatments (aka albuterol, nebulizers, nebs, etc.), which are grossly over-ordered to the extent that even in a good hospital upwards of half of all breathing treatments are completely unnecessary.  In practice I often feel that the treatments exist to give us something to do while we wait for a crisis, which is our real job.  Managing an airway is an esoteric, specialized job that needs to be done promptly and can easily go terribly wrong.  I like this because it's pretty solid money and makes me feel like my work matters and suchlike.

It's also our job to advise doctors, and sometimes, bluntly speaking, to intercept and discreetly smother their bad ideas before they see the light of day.  If you've ever seen Aliens, think of the Sgt. Apone-Lt. Gorman dynamic.  It's very important to respect the chain of command, and to maintain respect for superiors, but sometimes your superior is in way, way over his head and you need to keep him from mucking it all up without making it obvious that you're doing so.

One recent example, which I'll try to keep short(ish): last week I saw a lady who had been put on BIPAP (non-invasive ventilation through a tight-fitting mask) by the night hospitalist (doctor who only works hospitals, which >50% of the time translates to "Fozzy Bear with an MD"), because her ABG (arterial blood gas, test to show blood oxygen, CO2, and pH among other things) had really high CO2.  Like, stupid high CO2, I think it was over 100.  That's scary.  CO2 is bad because it's acidic in the blood, and in high quantities can drive your pH down to levels incompatible with life.  45 is the high end of normal for CO2.  Normal pH is 7.35 to 7.45.  This lady's pH was ... 7.29.  That's not very low.  Not good, but very far from life-threatening.

So, what gives?

This woman had COPD, Chronic Obstructive Pulmonary Disease, AKA "that eventually-fatal disease tobacco gives you which isn't a kind of cancer."  Like many COPDers, she'd had high CO2 for a very long time due to her lungs being shot.  Long enough for her body (specifically the kidneys) to notice and deploy countermeasures in the form of HCO3, bicarbonate (basically baking soda!).  Bicarb is highly basic.  Normal bicarb range tops out around 28, hers was over 40.  And a lot of COPDers are chronically acidotic anyway, so odds are good that this ABG revealed this lady's normal.

NB she was quite senile and her family was leaning towards hospice, so we were putting her through the considerable discomfort of BIPAP (it feels like trying to breathe while sticking your head out the car window at highway speeds with your mouth open) for essentially no reason.  The night hospitalist saw high CO2, ordered BIPAP RIGHT NOW! and the night shift RT, overworked and tired at the tail end of her shift, didn't dig or push back.  It was my job to diplomatically persuade the day shift hospitalist (who wasn't much more knowledgeable) that BIPAP was not the way to go.  I originally meant this to be a much longer chronicle with specifics of how I managed the situation, but this account is already several paragraphs.  So I'll leave it at that, and see if anybody has questions or comments.  The above is one example of why respiratory therapy exists.

Title: Re: Healthcare junk w/Elok
Post by: Buster's Uncle on July 29, 2025, 01:42:50 am

 :luv:

I'd love if everyone with special skills and/or vocational knowledge did this - tell stories.

Yes, sergeant; please tell us how you diplomatically handled the green Lt.

Title: Re: Healthcare junk w/Elok
Post by: Lorizael on July 29, 2025, 01:48:50 am

I'll note that while The Pitt doesn't have RTs, they do have a scene where a green doctor uses BIPAP in a stupid way and gets scolded for it.

Title: Re: Healthcare junk w/Elok
Post by: Elok on July 29, 2025, 02:03:27 am

Okay, you have my interest.  There are a lot of ways to use BIPAP stupidly.  Which sin did the doc commit?

BUncle, I'll try to do a full breakdown tomorrow.  Have to get kids to bed.

Title: Re: Healthcare junk w/Elok
Post by: Buster's Uncle on July 29, 2025, 02:11:58 am

The kids come first.  You do you.

