Thursday, March 26, 2009

Why No Neo-Pedes For Me

This is a hard blog entry to write.  I've been thinking about it for several weeks, and I've decided that whatever I write will be less than ideal, no matter what.  Every Respiratory Therapist has areas they aren't good at.  Neo-Pedes is such an area for me.  

I recently finished my clinical rotation at a prestigious regional pediatric hospital.  I didn't have any special trouble with the skill set.  I didn't lose my nerve, dealing with tiny preemies or very sick little people.  For me, it was the families, the decision-makers that I couldn't handle.

In adult intensive care, most patients have had an opportunity to express what sort of care they want, somewhere along the line, formally or informally.  That isn't a bullet-proof guarantee that granddad won't die a long and tortured death because family members are battling over him and his stuff.  But nearly always, there is up front discussion about how granddad probably feels or what he might want.  In neo-pedes, this isn't the case.  Children have no rights, so discussion about what they feel or what they want is always 'in the air'.  It is always up to someone else to interpret their situation and decide what is "best" for them.  My point is it is never up to the child.  Never.

For me, the breaking point was a beautiful little boy born full term to a very young teenaged mommy.  The baby had been diagnosed in utero with a collection of 'blue-baby' heart defects.  These sorts of problems run the gamut from small holes in the heart's septum than can be fixed in one surgery, to little hearts that are so jumbled up that even after many surgeries they are sort of functional but nowhere near 'normal'.  This little boy was in the latter category.  His mixed up heart worked just well enough for him to breathe and eat and be alert as a newborn.  As soon as he grew a little bit, his heart would be unable to keep up and he would die (rather peacefully, though).  Multiple heart surgeries, if he lived through them, would leave him able to live in questionable condition for a few years, in the hope that more successful surgeries might be invented in the mean time.

The surgeon, the cardiologist, and the neo-pediatrician all concurred on the baby's slim chances in surgery.  They all outlined the option of comfort care, and a very brief but normal life with a peaceful end.  After listening and thinking, the grandfather said, "if there is a 10% chance to save my grandson's life, then I want you to do everything you can to save my grandson's life."  

So off to surgery went the baby.  He looked his mom in the eyes for the last time when he was 3 days old.  Back from surgery, we were obliged to leave his chest open so we could access the heart directly for manual massage.  He had had that many arrests.  Before long he was on ECMO (extracorporeal membrane oxygenation), along the with the open chest.  His lungs began to clear up on ECMO, but then we had to take him off it, because the blood thinners that must be used for ECMO resulted in a massive grade 4 brain bleed.  We removed the ECMO, we closed his chest.  His reflexes never returned and his eyes never opened again.  But his little heart kept strokin' on, and his grandparents talked about how excited they were to take him home soon, with a tube in his abdomen for nourishment and a tracheostomy in his little neck for a ventilator.  They said they loved him even though he wasn't 'perfect'.  And they were smart, educated, middle-class people who were only trying to do the right thing for their pregnant high schooler and their new grandbaby.

It's not just that I would have made a different decision if it had been mine to make.  I understand the passion one has for one's babies.  Yes, I think I would have decided to bring my baby home on comfort care and let him be a completely wonderful little baby for whatever short life he had.  I have NO criticism for the grandparents who decided differently.  All I know for sure is that I don't want to use my new skills to close the bright eyes of a little baby as I help intubate him for surgery, knowing I will get him back by evening after helping put great tubes in his carotid and jugular, while his blood pressure and heart rate jump and the anesthesiologist struggles to balance him between life and unconsciousness.  I would rather use my skills to torment a dehydrated drunk with a TBI back to life, so that he can decide if he will take this one last chance to have a relationship with his family.  I felt ashamed to place this forever unconscious baby back in his mother's arms, thinking how they could have gone home together and loved each other so vividly, although not for very long.  I knew for certain, at that moment, that this was an area of medicine I was unfit to facilitate.

The economy is bad, and the pediatric hospital is hiring.  But I won't apply.  I have a casual position at a big metropolitan hospital with a big trauma unit and an even bigger ICUs -- also a huge hospice floor.  These are areas where I work hard, but I come home at peace with myself.

Every RT is different.  Someone else will be right for Neo-Pedes.  It won't be me.


Monday, March 9, 2009

Why RT As A 2d Career (or why not)

Tonight, I would prefer to be selfish and blog something about my clinical rotation in my region's prestigious children's hospital.  But I think I'll wait for that.  Instead, I think I'll feel better all around if I share some ideas about "why Respiratory Therapy" (or why not), if you happen to be changing careers right now.

You might want to switch to Respiratory Therapy if:

-  you're an unredeemed hippie at heart, and you believe breathing is a Fundamental Mystery.

