Sometimes it gets busy.

I've been off for 3 days now and I walk into work at the beginning of my 12hr shift with a note on the desk that says "Come down to ICU and join the fun!", now this is probably not a invitation to a party in the ICU I'm thinking. Nope it isn't after I answer the phone right after I read this it's a coworker wanting me to come on down asap, ok let me just hang my jacket up at least and grab my stethoscope and off to the ICU I go.

In I walk and there my coworker is getting things ready for the Doc to intubate a patient. I can hear this patient outside of the doorway...wow major fluid issues, then I look, puffy like the stay puff marshmallow man and gray, yep this is gonna be fun. We finish getting the intubation stuff ready and the Doc slides the tube in, I place the CO2 tester on and give that first breath and it takes all my hand strength to get a breath in, wow is this patient tight...then I see it, pink frothy and bloody THICK secretion up the tube. Yep that could be a problem, time to suction. Finally I look up and see one of my coworkers, she looks about ready to cry...it's been one of those days I can see. The vent is set up and we place the patient on and that vent is just high pressuring, wow this person is tight from fluid time to try pressure control. I adjust the pressure and I times and I get volumes anywhere from 70 - 250ml's, not good we need a bit more but I have the pressure already up to 35 cmh2o time to continue bagging.

Back with the bagging the monitor starts alarming we look up and just watch the QRS's widen on this patient until it turns into V-Tach, not good. Check for a pulse, there is one and she converts back, phew dodged that code. A couple minutes later there it goes again, V-Tach, this time is stays, and we shock, back to a normal rhythm but a BP of 30 systolic. Again back to V-Tach and it stays, but there is still a good pulse so my coworker asks the patient to squeeze her hand, which she does, asks if she is in pain and the patient shakes his head no, can you move your feet, they move all over. We look up and still a full out v-tach on 2 different monitors and a good pulse with good responsiveness but the BP is still 30 systolic, now this is something I haven's seen before, a responsive patient in a condition like that. The doc now decides that there is now way this person can be responsive with a BP that low so it must be wrong. Now we need blood work and a ABG.

Here is where I feel like a stud. A doctor has already tried a A-Line and wasn't able to get any blood, another RT has tried to get a ABG already and nothing, so I say let me do it. I fell zero pulses in either the radial or brachial areas so it's time to use anatomy. I grab my kit, take aim and go for it...nothing...readjust...nothing...again and I strike blood!!!! WOOT!!! The syringe fills and I get the gas, it was said it couldn't be done.

Finally this patient stabilizes for the most part and we are able to ventilate but for most of the night it's back and forth....V-Tach and Sinus heart rhythm until finally in the morning things just give up and HR drops, BP drops and QRS's widen and the patient passes on.

Busy night, and from what I hear busy day I was told from the RT who looked like she was going to break down said and ultimately did break down and cried in a back room. I don't know exactly what all went on during the day but it was enough to get to her and she still felt like she should stay and help us until things got caught up with. I told her to get out of here, go home, have a drink and relax we will be just fine.

Yes our small hospital's can become very busy at times and it ways can be more stressful because of the small amount of staff we have to run with, but you adjust, adapt and make it work with what you have, all in all people do understand that you can get busy.

What is this post about, nothing educational just a post to talk about my night and how it can be. But ya know these are the nights that make this job fun, I enjoy the stressful situations like this.

Keep it up RT's and drive on.

Lets Lighten it up a bit.

Ok so that last post was a bit on the downer side so now I have to lighten up the mood a bit with a anecdote from my wife and where she works. She is a ER nurse at a much bigger hospital than mine.

Anyways I thought this was hilarious.

A nicely dressed lady in her late 30's comes in complaining of stomach pains. My wife goes in to get her history and information about the complaint and the patient goes on telling her that she and her husband drank a big the night before and started playing around and her husband decided to try something new and use a beer bottle as a ----- on her and she awoke this morning with stomach pains. So off the xray she is sent for a abdominal series and the xrays come back to show a bottle cap insider of her. Yes the husband used a unopened bottle that seemed become open, OUCH I would think and where the hell did the beer go. Ok now that isn't the funny part. So the doctor does in to do a pelvic exam to get the bottle cap out, and after the exam he comes back out to the nurses station with a Budweiser cap in a biohazard bad and exclaims:

"DAMMIT, I said I wanted a Bud Light."

True story, what a great sense of humor this doctor has. ER's are always fun to hang around at they people there are a different breed, especially night shift ER personnel.

Drive on and go have a beer.