Title: Re: Healthcare junk w/Elok
Post by: Metaliturtle on July 29, 2025, 02:38:30 am

Thanks Elok for sharing about your job.  It's oddly fascinating to me.  Looking forward to reading more and learning what hospital shows get wrong so I can annoy my wife with know-it-all comments ;gam

Title: Re: Healthcare junk w/Elok
Post by: Lorizael on July 29, 2025, 02:59:28 am

Quote from: Elok on July 29, 2025, 02:03:27 am

Okay, you have my interest.  There are a lot of ways to use BIPAP stupidly.  Which sin did the doc commit?

I don't remember anymore; it was just a scene or two.

/me googles

First year resident put BIPAP on patient with pneumothorax, turned into tension pneumothorax.

Title: Re: Healthcare junk w/Elok
Post by: Elok on July 30, 2025, 01:27:00 am

Oh.  I'm mildly disappointed, that's so textbook and not actually that common "in the wild."  Much more frequent for them to restrain a bipap patient, or put the mask on somebody who's liable to vomit, both of which are extremely dangerous and contraindicated and common practice.  But thanks for letting me know.

So.  The thing with the BIPAP lady.  She was one of several floors I had that day.  She was placed on BIPAP in the wee hours of the morning by panicky night doc.  I should explain that BIPAP, as a rule, does not belong "on the floors."  You can wear one if you only need it for sleep (many people wear CPAPs for sleep apnea), but if it's being used to actually ventilate it needs to be on ICU or at least PCU/stepdown.  So this lady already had orders to transfer her to PCU, there just wasn't a bed open.

I'd got report on her, but was on another floor when I got a call from a nurse: "hey, her BIPAP is alarming 'low oxygen.'"  This was instant frustration for me because

A. The night RT specifically said she'd left the BIPAP off the lady after losing a battle of wills, which meant some idiot floor nurse had put the patient on BIPAP on her own, messed it up, and was expecting me to come fix it, and
B. I couldn't go right away because I had a vital bit of information to pass on; a patient on my present floor had divulged to me that she planned to have her family bring in her home insulin, since she felt the RNs weren't managing her diabetes properly, and she refused to listen when I tried to explain that double-teaming blood sugar management is how diabetic comas happen.  I didn't feel comfortable leaving without passing that on directly to her nurse, who was hard to find.

So I found the nurse, passed on warning as tersely as I dared, then sprinted downstairs.  As I expected, the nurses hadn't plugged in the damn oxygen.  Night shift RT had unplugged the BIPAP from the wall O2 outlet to put on a nasal cannula instead, and the nurses, after doing my job without permission and getting it wrong, had decided to pass the ball to me instead of doing some very elementary troubleshooting.  Old lady's oxygen saturation was 63% when I got there (normal is in the nineties).  Fixed bipap, adjusted the settings to boost oxygenation and give her better volumes, adjusted the mask ... by the time I had the patient good and fixed, her daughters showed up, full of questions.

Another complication: I got report on this floor as an afterthought, because the RT who should have got it no-call no-showed due to a miscommunication about the schedule.  I didn't actually know the lady's full case, just some stuff that was blurted at me before night shift ran out the door.  I also didn't want to say, "yeah, nursing just tried to kill your mom."  So I BSed it for a bit, looked up her blood gas, said, oh, she's only a little bit acidotic, I think the doc was being conservative to be safe [I am not saying he was an ignorant panicky twit just thinking it real loud].  All this while the old lady kept trying to take the mask off, while the daughters tried to explain to her NO MOM YOU NEED THAT TO BREATHE with little success.  Senile old lady knew better.

