Do you want to Live, or do you want to Die?

I had been working as a Respiratory Therapist for over 20 years. Over those two decades there were many advancements in medical technology, and by and large the technology was good and saved many lives such as the advent of better Infant Ventilators for the treatment of babies born pre-maturely. But as the technology made possible to extend and save lives, there was a downside. It seems that as the technology boomed, the Doctors, Nurses, and other allied health professionals lost sight of the purpose of the technology while also losing their ability to communicate with the patient, the family and clergy about "end-of-life" decisions.

The last decade of my practice of Respiratory Therapy saw so many occasions of what I would call "very inappropriate use of high technology medicine", applied to extend end of life situations. More tubes, more drugs, more monitors, and often all of this while increasing the physical distress to the already greatly suffering patient when palliative care would have been the proper course. This at great financial and emotional expense to family in order to only extend the suffering of a patient that is dieing.

Now I am not putting all the blame on hospitals, doctors, and health care workers, as I put equal blame on family and clergy. There is no longer the communication channels that we counted on so often to help make decisions. Families of course want to do all that may be possible to help a loved one. This is natural, but there are times when it is no longer appropriate to pursue more technology that may only increase the suffering, while there is really no chance of surviving the end stage disease. But without communication between patient, family, doctors, nurses, and clergy, we are often left with the patient having technology applied simply because it is available, and the family has not been properly informed of the impact that this technology will have on their loved ones last days.

I will tell of a particular personal experience of mine while working the Intensive Care Unit. I will call the patient Mr. Jones, (not his real name) and the doctor, Dr. Fredricks, (not his real name). The Hospital Facility and State remains anonymous as I have worked in a number of facilities in a number of states and have witnessed similar situations in each.

Mr Jones had been transferred to the Intensive Care Unit. He was suffering from end stage Emphysema and I had seen him on many occasions over a number of years doing what we could to help him through tough times of this progressive disease. He was a kind gentleman, and was stoic in how he managed with his illness. But, it is a progressive disease, and at some point in time in the near future it would be the cause of his death.

In the Intensive Care Unit, we would be better able to closely monitor Mr. Jones, as his breathing was very labored and his blood pressure was unstable. We all pretty much new that this very well may be his last visit to the hospital. As the night went on, he became worse. His breathing was so labored he could barely speak. He could no longer maintain proper blood oxygen levels with oxygen mask. Checking the chart, the nurse noticed that there was no statement as to whether he would be coded if his breathing failed. Calling a code (implementation of artificial resuscitation) provides ventilation by artificial support.

Calling a Code would mean the application of artificial breathing devices as well as external cardiac message if needed, (CPR). In a hospital setting the Respiratory Therapist may have to intubate the patient of which the code has been called. This is the placement of a tube into the airway by way of the mouth or nose. It is a very painful procedure for the patient that is awake and aware to endure. The therapist positions him or herself at the head of the bed, and a laryngioscope blade is inserted into the mouth and is advanced deep into the back of the larynx. The blade is lifted pressing the tongue against the floor of the mouth and lifting the jaw until the vocal cords can be visualized. A tube that is about the diameter of your thumb is inserted through the vocal cords and into the airway. A balloon at the end of the tube is inflated to seal the airway, and we are able to hook up a ventilator to force air into the lungs.

This a very common procedure and is frequently used in emergency situations and surgical settings. It does save lives, young and old and is required anytime a mechanical ventilator is put in use.

Back to Mr. Jones...

Without a Code Status statement in his chart, we will be required to perform a code on Mr. Jones. The Nurse placed a call to inform Dr. Fredricks of the worsening situation with Mr. Jones, and to hopefully get a "No Code" order written. When the nurse hung up, she stated the Dr. Fredricks did not sound very pleased having to come in at 2:00 in the morning. When the Dr. arrived we updated him on the situation and hinted that we were needing a "no-code" order as the nurses as well as myself felt that it was very likely that Mr. Jones would not recover despite all our efforts. Dr. Fredricks called the family and the conversation went something like this.... "Mrs, Jones, your husband is having more difficulty with his breathing. Do you want us to do all we can to help him?" We could not hear the conversation of Mrs. Jones, but when the Doctor hung up the phone, he said that the family wants us to do all that we can. We were greatly dismayed about the manner in which he confronted the family as he did not fully explain the impending crises, nor the procedures that would be put into place. He then went in to talk with Mr. Jones. Now Mr. Jones was hard of hearing, so Dr. Fredricks got close to his ear and was almost yelling to Mr. Jones.

"Mr. Jones... Do you want to live, or do you want to die"?
"Mr. Jones... Do you want to live, or do you want to die"?

