RT!: Reflections on a Career in Respiratory Therapy

RT!

Reflections on a Career in Respiratory Therapy

By

Jeff Maurer

Smashwords Edition

Copyright 2018 Jeff Maurer

INTRODUCTION

Responsible nurses do try

to ensure that their patients don't die.

But though drugs and compassion

both work in their fashion,

when pressed it's RT nurses cry.

Let me explain.

Suppose you are a nurse caring for a patient on a ventilator (a breathing machine). Suddenly an obnoxious ventilator alarm sounds, demanding immediate intervention – a demand impossible to ignore because the ventilator alarm is even more obnoxious than the variety of other obnoxious alarms that seem to be constantly sounding off in Intensive Care Units. You know there is a chance your patient will die if you do not figure out and fix what is wrong – and soon. The first thing you do is make sure that the ventilator tubing did not become accidentally disconnected from your patient, which can happen during some patient care procedures. It appears to be securely connected. The alarm is still blasting. Instead of the rhythmic inhalation-exhalation sounds of a properly functioning ventilator, you hear a constant, disturbing whoosh. And your patient’s chest is not moving, so clearly he is not getting any air. Multiple potential explanations exist for why the ventilator isn’t doing its job, but your training and experience has been largely focused on other of the innumerable aspects of patient care. (There are only so many things that any one person can be expert at.) But there is someone in the ICU, probably not more than a few yards away, whose training and experience is entirely centered on respiratory issues and technology – the Respiratory Therapist. You grab the bag (a plastic hand-held breathing device which will hopefully enable you to take over for the ventilator until help arrives but which you really don’t want to have to use for very long because there are other things which your patient will need from you and besides, you’re not a machine) and yell for help.

RT!

Or, suppose you are on the night shift taking care of a baby who, though not on a ventilator, is significantly premature and therefore at risk for apnea (not breathing). You’ve been a nurse for a while and have seen this happen to several of your patients. And more often than not, all you had to do to get them breathing again was provide a little stimulation. But that isn’t always enough. You’ve bagged babies before (provided manual respiration with the plastic breathing device), but since that is only one of the many things you need to know how to do and since you haven’t actually done it all that often, it’s not something with which you are as comfortable or competent as someone who does it frequently and whose training is specifically centered on that kind of thing – namely, the Respiratory Therapist. Sure enough, your baby stops breathing. And simple stimulation is ineffective. You try using the bag but just can’t get the baby’s chest to move up and down as it would if air was actually moving into and out of the baby’s lungs. (Positioning a premature baby’s head in just the right way to get the airway open can be tricky.) The doctor (a new Resident whose anxiety level tends to aggravate rather than diminish the tension which pervades emergencies) is probably in the sleep room around the corner and down the hall. The Respiratory Therapist is someone whom you know has saved the day in multiple such situations. If the problem is more complicated than just apnea, calling for the doctor would be a priority. But even if that were the case, establishing adequate ventilation is the single most important objective in the neonatal population. So, who ya gonna call first?

RT!

You know those dreams when you suddenly realize, the night before it is due, that you have completely forgotten about a term paper accounting for half your final grade, or you’ve completely ignored an entire course you were supposedly taking for the last three months, or you find yourself on the way to a class without having any idea at all where it is? Maybe you don’t dream. But I do. And I had those dreams for decades even after I stopped going to school. The good news is I no longer have those dreams. The bad news is the school dreams have been replaced by work dreams – such as being confronted by a nurse who knows full well I have completely ignored one of my patients for the first 11 hours of my 12 hour shift, or, still worse, turning my patient’s ventilator off so I can suction excess secretions from his breathing tube without the dang disconnect alarm going off but then fatally forgetting to restart the ventilator after I reconnect it to my patient.

Trust me. My bad work dreams are worse than my bad school dreams. So if anyone is wondering why I decided to write this book, the primary reason is to hopefully exorcise that particular dream demon by manifesting my Respiratory Care memories in some medium other than my fragile and apparently self-loathing subconscious.