I excused myself to message the day shift hospitalist--the doctor who ordered this goofup was gone by this point.  Dayshift hospitalist saw the abg and messaged back "golly, that's some high CO2, keep her on BIPAP and get another gas!  I'll be up soon."  I told the concerned daughters that the doctor would be up ASAP, then instantly realized I would be stuck there on that floor until the doc arrived and I was able to make sense of the situation.  I messaged the doc back that since I'd just got the patient settled on new settings it wouldn't make sense to get a gas just yet, and doc didn't disagree.  This bought me time to not get a gas, which is good because arterial blood gases come from arteries and your body, for obvious reasons, likes to put nerves very close to arteries, so driving long steel needles in there tends to really hurt.  I did not want to torture a senile old lady for essentially kayfabe reasons.  I went around doing the less frivolous breathing treatments I had due on that floor; so much time had passed that breakfast trays were already arriving, and patients tend to refuse to inhale mist while their scrambled eggs get cold and gross.  Essentially, I gave up the rest of morning rounds for lost.  This was fine.  We were short-staffed and, in the last analysis, nobody actually looks or cares to see if I do that part of my job.  Most of the time.

Time passed, and the doctor didn't show up.  It struck me as bad form to say "hey whereTF are you?" for a non-crisis situation, and this wasn't a crisis, it was just ... urgently stupid.  Trapped on the floor.  I got a moment to politely explain to the nurse who called me that she was a stupid careless [complaint or disagreeable woman].  She replied by saying, "Oh."  Then shrugging and adding, "well, she wasn't keeping it on anyway."  I already knew this was all the correction the matter would receive.  Incident Reports are a thing, but it's a sucker's game filling them out.  Even if you somehow manage to actually put the fear of god into a nurse, she's still just one nurse and the hospital will soon recruit dozens more who are just as clueless.  It's like they're all callow twenty-two year olds turned out en masse by lazy cultlike schools that teach them they're the most important part of the hospital, or something.

ANYWAY!  Time passed, I did all the nebs I was going to on that floor, and the daughters gave up trying to keep the mask on Mom since she was being impossible and I'd already explained the doctor was just being extra-super-cautious.  I immediately messaged the doc that the patient had been off bipap for an unknown period of time so the gas wouldn't really reflect anything useful.  She agreed to cancel the gas.  Old lady was now on plain oxygen.  Both objectives accomplished.  I added, truthfully, and for the second time, that the family really was leaning hard towards hospice, but here we were planning to escalate patient care ... judging the situation stable, I went to my third and last floor (PCU, as it happened) and found a coworker had jumped in and done morning rounds there for me.  Verified everything was stable there, went back up to the old lady's floor and found that the doctor had finally arrived in my absence, and promptly agreed to hospice.  BIPAP unnecessary.  PCU move unnecessary.  Respiratory signing off.  I cleaned the miserable machine and put it back in storage.  The end.

This was a fairly absurd incident, but it's a fair sample of the kind of weirdness we deal with routinely.

Title: Re: Healthcare junk w/Elok
Post by: Buster's Uncle on July 30, 2025, 01:31:57 am

;nod

MOAR!

Title: Re: Healthcare junk w/Elok
Post by: Geo on July 30, 2025, 09:50:52 am

Quote from: Elok on July 30, 2025, 01:27:00 am

This was a fairly absurd incident, but it's a fair sample of the kind of weirdness we deal with routinely.

And all the time the $ counter was tickin' for technical services (more or less) unnecessary. At least, that was what I gleaned from this story? ;relish

Title: Re: Healthcare junk w/Elok
Post by: Elok on July 31, 2025, 02:22:25 pm

Well, yes, but really I'm small potatoes.  There's a lot of waste in healthcare, but most of the expense of respiratory care is going to be from our wages (which are solid skilled-labor, maybe slightly lower than nurses', nothing extravagant), and from buying or renting heavy equipment like ventilators.  I'm sure all the little expenses add up, but if you instantly got rid of, say, all the unnecessary breathing treatments at my hospital, and kept them gone, you'd be able to cut maybe one therapist, save the hospital a few hundred bucks every twelve hour shift.  The real expense is going to be in unnecessary ventilator hours, which is mostly driven by end-of-life stuff and coordination problems.