It was very difficult for Mr. Jones to talk as his breathing was so labored. Each breath was a gasp. He finally was able to say with a raspy voice in-between gasps, "I.... gasp.... want...... gasp.... to.... gasp.... LIVE... gasp".

I looked at the nurses and we could not believe the heartless manner in which the Dr. handled this. Neither the family nor the patient was informed of what was to transpire when Mr. Jones's breathing failed. I wanted to make sure of what Dr. Fredricks orders meant specifically, and he did state that if his breathing fails, we are to intubate and ventilate. And with that the good doctor was off for a good nights rest.

Mr. Jones's night would not be so restful. His breathing finally did fail and we had the crash cart standing by. I was able to intubate fairly quickly and had him hooked up to the ventilator to support his breathing. He had to be restrained with his wrists tied to the bedside as he was frantically trying to pull out the breathing tube. He was medicated to ease his apprehension. And thus our technology was now prolonging his life. I went home in the morning feeling just terrible. For the next two weeks we pumped air into his failed lungs, while his wife anguished at his bedside over the obvious suffering of her husband of more than 50 years. She would ask over and over... "Is there not anything you can do to help him?" All I could think of in my mind was "Unfortunately, we have done everything we can". A very sad situation. He lived on the ventilator for two weeks then his heart failed. I was not present at his death, but full CPR was performed to no avail on the Doctors orders.

It seems in this situation, that the Doctor simply had lost all ability to communicate with patient and family. The families decision was based on limited information. If all had been explained and also if they had been presented with the very low odds of his surviving despite extreme measures, I am sure they may have chosen a different set of options. Unfortunately those options were not made available to the patient nor to his family.

I am not sure what has happened to our society. It seems that we cannot accept the fact that we are all mortals, and we will all pass from this earth at some time. Nobody has gotten off of this planet alive to the best of my knowledge. The question is not "Do you want to Live, or do you want to Die?", instead we should be asking how can we better face the inevitable, and pass on to the next realm with some dignity and course of action based on sound advice.

Mr. Jones had suffered for many years with his disease, and the last two weeks of his life was pure Hell for him and his wife as well as those that had to care for him. It was because of so many situations such as this that I finally retired from the practice of Respiratory Therapy. I could not any longer play a part in this all to often practiced ritual of High Tech Death. Too often the skills that I had at my disposal were inappropriately applied, and was used to prolong suffering rather than to relieve suffering. One does have to go home at night, and live with the knowledge of what you have participated in.

I have great respect for those who serve in the care of the sick. They are often working long hours, crazy work schedules, on call at times, for poor wages while having to deal with moral dilemmas on a daily basis. I have known many skilled nurses, doctors, and other allied health care workers who dedicate themselves to this somewhat less than perfect health care system.

Valuble Links

End of Life Issues- MedlinePlus
Sometimes, in spite of treatment, a condition or illness will cause death. In those cases, patients can decide what they do and do not want done. They can decide whether they want aggressive treatment that might prolong life or whether they prefer to stop treatment, which could mean dying sooner but more comfortably. They may want to plan their own funeral. Advance directives can help make the patient's wishes clear to families and health care providers.

Care at the end of life focuses on making patients comfortable. They still receive medicines and treatments to control pain and other symptoms. Some patients choose to die at home. Others enter a hospital or a hospice. Either way, services are available to help patients and their families deal with issues surrounding death.

The above courtesy of MedlinePlus.
Visit MedlinePlus for more information on Advanced Directives.

Also a very good on-line resource to assist with end-of-life decisions is
www.doyourproxy.org

Where There Is Fire... There May Be A Smoker!

I was working the night shift at the small town hospital as the Director of Respiratory Therapy. The night shift only required one therapist, so I was performing the routine therapies for patients requiring therapy through the night. It was a slow night and we did not have many patients requiring therapy. This slow night would suddenly be broken up with an emergency situation that I had not encountered before. My pager sounded off, and I called the operator to be informed that there was a fire in the Emergency Room parking lot. I asked if they had already called the local Fire Department, and they stated that they had, so I headed for the Emergency Room parking lot.

Now I should explain that at the time in this small hospital, the respiratory therapist duties often included areas that were certainly outsider the normal duties of a respiratory therapist. At this time the night duty respiratory therapist would not only be responsible for the respiratory care of the patients, but would also be called for security issues, and in charge of monitoring the boiler room, and we were also to respond to fires.