Before proceeding, I wish to point out that while all the stories told here really did happen, none of the individual characters (except for Steve and William) is or was a real person. Names have been changed. Also, I am distilling over thirty years of experiences into a few pages. Many of my characters are amalgamations of multiple individuals. The same could be said of institutions – I’ve worked in over 10 different hospitals. And though I will, at times, portray some individual character or institution in a way that could suggest they deserve criticism, please keep in mind that everybody has flaws. The intensive health care environment is a particularly difficult one to function consistently well in for even the most competent of us. We all make mistakes. And we all deserve forgiveness. Also, coping with potentially deadly mistakes is a challenge that not everyone is up to and is something that should be taken into account by those considering embarking on any profession that would routinely place you in a life or death situation.

It may also seem that most of the stories I tell involve bone-headed blunders. This does not mean that bone-headed blunders dominate health care. One of the reasons they are so memorable is that they are unusual. The usual is for everyone on the health care team to know their jobs and do them proficiently.

In my opinion, based on decades of experience, health care professionals are among the most caring, compassionate, competent, wonderful people ever. To every single one I have shared healthcare trenches with throughout my entire career, even including the ones I at times found myself in disagreement with and who might (or might not) provide some fodder for some of the stories here, it has been an honor and a privilege. Thank you.

Chapter One

MAKING IT REAL

My third attempt at a career found me taking a stinking, crammed like sour in a lemon bus from Haight-Ashbury to the financial district where, with a bunch of other faceless suits, I toiled away in my cubicle manipulating figures, charts, and computer programs to arrive at the most actuarially sound contribution levels to ensure appropriate pension funding for our client corporations.

Maybe your reaction to that is, Wow! How interesting! But the reality of it, for me, was that I was losing my mind. It was San Francisco. It was the seventies, man. And there was love in the air – if only I could escape the vibes of the financial district. So by a series of events nearly as circuitous as those that led me to be an actuarial assistant, I became a Respiratory Therapy student.

In case you’re wondering, I would have been far, far better off financially had I stuck with the actuarial sciences. But I would have been a different, even more eccentric, less socially responsible me - might even have swallowed the whole loony, market worshiping, greed justifying Ayn Randian philosophy. So it’s not at all clear that the best choice financially would have been the best choice for me. Anyway, a Respiratory Therapist makes slightly less than a Registered Nurse. And nurses also have somewhat better career options. So Nursing might seem to be the wiser career path choice. But in deciding whether to pursue Nursing or Respiratory Therapy, there was one absolutely essential debate to resolve: shit versus sputum. Shit, you know about. Sputum, in case you don’t, is the potentially putrid slime hacked up by patients with diseased lungs – think rotting oysters. With rare for me insight, I knew even then that nurses were the kind of people who were grossed out by sputum but didn’t mind shit, whereas Respiratory Therapists simply did not want to have to deal with shit. So for me, the clear choice was Respiratory Therapy. And, though my RT career did not turn out to be as shit free as I had hoped, this remains my observation on a fundamental difference between the two professions even today.

Beyond my preference for avoiding shit, there were other, more altruistic motivations for choosing to pursue a career in Respiratory Therapy, especially as it compared to other, less helping professions. What I wanted, and what I got, was a profession that enabled me to actually feel like I was doing somebody some good. I can’t tell you how satisfying it is to be greeted by a family of two grateful parents with their beautiful, healthy young daughter who survived severe prematurity in part due to my efforts and skills. Whether a chance encounter on the streets of the city where I concluded my career and still live, or the result of their return visit to the hospital years after discharge just to say thank you, these reminders of our successes were what kept us going in an intensive care environment that saw far too many heart-breaking defeats.

My fourth career ended up being a keeper. Though aspects of it infuriate me still, I’m not sure I could have tolerated anything else even nearly as long. I am grateful that I found it. But the heartbreak is very real – at least for the kind of person who ought to be doing this kind of work.