For the former, an example: we just had a patient who was a massive alcoholic, dead liver, dead kidneys.  You can't really live with that level of multi-organ failure; dialysis can sub for the kidneys but for liver you need a transplant.  Massive alcoholics don't get liver transplants, that's like giving a new car to a drunk driver right after a crash.  Waste of an organ.  You need to stay verifiably stone cold sober for six months to get on the liver list if you trashed your first that way, and that, generally speaking, doesn't happen.  So the guy was doomed.  He was doing mediocre but stable enough on high-flow oxygen.  I wanted to go the low-intervention route for as long as possible to give the palliative/hospice people maximal time to talk the family down.  RN had other ideas, and the newish ICU doc, sadly, agreed.  So we tubed him, and his whole family came in to see him unconscious on a ventilator.  Then our top hospice doc (love that dude) came in and talked to the family, and they agreed to withdraw on him the next day, rendering the hassle and expense of intubation more or less a complete waste of time.  And that was a relatively straightforward case.  Sometimes the family isn't reasonable and you have to leave them on the vent for weeks playing chicken.  House always wins in the end, because dead is dead, but you can dump a ton of finite resources into a bonfire along the way.

The latter is basically a difficulty getting everybody's ducks in a row; a patient gets cut, and OR wants to go back in later, but his lab values aren't quite right yet, or they're busy with other cases, or a weekend rolls around.  No point extubating when they're just going to intubate to operate in a few days, and maybe leave him on the vent a little after.  So he stays intubated and sedated round the clock to spare his throat.  Or you can stay intubated because the ICU doc is feeling timid, or because a failure of communication keeps the patient sedated till too late in the day, whatever.

Title: Re: Healthcare junk w/Elok
Post by: Buster's Uncle on July 31, 2025, 08:54:05 pm

I hope you will take it as read, ongoing, that yrs truly is reading and loving your stories - I just hate to keep making 'go on, go on/MOAR!' posts...

Title: Re: Healthcare junk w/Elok
Post by: Elok on August 01, 2025, 01:27:24 am

Well, Dormition fast starts tomorrow and lasts two weeks, so it'll be a bit.  I'm slow-going on this because I complain so much about my job in other places online that it's kind of old hat to me now.

Title: Re: Healthcare junk w/Elok
Post by: Buster's Uncle on August 01, 2025, 01:56:09 am

Not to us, oh my goodness.  Consider it penance, if that's what it takes...

Title: Re: Healthcare junk w/Elok
Post by: Green1 on August 01, 2025, 02:27:30 pm

Elok, I used to date a respiratory therapist before I met my current wife. She broke up with me because I was getting custody of a teenage daughter. A bit thankful the trash took out itself.

Also was a nursing assistant in hospitals and psych wards for a bit (agency, suicide watches, tying down dangerous patients).

They run RTs to death.

I was considering at a time going to occupational therapy assistant school, but the highly selective waitlist BS or be forced to pay 80K for a two year degree at some barely accredited place in Florida that is sink or swim did not appeal to me. So i later went draftsman.

Slight after edit: Plus, I think it is crappy that the medical industry would let me wipe butts and get the crap knocked out of me by deranged patients but if I tried to get better, they'd make me want to write a 10 page apology about why I got busted with weed in New Orleans 20 years ago which is silly and has no bearing on how I act professionally. Plus, I heard story of an RT in Tulane Hospital in New Orleans that went through dirty sharps boxes to get the waste opiates. Drug tests and background checks did not stop them. And the admins of hospitals get crapfaced drunk and are on all sorts of drugs (I have worked country clubs). I had to choose another field that is more sane. Sad, I liked helping folks.

Title: Re: Healthcare junk w/Elok
Post by: Unorthodox on August 01, 2025, 06:24:43 pm

Quote from: Elok on July 29, 2025, 01:14:04 am

So, I'm a respiratory therapist. 