-  your work-life has disintegrated under you, and you realize that breathing cannot be outsourced to a phone bank in India.

-  you've been working (or hardly working) at something you believe is trivial, and it occurs to you that breathing matters a LOT.

-  you're amazed at how stubbornly persistent Life is.

-  you like finding out about stuff that is all around you, that you take for granted, and you like learning something completely new about it.

-  even though blood and guts and snot might bother you, you try a clinical shadow and discover that seeing grey people turn pink and open their eyes and say "thank you" can cure your nausea instantly.

-  you like science, OR you always thought you were too stupid for science (science isn't hard).

-  you've had more than your share of school and tests, and coached your kids through still more school and more tests, and you figure h#ll, two more years of school and tests can't be the end of the world if it gets you to something fresh and interesting.

-  you like helping people; OR you are a shy person who prefers to deal with people within strictly limited parameters.  (That's me.  I'm miserable at a cocktail party, but I'm very happy to provide a defined service I've been trained to do, for strangers who stay put in their hospital beds.) 

You might NOT want to switch to Respiratory Therapy if:

-  you sincerely like your current work, despite its disappointments, and you want to find another way to apply your existing skills.

-  you can't stand (or can't understand) working as an hourly employee.

-  you don't like working in a predominately female environment.  Respiratory Care is about 1/3 male -- a larger percentage than many other allied health professions.  But I switched from a predominantly male professional setting, and the henhouse politics were new to me.  

-  you find it hard to work with or work for people who are younger, less experienced, and less mature than you are and who have more extensive credentials than you do.  (Get used to this.  If you change fields late in your career, this is inevitable.)  

-  you are deeply invested in "being somebody" in the broader sense.  No one in an allied profession will be "somebody", unless they write a book or make a movie like Erin Brockovich.  However, you will definitely be the most important person on the planet to the patient you help to breathe. 

Hope this helps.  As an RT, you have tremendous career flexibility.  You can go into management, or you can kick back and be hourly.  You can travel to cool places where there is a short term need for respiratory therapists (very cool places or, for even more money, less cool places).  You can work a standard full-time schedule, or you can work contingent when you feel like it.  You can do research. You can write or publish in your new field.  You can just do a good job keeping sick people breathing and put it all out of your mind when you go home, but believe me, that matters a LOT.  (Just don't tell your patients that you forget all about your workday when you go home.)

Do remember that this is not investment banking.  Absent the best-selling book or the movie deal, you're not going to get rich doing this.  But you won't be out of work (everybody breathes).  And if you like stimulating work that matters to other people, you won't be bored or feel worthless.


Tuesday, March 3, 2009

"Lots of Sick People"

Here in my midwestern state, February has been like November at the hospital.  The census is up.  My supervisors are calling me, asking if I can come in, even on days when I have notified them I am in class at the college.  ("Well, what time is your class over?  Can you drive down and pick up a shift?")   When I come in for an 8 hour shift, I am always asked to stay for a 12.  If I am scheduled for Saturday, I am asked if I can do Sunday too (even though I have a 12 hour clinical on Monday).  If I weren't staring down the barrel of my licensing exams, I'd be happy to work.  And God knows I need the money, even now...

But, to be honest, 12 hour shifts are hard.  I had been chalking it up to my age (I'm 56), but even my younger student colleagues tell me they are wiped, the day after a 12.  Hardest of all, a much larger percentage of my patients are now very, very sick this time of year.  Most of the year, approximately a quarter of my patients are fighting for their next breath.  Now, fully half of my patients are fabulously sick, and they are not DNRs either ("do not resuscitate").  They are trach patients from skilled nursing facilities with pneumonia, patients with asthma and COPD with refractory exacerbations...  

I hate doing repeated nasotracheal suction ("NT suction") on my very sick patients.  It seems to me that we don't decide to install a soft nasal trumpet in a patient's nose to protect the nasal tissues until *after* the nasotracheal passages are all jammed up and irritated and edematous from frequent suctioning.  

With my adult patients, I try to talk them through an oral access instead of putting a suction tube in the nose -- inhaling, exhaling, swallowing on cue so that I can move from the back of the mouth into the trachea to get down and get out the junk.  Lots of surgilube, coaching, peaceful breathing.  Nasal passages are narrow and fragile, in my opinion, even in grownups.  By contrast, oral passages accomodate a lot of "stuff" going by, on a volitional basis.  It feels familiar to patients to go in through the mouth.  Patients put stuff in their own mouths on purpose, and take stuff in that way.  They don't shove things in through their noses, as a rule.  That's scary.  And they don't want me to shove anything through their noses either, if there's a choice.