How low can you go

So I'm going around doing my oxygen rounds (for the RT students, this is the fun time you get to check on all the patients who were or are on oxygen, mainly for charging purposes and sat checks), and I come upon this patient who has been in the hospital for awhile and notice that she looks awefully purple grayish in color, especially her lips. Now mind you this is in the middle of the night so the lights are off of course its 4 am. I proceed with my check by saying "Mrs. Namewithheldduetohippa I need to check your oxygen saturation levels" for which she complies and gives me the regulation oxygen check finger into my pulse ox device. After looking at the flow meter to see what flow she is on I look at the pulse ox and WHOA it's 52%!!!! So quickly I turn on the light, damn she really is purple grayish and not red in her lips at all. This lady has been on a 10-15 liter high flow nasal cannula and she had decided to take it off. I then ask her if she had been the one to take it off, she replied "Yes I did, I'm going to be a hospice patient and I cannot go home with this much oxygen on." So I go into my RT talk as to how with that low of oxygen in you blood you can cause damage to your heart and brain, along with a large increase of CO2 you your blood you might not wake up. Then I get the stunner "That's the point, I don't want to wake up. My lungs are really bad and I'm not good to anyone anymore, I don't want to be a burden on anyone, I'm just ready to let go and die." she says. Ok I'm a little shocked now and trying to figure out what to say next. How do you go about trying to lighten up this situation and help a dying person think they are worth being alive to people. Yes she is in bad shape but with her lungs, but her mind is in perfect shape and no she cannot run around with her grand kids in the yard, but she can talk with them, tell them stories. So I tell her, "You are not burden to us here, thats what we are here for it to help you out, and besides I enjoy talking to you and so does other people I work with so I'm sure your family enjoys just having you around to talk with." Not sure how much that helped but the nurse chimed in and added some more encouragement. So after this discussion with her I rechecked her sats and they were back up to 86% after about 15 minutes. This person is a great patient to have, had never complained or given anyone a hard time and yes she is enjoyable to chat with during treatments but yes she is past the point to getting well she was a 50 pack year smoker who was told 10 years ago that her lungs were bad and decided not to take the warning and get some help and now it's to late and she knows it.

How do you talk to patients like this, they are at the end of the line and they know it. I don't know it's just a bit surprising when something like this comes around, you never expect people to tell you that they are ready and want to die and they are being serious. This is a subject that comes up in our profession due to respiratory being involved with very ill patients but it's a population we have to deal with. Along this same line we deal with turning off the ventilators with patients have not chance to recover and are brain dead, these thoughts are very well explored over at Keep Breathing in a post he had about doing a terminal wean. I once worked with a RT who would refuse to do a terminal wean, he couldn't handle it personally and religiously... I don't think he is a RT anymore.

Once again it takes a certain type of person to do a medical job and it's not for everyone, but sick and dying people need this type of person, compassionate. That's what I would hope for if I was in their shoes.

Drive on RT's.

The Calm Before the Storm

Only 2 patients tonight, one a Q4 and one a Q2, yep nice and quiet. This actually give me 2 more nebulizer treatments I have to do than the last shift I worked, of course the Q2 isn't as bad as this person is thought to be, but no protocol is wanted on him so I kind of feel bad waking this patient up and taking loudly just to keep him awake and deep breathing. So ok he is wheezing and sats do drop without O2 so there is a need for something.

Wow ER just paged for a EKG....
Turns out nothing exciting, patient just left 10 days ago and has a Doctor appointment tomorrow oh and yep EKG was fine, doc says it's probably musculoskeletal pain, now get out of here and go home.

There has been some lazy shifts lately for my old RT department but isn't that how this job goes the patient load ebbs and flows like the tide. Feast or famine, you either run all night or you might sit all night and chat with the nurses or better yet blog about it.

Over my time in the profession I have noticed some trends of things where the patient load with increase or decrease and most of these have been fairly consistent, I'll try and lay them out and explain the idea behind these times.

Things that cause patient load to INCREASE or decrease:

• Summertime causes a decrease due to it being nice outside, and who wants to be stuck in a hospital when it's nice outside so more people come in for injuries than breathing.
• Exception to summertime is when humidity is high there is a increase, bring in the COPD'ers.
• Wintertime there is a major increase, it's cold outside and there are more sicknesses, cold air can set off a asthma attack, RSV is back along with croup.
• The night of or day after Thanksgiving there is a increase. Why you ask? Here you will see a large amount of Congestive Heart Failure patients because of the large amount of food people eat with a large amount of SALT which cause fluid retention.
• Christmas and Easter see directly above. Same thing with the CHF.
• Holidays in general you will see a surge of Frequent Fliers. Now these are mainly nursing home frequent fliers who want attention from the family during the holidays so on comes the sickness. I have seen this and could pretty much track it, when the holiday came so did these people.
• A Full Moon. I don't care what anyone says but a full moon always brings in more people, superstition or not. I have also read that the closer the moon is to the earth there is a larger gravitational pull on fluids which can affect fluid retainers.
• After the Super Bowl. The excitement of the game, the drinking, and the major one is the eating. Here you will get asthma attacks, CHF, and chest pains. Mainly this is evident in the ER but it's true.