So is hEt.  i'll attempt a summoning.

Title: Re: Healthcare junk w/Elok
Post by: Buster's Uncle on August 01, 2025, 06:35:05 pm

And there she is.  ;danc

Title: Re: Healthcare junk w/Elok
Post by: Unorthodox on August 01, 2025, 06:44:09 pm

oh, she might enjoy being able to share stories with people that can't just nod and pretend they understand the words like I do. 

Title: Re: Healthcare junk w/Elok
Post by: Buster's Uncle on August 01, 2025, 06:51:53 pm

I might just love love love the stories, too.

Title: Re: Healthcare junk w/Elok
Post by: hEtErOdOx on August 02, 2025, 02:29:19 am

Well. I’m glad to know that MD stupidity is the same in the adult world as in the NICU…

I’ve been a primary NICU RRT for 25 years. With my skill level and the way they staff us, I’m always in the NICU unless it’s an overtime or on call shift. When I’m out of the NICU, I pray that they give me Peds or surgical…adults on Vents and BiPap are terrifying. Once, a doc wanted me to put a guy with an esophageal tear on bipap…which is about the worst thing you could do.

Healthcare is breaking my heart since covid, but I reached a really bad place 3 weeks ago. We had a 30 weeker, mom had been ruptured for 5 weeks before delivery, and the baby started out pretty strong, but progressively got worse over the first few days. Our RRT’s brought up multiple concerns with the MD’s that were ignored…until the patient coded. Turns out, the lungs were infected with a really, really bad bacterial pneumonia. Somebody should have caught that…oh wait, the RRT’s did suspect that…and were ignored.

The problems arose when none of our physicians group agreed on how to treat the baby, and the RRT’s actually at the bedside were ignored. This patient was on 3 different ventilators multiple times over a 2 week period, culminating in a doctor pulling this patient off a vent she didn’t like, despite having a stable blood gas for the first time in days. She was pissed we pulled the patient off that vent a couple days earlier, despite being told multiple times that we were maxed out on settings and couldn’t ventilate the patient on that vent (The jet). I spent an entire shift with crap blood gases, CO2’s in the 80’s to 90’s (really bad) maxed out on the Jet settings, and when the baby’s poor mom asked me if they were going to live, I couldn’t tell her yes. And I broke.
The baby was transferred to the local children’s hospital the next day, mostly so that there would be consistency in care and order sets. But they’re  still on the vent and will probably end up with a tracheostomy, and a lot of that is because of the egos of our doctors.

I used to love my job, but healthcare just sucks since Covid.

Title: Re: Healthcare junk w/Elok
Post by: Bertilak on August 02, 2025, 04:11:25 am

My direct interactions and stories with the American healthcare system have involved my parents.

My mother died in 2020 after she suffered prolonged complications from a late diagnosis of a potentially congenital defect in her tricuspid valve. A defect in her tricuspid valve caused increasing deleterious health effects from the regurgitation of blood into her liver and related organs. She required consultations over multiple years with medical professionals and different facilities for treatments on breast cancer, unexplained chest pain, a rare calcareous growth on her tricuspid valve, mysterious issues in her respiratory system, and problems with liver functionality. Temporary replacement of her deformed tricuspid valve in the late 2000s produced brief relief, but an experimental surgery in 2020 for permanent replacement of her potentially defective tricuspid valve resulted in her death.

My father developed pneumonia in the middle of 2023 and has required continuous mechanical ventilation for survival from late 2023 through the present day. His treatment in certain medical facilities directly illustrated the strain on medical staff in hospitals. Medical staff in hospitals even explicitly denied ideal care plans because the hospital staff lacked adequate staffing for ideal treatments on my father. Facilities in California have provided decent through substandard treatments. His deteriorated current physical health partially emerged from his neglect of his physical health over the previous few decades.