First rounds on Wednesday, I had 56 treatments.  When I have that many, the hospital computer shows about 1/3 of my treatments as late.  So, I don't get such a good rating as an employee.  Of course I "stack" treatments, instead of staying with each patient until the treatment is finished.  Our protocol says that if the patient is alert, familiar with the treatment, and their vital signs are stable, we are supposed to go on to the next patient and come back to check the previous patient when their treatment is finished.  That's not the old fashioned way, but it makes good sense.  I do get jammed up sometimes in my "efficiency" ratings, at times like this -- even if my patient is getting a routine aerosol treatment, if they are frightened and anxious I won't leave them on their own.  So the next treatment is "late", but that treatment is not for a patient who is breathless and frightened.  It's for someone who is just supposed to have a treatment to keep things on an even keel. 

And then there's the business of getting the class work turned in on time.  But I hit the target this week.  Stayed up late, assignments done, turned in today.

It's still a good business.  Breathing matters.



Saturday, February 28, 2009

"Let's Roll"

Too tired to do much more work on this academic quarter's project on Home Health Care tonight.  My college has an excellent AAS program in Respiratory Care (contact me personally for details).  But this particular class in my senior year doesn't quite meet my standards.  The college is understaffed (surprise!).  Our dedicated department chief is teaching nearly every class for us seniors.  His solution is to assign pathology and health care industry topics to small groups of students, which we are to research and present to the rest of our class according to a standard rubric.  That works pretty well, and it's certainly all I could expect at $86 a credit hour at a state college.  But I sure would prefer to have a professor with expertise in cardiopulmonary pathology teaching our Path class -- instead of us teaching each other.  Still, I've researched these curricula within an inch of their lives, and this is honestly the best curriculum available in my state.  You can pay more, and spend more time, at some of our state's newly minted 4 year programs.  But this Associate's Degree Program is jammed to the gills with practical and academic content, and the new 4 year BS programs are basically our two year program plus a lot of entry level college core material.  I already have both a bachelors and post graduate degrees, so the last thing I want is academic fluff.

All the same, I sure wish we weren't teaching Pathology and Current Health Care Work Environments to ourselves.  On the other hand, since we are supervised while we do it, we are giving ourselves a lot of quality content.

Hauling off to bed now.  Have to leave at 0515 to catch a 12 hour shift at the teaching hospital where I work on a Limited Permit, an hour's drive from home.

"He can't hear a word you're saying"

Last week they called for Respiratory in the Emergency Department.  Since I'm a newbie who is mostly supposed to be doing floor care, I'm usually not available to run along for these -- even though they represent great learning experiences for me.  But this time I had finished all my treatments and charting, so I ran.

The patient was a big guy, apparently a drug overdose (party too hearty?).  He didn't respond to commands, but he was far from unconscious, flailing and moaning, and pushing the mask away with both hands.  It took a long time to get IV lines in, to get him sedated, to get restraints on him.  It became clear pretty quickly that we would have to intubate him.

The hospital was jammed that weekend.  There was only one ventilator left in the whole place (all the others were in use), and someone went off to find it.  So we were bagging this fellow for a long time.  The lead therapist's hands were getting tired, so I took a turn at the head of the bed.  The patient began to stir, then to toss his head, as the sedation was wearing thin.  I talked to him quietly, telling him where he was, what we were doing to him.  I told him to try not to be afraid, to try to relax as much as he could and to let me help him breathe with the bag.

The woman who was lead therapist on that response is someone who doesn't like me much.  I'm not her style at all.  She rolled her eyes and said, "Oh, for God's sake, Maize, you are so irritating.  Will you shut up and bag?  Believe me, this guy can't hear a word you're saying!" 

I'm a wise-ass by nature, but never at work.  Unlike my former work environment, smackdowns don't help the process in healthcare.  What I wanted to say was, "It's fun to pretend he's a person".  But I said, "Oh, we don't know that for sure.  I've been where is he now, and I could hear every word."  The other woman folded her arms and leaned against the cabinet.  "I guess no one can tell you anything, right?"

I kept bagging.  And I kept talking to the patient.  Eventually someone came along with more propofol, and the missing ventilator.

As someone who is new to allied healthcare, and as someone who has been a hospital patient from time to time, I object to the practice of treating a patient as if he were a pizza that had just been delivered to your workplace.  No one knows better than I do that we have a ton of stuff to do for a ton of people in not nearly enough time.  But it doesn't save time to act as if the patient is invisible.  I speak to my patients when they're awake, when they have tubes down their throats, when they're paralyzed, when their sedated -- and even when they're dead.  (I have a feeling they are still nearby somewhere.)  I'm learning a lot of things I can do to help, and I plan to keep learning.  But I'm still convinced the first and best thing I can do for a patient is to see them as a person -- a hurt person, a sick person, an unconscious person, maybe a dying person -- but a person.