Well these are the major ones I have noticed but of course there are other trends for different places in the hospital like the ER, for example the weekend magic hour is about 02:30 am, this would be the end of bar time....let the drunks get hurt and sick. Never know whats going to happen at any given time in the world of health care but some things just seem to fall into place.

I would like to hear any other trends that people have figured out, I'm sure there are more.

Drive on RT's

Vaseline and Oxygen: Flame On

I have been told before that you cannot mix oxygen and vaseline together because they can cause a flame and cause problems. How many others of you have heard this information, maybe this should be put on a new Myth Buster's show.

So I started looking around a bit and have came across some posting on nursing sites about whether this is a myth or not. I have found numerous references to this article, "Dispelling the petroleum jelly myth," in the November 1998 American Journal of Nursing but I have no way to access this article and cannot find a good free source for this. If anyone out there has access to this I would be interested to hear or see the information in this article.

Information I have found out about this being a combustible subject is that when a patient used a thin layer of petroleum jelly on their lips due to dryness from the oxygen that the oxygen from a oxygen device to provide the patient with oxygen can cause the petroleum jelly can cause a gas that when combined with oxygen can become very combustible, and then is a static spark can cause a flame. Supposedly there are many reports if this in a surgical rooms versus not many report from patient floor rooms. Could this be from a lack of people reporting this problem, I don't know but I think it's a interesting subject because I see vaseline and Carmex used a lot to moisten the lips of patients on oxygen. I do understand that oxygen does make your mouth and lips dry.

I am interested to see if anyone else out there has any good information on this topic.

Keep Driving on RT's

The Lungs have the Sound of Music.

Breath sounds, breath sounds, breath sounds. We all know and love them and listen to them daily but did you ever stop and think that there is a certain breath sound that you really enjoy hearing?

Fortunately tonight I have had the time to contemplate this and I came to the conclusion that there is a certain breath sound I really like the sound of. So much so that I much just try and get it onto my IPOD, or even better yet...as a ring tone.

So I'm sure everyone is in suspense wondering what the breath sound is that I find audibly pleasing, well wait no more because my favorite breath sound is the great and powerful CRACKLES!!! Why this one? Well it has a deeper bass sound and there is a range of pitches in this sound. The beginning of the crackles there is a faint noise of the crackling, then it gradually increases to the loudest sound, which this process in the musical world is called a crescendo, and then the process reverses and its gone. During the crescendo of a breath sound there is also the sound of the cracks, cracking on and off so you have a variety of sounds in this lung sounds. Yeah for pneumonia and CHF.

Anyways that's my take on my favorite lung sound, does anyone else have a favorite or is it just me? Could you imagine hearing Crackles or wheezes as a ring tone, would that not freak some people out. Oh my Gawd that person is having a Asthma Attack!!!!

Here is a website I found a long time ago called Lung Sounds, but on here are audio files you can click on and listen to different sounds I found this years ago in school and surprisingly it is still online and it is in my Respiratory Link section so enjoy.

Until next time Drive on RT's

A Stereotypical Patient

Everyone has some patients who are just stereotypical patients. The ones who are they way they are because of how they are. What I am going to do is try and describe a type of patient that I have noticed at every place I have worked as a RT and the reason they are this way.

Yep you might of guessed it, these types irritate me a bit because of what they could do to change their symptoms.

• They become short of breath with exertion.
• They most likely are diabetic.
• They are usually younger 30-50 years old.
• They have "Exercise Induced Asthma".
• They have hypertension.
• They seem to have back problems.
• They like to sleep and are become tired a lot.
• They like to order food at all hours, or have a stash of snacks in the room.
• They have decreased lung sounds.
• They get pneumonia a lot, or just plain sickly.
• They give a very lazy effort when asked to do a peak flow.
• They have that certain smell about them.
• They all seem to smoke.
• They seem to be on public aid.

Now you ask what patients am I talking about here, well these would be the morbid obese younger patients who have no motivation to help themselves. Just think how many trips to the hospital they could save just by losing weight.

Their breathing problems with exertion would be less, hypertension could be better controlled, diabetes better managed, they would have more energy, back problems could be gone, they could get a better job or a job in general with insurance and there possibly is not real asthma component. Finally that smell could disappear.

Now I'm sure this sounds like I'm bashing overweight people but I'm really not. The people I'm talking about just do not take care of themselves, are lazy and leech off the system. There are many overweight people who don't fit into this mold at all, but as for who I'm talking about...You RT's and RN's know exactly what I'm talking about.

Feel free to comment me on this but as always

Drive On RT's