Title: Re: Healthcare junk w/Elok
Post by: Buster's Uncle on August 03, 2025, 02:45:40 pm

When they found my dad's cancer, it was already stage four, and they were REAL quiet about it when they sent him home to die.  SOMEbody had screwed up -several; he'd been looked at on the regular before- and killed him.  That's hard to live with.

Mother's mother died two months to the day before him, of complications from neglect in a home - she fell into a coma, and went unmedicated for an extended spell before they transferred her to a hospital.

It was very expensive in both cases, paying a LOT of people to neglect my father and grandmother to death.

Not a fan of the System here.

Title: Re: Healthcare junk w/Elok
Post by: Green1 on August 03, 2025, 07:37:05 pm

Urgent care told me my cancer was a UTI and the abdominal pain was that I needed to stretch and lose weight.

Turn up at ER doubled over and they find a gall bladder smack full of stones and stage II bladder cancer! The hospital doctors were laughing "Yeah... just call it a UTI and be done with it. Sounds like urgent care".

For -months- I was struggling and working in misery.

Good thing is I am not going to be peeing in a bag and am unlikely to die from this. But I start chemo/ radiation later this month.

Really, really set back my plans. I had just gotten a degree in my 50s  and was doing draftsman work for a maritime company.

Title: Re: Healthcare junk w/Elok
Post by: Buster's Uncle on August 03, 2025, 09:06:31 pm

Ouch.

Dude.  Anything I can do to be helpful on the innerwebs, just say; I care.

Title: Re: Healthcare junk w/Elok
Post by: Green1 on August 03, 2025, 09:32:02 pm

I am doing okay.

My partner works and I have quite a bit of pad and stuff going on. My rent is literally 600 a month for a 2 BR. I found the place abandoned, talked to the landlord, helped evict the squatters and cleaned the place up for me and my daughter to move in. Been here 10 years.

If anything, I can now legally smoke weed via LA MMJ programs and being I am in a state with expanded Medicaid, they are covering almost everything doctor-wise.

Though it's kinda screwed up. I was recovering from back to back to back surgeries and am just getting better, now chemo and radiation coming.. sigh.

Title: Re: Healthcare junk w/Elok
Post by: Buster's Uncle on August 03, 2025, 09:52:27 pm

Have you seen E_T's butt cancer thread?

I burned a weekend once making him laugh while he was in the worst of radiation/chemo...

Title: Re: Healthcare junk w/Elok
Post by: Metaliturtle on August 04, 2025, 02:10:07 am

Quote from: Buster's Uncle on August 03, 2025, 09:52:27 pm

Have you seen E_T's butt cancer thread?

I burned a weekend once making him laugh while he was in the worst of radiation/chemo...

Didn't burn anything, you showed up in your way for a buddy, that's building up.

Title: Re: Healthcare junk w/Elok
Post by: Buster's Uncle on August 04, 2025, 02:30:22 am

Sure, but it cut into an obligation I'd made to Elok to read and respond to his excellent novel - which got delayed a couple days right there when I hadn't been fast to begin with...

That's priorities straight, but you know, sucked...


The Texas years sucked that way, too.  My sister needed me more, but Momma didn't stop needing me while I was a thousand miles away and some things DID fall through the cracks.

Title: Re: Healthcare junk w/Elok
Post by: hEtErOdOx on August 04, 2025, 03:25:08 am

Quote from: Bertilak on August 02, 2025, 04:11:25 am

Medical staff in hospitals even explicitly denied ideal care plans because the hospital staff lacked adequate staffing for ideal treatments on my father.

This is an unfortunate reality in the current environment. During Covid we worked significantly understaffed just trying to keep people alive, and now administrators seem to think we should be understaffed all the time, because we did it back then. It’s a money grab.