After taking some prerequisite courses, I started my two-year Associates Degree program in Respiratory Therapy. After the first year, while still a student, I got my first job as a Respiratory Therapist. This would not happen in today’s world of stricter education and licensure requirements. But back then, the profession was still young. Some still referred to it as inhalation therapy. (I’m too embarrassed to say how long it took them to realize that inhalation without exhalation didn’t do much good – so respiratory really was a much more appropriate title.) Heck, because some roots of the profession lie in needing somebody to move oxygen tanks around the various parts of the hospital, when I first started there were still some who referred to us as oxy jockeys. (Round about 1986, somebody decided that the ever-expanding role played by Respiratory Therapists demanded yet another update to our professional designation. Thenceforward, it was decreed, we would be known as Respiratory Care Practitioners. Really rolls off the tongue, doesn’t it? Twenty-five years later, despite the officially preferred title, nurses in need of assistance were still calling out RT!)

That first while still a student job in RT had me providing low risk treatments on the floors, as opposed to the more highly intensive responsibilities reserved for the more experienced RTs in the unit. I did med nebs, IPPB, and CPT. CPT (chest physio-therapy) involved placing the patient in several positions (mostly with the head lower than the body) while striking their chest with cupped hands in such a way that made loud popping sounds while supposedly mobilizing pulmonary secretions so the patient could more successfully cough them out. To my knowledge there has never been any experimental validation to suggest this actually works. But there is plenty of anecdotal evidence from pulmonary patients who swear by it. I was once complimented on my CPT rhythm by a patient who had been a professional drummer. Med Nebs (medication nebulizers) turn liquid medication into a mist that is passively inhaled into the patient’s lungs. IPPB (intermittent positive pressure breathing) is a lost art. It used positive pressure to help the patient take a deeper breath so that the medication could get better pulmonary dispersion while also treating and preventing the hopefully minor regional lung collapse known as atelectasis. Properly used it was effective. But in the hands of the less capable or less artistic, there was potential for undesirable side-effects. Today, both the artistic and the incapable have been homogenized into a middle ground of proper procedure that does a fair job of minimizing both.

Jerry was one of the COPD (Chronic Obstructive Pulmonary Disease) patients I truly enjoyed treating with both IPPB and CPT. And I had the pleasure of providing him with those treatments on many occasions. He was a happy, engaging older gentleman who offered me a stick of chewing gum every time I entered his room. Our treatment session usually lasted about 25 minutes (which was shorter than it would have taken to do it text book correctly, but longer than he was sometimes willing to tolerate) and I probably did him twice during my eight-hour shift. So we had plenty of time to talk and get to know each other. He had been discharged a few days earlier when I heard an overhead page for Respiratory Therapy STAT to the ER. (The director of Respiratory Therapy at that hospital preferred his therapists be paged overhead instead of via personal pager because he thought it was good PR for the profession to be heard as being needed so often. STAT means right now if not sooner because the shit is hitting the fan.) When I arrived in the ER I followed the general hubbub into the room where a code (resuscitation of a possibly dying patient) was underway. One of the ER nurses already had a mask securely covering the patient’s nose and mouth and was providing ventilation with the bag. I took over responsibility for that just as the patient’s heart monitor went flatline. The nurse I’d just relieved started compressions and soon the defibrillator pads were placed to hopefully shock the patient’s heart back into a life-sustaining rhythm. At the all clear notification I removed the bag/mask from the patient and stepped back to expedite defibrillation. It was only then that I realized the patient was Jerry.

We bagged and compressed and shocked the heck out of him. But he didn’t make it. Jerry’s was the first death I ever witnessed.

As you go through the mouth or nose and down the throat, you arrive at two openings. One is the esophagus, which leads to the stomach, and the other is the trachea, which leads to the lungs. It is possible to position the head of a coding patient