As I headed for the sliding doors providing access to the parking lot, I grabbed the fire extinguisher from the wall. In the parking lot, I locate a vehicle that has smoke coming out of the hood. I check inside the car to confirm there was nobody in the vehicle. Now to deal with the fire. I peered into the grill of the vehicle and could see some small flames. It was an older vehicle and I would be able to pop the hood if it was not too hot. I released the hood and it popped up enough for me to be able to direct the fire extinguisher at the flames. A short blast from the extinguisher and the flames went out.... but seconds later re-ignited.

The fire did not look large and did not look to be spreading fast, so I just kept dousing the flames when they would re-ignite, trying to avoid depleting the extinguisher. I could hear the sirens of the local fire department on their way. As soon as they arrived they quickly took over and were able to completely extinguish the fire.



I headed back into the Hospital with the spent fire extinguisher. I needed to bring a new fire extinguisher in the Emergency Room, so I was off to maintenance to exchange the extinguisher. There was nobody on duty in maintenance, (curiously that was also a duty of respiratory therapy at night... checking the boiler room of all things) so I left a note on the spent fire extinguisher stating that I had used it on the car fire in the parking lot. But as I was leaving maintenance, the mischievous light went on in my head and thought I could write a better note than what I had left.

Now it would help if you understood that the hospital had just recently enacted a long needed "No Smoking" policy throughout the hospital. I had battled for this policy for many years, and had butted heads with a particular nurse, (I will call her Ethel) who battled for years for her right to smoke in the hospital. So, I felt it might be appropriate to have a bit of fun.

I wrote another note to be attached to the spent fire extinguisher for morning maintenance shift. "Maintenance- I caught Ethel smoking in one of the bathrooms and I used this on her." I signed my name and left to finish my shift figuring the director of maintenance would enjoy my little joke.

I was at home asleep when the phone rang. It was the respiratory therapist on duty, and she stated that I needed to come in right away to talk with the Hospital Administrator. She explained that the director of nursing was very upset about the incident last night and was seeking to have me fired. She continued, explaining that I needed to come in right away to speak with the Hospital Administrator about the incident last night. I looked at the clock. It was 11:00 in the morning and I had only been asleep for a few hours. What the heck! I put out a fire, and my job is being threatened?

So I am on my way to visit the Hospital Administrator and I am perplexed as to how my putting out a fire would be a problem. The Administrator's secretary tells me to go on in, and I am instructed to have a seat next to the director of nurses and the director of maintenance. The Hospital Administrator explains the reason for calling me in was about the incident last night.... going on he expressed deep regret that I would use a fire extinguisher on one of our personnel. I looked at him try to see any hint of a grin. He looked serious. Then I looked at the directors of nursing and maintenance and they were stone faced as well. The director of maintenance was holding "The Note" in his hand.

This had to be a joke! A grand plot to pay me back for my little joke. Were they serious? Apparently so. The directors of maintenance and nursing had spent most of the morning searching the bathrooms to find the room where this evil deed had been perpetrated. They could not find the evidence and they were upset about having to spend their morning looking in all the bathrooms. They were very upset. They were sure they should have been able to find the residue left by the fire extinguisher.

I asked them if they had spoken to Ethel. They had not. I asked them if they were aware of the fire that had occurred in the parking lot early in the morning. They stated that they were aware of that. Had they heard that I had put out the fire with a hospital fire extinguisher. They stated that they had. It was still obvious they were not seeing the connection.

So I started explaining to them that my note was placed in an effort to make what I thought would be a harmless but funny joke. I apologized and stated that I did not think that anyone would take it serious. They continued to not see the humor.

The Hospital Administrator dismissed the nursing and the maintenance directors, so that he could speak to me personally. Standing up, he stated that my note was not according to policy and highly recommended that I refrain from such practice. I stated that I would... He then leaned over his desk towards me, and remarked in a hushed voice... I did think that was pretty funny though, and gave me a wink.

My 25 years working in hospital settings has made it very clear. There is nothing like a long night shift in the hospital to elicit some high jinx and practical jokes. I guess it is what I would call the ultimate in "Gallows Humor". I have a number of other curious tales from the night shift that I will share in the future.

Related Links
National Board for Respiratory Care
Fire Safety
American Lung Association

My First Day as a Respiratory Therapist

After graduating from High School in 1971, I took a job at the local car wash. I was making $1.25 an hour and was pleased to be employed. It was hard work, and fun but I certainly did not see myself wiping down cars for very long. My older brother had just finished a course so that he could become an "Inhalation Therapist". He got a job right away and was making $1.65 and hour. He encouraged me to take the one semester course to become an Inhalation Therapist. I asked him if I too would be making $1.65 an hour. Sure he said, and maybe even more! I was sold.... I did not know what an Inhalation Therapist was, but I was pretty sure it would beat wiping down cars.