Title: Re: Healthcare junk w/Elok
Post by: Elok on August 15, 2025, 06:57:21 pm

I have no patient care experience pre-COVID, since I only graduated in '21.  So I have no grounds for comparison there.  I've never worked NICU and never want to; babies scare me.  But we have similar stories where doctors want bizarre or stupid things done with the ventilator, and all you can do is shrug and try to mitigate the damage.  It isn't nearly so tragic, though, because most of our patients are elderly, self-destructive, or both.  When a 78yo COPDer dies in the ICU, it's sad but not earthshaking.  That's just what happens at the end of COPD.  If a thirty-year-old meth user with an eighty-year-old's organs dies, we're mostly annoyed with the kid for wasting our time and his life being an idiot.  It's very rare for me to encounter the genuinely tragic, where death isn't the expected outcome for the patient's age or lifestyle.  I don't want to work in NICU and see little preemies die because mommy hit the bottle.  I'm callous enough as it is.  If you can take it, I salute you.

Adult work I guess has its challenges in that a tremendous amount of your job involves dealing with death.  This is a function of math; if two-thirds of people with dying relatives come to terms with it pretty quickly and sensibly, and most of the remainder will take a while to accept it, and the tiny little 10% nubbin left over are basically insane about it ... well, what that adds up to is that a decent-sized ICU will ALWAYS have at least one ventilator patient who has no hope and is being kept alive because basically the doctor and the family are playing chicken.  They stay and take up the bed/room and sometimes get in ugly fights with the doctor and threaten to take them/us to court.

Then there are hearts.  Open-heart surgery is top-flight stuff.  We do, I'd guess, something like eight of them per week.  It's obviously important, and I'm glad to live in a world where it can happen, but I don't know any RT who enjoys doing them.  I'll do them, because I have to, but hearts are pretty much my least favorite kind of work.  Basically, how a heart works is, they get intubated in the OR for the surgery, then brought up and connected to our vent to recover.  As soon as they go on our vent, the clock is ticking.  We have six hours to get them off the vent.  See, an uncomplicated extubation post-CABG is defined as one where they get off the vent in four to six hours, and the doctor gets reimbursed at a higher rate (and gets better-looking statistics, which patients are known to shop for) for uncomplicated extubations.  Naively, this makes sense, because quick extubations are associated with better outcomes, but I think this is because healthier patients get off the vent faster.  If you take a weaker patient and rush them off the vent, you aren't improving their outcome, you're just gaming the system for cash.

When I do hearts, I have basically no authority over my own vent.  The RN, the NP or PA, and the surgeon are calling the shots, even though they don't really understand the vent, and they will prioritize quick extubation even if it's under circumstances an RT would never tolerate normally.  Everything's big rush and big egos and the stupidity gets dialed up to eleven.  Now, we have it particularly bad because one of our CT surgeons is a strong contender for the most immoral person I've ever met.  The other one is at least a decent person, who will take it philosophically if a patient just needs a little extra time to wake up or stabilize.  But this guy ... I've seriously seen him extubate a patient who coded on SBT.  For you non-RTs, this means we set the vent to let him breathe on his own to see if it was safe to take him off, and he responded by trying to spontaneously die.  Long story.  He ultimately survived ... for a couple of weeks.  Then he got transferred to the floor, coded, and actually died.

The other awful thing about hearts is that the patients aren't "allowed" to die.  If you die within thirty days of open-heart surgery, it makes the surgeon look bad.  So you can't be DNR and you can't go palliative, no matter how bad it gets.  This can be taken to ridiculous extremes; we recently had a lady who was obviously in awful shape the moment she got out of the OR, went back a couple of times, got a tracheostomy, waxed and waned for the full thirty days and more, and STILL was not allowed to die in peace.  The family were talking about hospice within like four days of her surgery.  Doctor wouldn't cooperate.  She wound up transferring to a rehab facility, with the express intention of going to palliative/hospice/comfort care once she got there.  The whole thing was a tremendous amount of needless suffering and wasted resources, and all of it was on account of the surgeon.