Healthcare junk w/Elok

[Elok]

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.

[Buster's Uncle]

 

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.

[Lorizael]

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.

[Elok]

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.

[Buster's Uncle]

The kids come first.  You do you.

[Metaliturtle]

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

[Lorizael]

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.

* Lorizael googles

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

[Elok]

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.

[Buster's Uncle]

MOAR!

[Geo]

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?

[Elok]

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.

[Buster's Uncle]

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...

[Elok]

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.

[Buster's Uncle]

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

[Green1]

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.