So I enroll in the course. Part of the program was learning the practical application of our skills. We would be assigned to a local hospital and would be assigned to follow an actual Inhalation Therapist as he or she went through the daily routine. So a few days a week with our noses in books and a couple days a week seeing the practical application of the skills we were learning.

A large part of the practice is the dispensing of various inhaled medications through various devices. We would also be involved with monitoring of ventilators for post-op care or other situations that would require a patient to be on a ventilator. We would also be drawing blood from arteries to monitor the effectiveness of a patients respiration. And occasionally we would be part of a team that would assemble during emergency situations where a patients breathing or heart had stopped with our duty being to establish an airway and support breathing. Pretty interesting stuff, and you have no way to know how you are going to react to the real settings. It was all just book learning so far.

So I show up late on my first day of "Practical". Instead of being assigned to an Inhalation Therapist, I am left with the supervisor who seems a bit miffed about me showing up late. "Speedy" is what everyone called the supervisor.

So I am hanging out with Speedy as he takes calls, and takes care of paperwork. This is looking to be a pretty boring day. All the other students are out with therapists seeing some action. I did not realize that the fact that I had shown up late and was now languishing in an office watching some guy named Speedy take phone calls would actually lead me to one of the most intense days I had ever experienced.

It was late in the afternoon when Speedy got a call, and after hanging up the phone, he said, "Hey Mike, your in luck! Your going to surgery with me." Surgery? Why are we going to surgery. Speedy explained that he will be doing oximetry readings during an angiogram. He explained it all to me on the way, and requested that I just keep behind him and stay quite. So we scrub up, gown up, and I even get to wear one of the doctor masks.

The patient is awake and obviously a little anxious on the operating table. There is equipment everywhere. Most of it I did not know what it was at the time, and I was pretty overwhelmed.

This particular patient was an elderly gentleman, and had been involved in an auto accident a few days earlier. He had been recovering well but was having some irregular heart rhythms. They hoped to determine with the Angiogram if there is any damage to the heart from the accident. A catheter is inserted through the femoral artery and is advanced up the aorta to the heart, and a blood sample is drawn. Speedy processes the blood in a Radiometer Oximeter that detects the oxygen level in the arterial blood. All is going well, and Speedy processes another blood sample about every 10 minutes. Dyes are being injected through the catheter into the heart and we see live motion pictures of the heart beating and watch the blood that has the dye flow though the heart. I looked on with amazement!

It came on suddenly. Alarms were going off! The patients blood pressure was dropping. He was in tachycardia, Speedy went to the bedside with an Ambu bag to be ready to apply artificial ventilation if necessary. The patient was conscious and was very frightened and was saying "don't let me die, don't let me die!" Speedy was reassuring him that they were not going to let him die. The patients condition deteriorated rapidly.

The patient stopped breathing and his heart stopped beating. The surgeon made the decision to rapidly open the patients chest to do manual compression of the heart. Speedy was forcing 100 percent oxygen into the patients lungs with the Ambu bag while the surgeon rapidly opened up the chest with a large incision on the left chest between two ribs. The ribs were spread open to reveal the left lung. I could actually see the lung being inflated by Speedy's efforts. The surgeon reached in to do manual compressions of the heart with his gloved hand and what happened next was a surprise to everyone. A huge blast of blood exited out of the chest hitting the surgeon and the wall.

"That's it.... were done here" the surgeon stated. Speedy was told to stop the ventilation. I was in a state of shock! I was thinking to myself that I may have just seen for the very first time... a person die.

The autopsy later revealed that the patient had a cardiac tamponade. This is a condition where blood collects between the heart muscle and the thin membrane sack that surrounds the heart. Probably a result of the auto accident, and indeed would be the cause of the irregular heart rhythms. His condition became worse during the angiogram. The burst of blood was the heart wall blowing out when the surgeon attempted manual compression of the heart.

As we left surgery, Speedy asked me if I was okay? Yeah... I think so. He said most days are not like that. My first day introduction to being a Inhalation Therapist was quite an eye opener. It was no longer about me making 40 cents more an hour than if I worked at the car wash. This was dealing with real people and real life and death situations.

I spent close to three decades working as a Respiratory Therapist. There are good memories, and a lot of hard memories. That is another story.... Or maybe a whole book.

As I am no longer working as a Respiratory Therapist, I extend my appreciation to those who continue to do the noble work as health care workers as Nurses, Radiology Technicians, Laboratory Technicians, Respiratory Therapists, Physical Therapists, and all the other ancillary health care workers. Overall these good folks are underpaid, overworked and under appreciated.