Category Archives: The RT

by the numbers

A part of having a highly variable workload from day to day is that it becomes necessary for me to show my work. I have to keep statistics, in the form of a list of time definers. Checkmarks, quite literally, for exactly what I did as part of saving a life.

I always have a bit of a chuckle as I’m doing my stats. How are these numbers even calculated? How have they figured out that it takes 17 minutes to do a respiratory assessment, 8 minutes to change a cylinder, 18 minutes to insert an arterial line? There are many where I write down actual time spent, and it seems a cold kind of truth to me that at the end of the day, 45 minutes spent counselling a family about the impending death of their loved one gets aggregated with other staff members for my department over the month, and written in a tidy little box. #3740, service recipient support, a nice round number for a bureaucrat to sign off on. The funniest part is that I’ve done stats at other places where this kind of service wasn’t even something they had a time definer for. As far as the bureaucrats could see, emotional support didn’t exist.

It seems funny to me that I can distill a really fraught encounter down to numbers. A code on the floors, intubated, sent to ICU, set-up on the vent and handed off. It rounds up to around 4 hours of work, spread across a multitude of time definers. What isn’t in the stats is the looks I exchanged with the ICU nurse, the frustration at the physician who was content to sit on his hands, using my ass to hold open an elevator door, rearranging a barely-set-up-freshly-clean ICU room, and the heartbreak of prolonging the inevitable indefinitely. It doesn’t include the bone-weariness that comes with five flights of stairs times five or six trips up and down. It doesn’t include an entire team of people content to place their anxiety at not knowing what to do squarely on your shoulders, because now you’re here, and they don’t have to worry. But no pressure.

No pressure. I mean, I don’t stat mistakes as mistakes, they just get lumped in with an actual time definer. (#4420, arrest attendance.) It’s funny to me that things which are truly chaotic, which can truly not be distilled down to a series of single actions are lumped in together. The time definer for arrest attendance may as well be #4420: unmitigated chaos.

How does one stat “agonize over a decision”? How do you stat “sat in boss’s office venting”? It’s a rhetorical question — I could find a way to stat either one — but the point is, I can’t put a numeric representation on how hard I’ve worked when sometimes the hardest things I’ve done aren’t things with statistics attached to them.

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the man and the machine

Gear comes up so often as an RT that a day where I don’t do at least some troubleshooting is a boring day indeed. Where most of the other equipment other team members deal with are either ways of gathering patient data (lab analyzers, patient monitors) or ways of giving drugs to the patient (IV pumps), there are relatively few situations where the patient is directly interfacing with the machine in question. It is, after all, somewhat frowned upon for patients to adjust their monitor alarms or change their IV rate.

For many RTs, though, it’s a daily thing. I can think of two examples in particular, and they’re polar opposites: the spirometer, and the ventilator.

Spirometry is a difficult test to do sometimes, as it’s almost 100% effort dependent on the part of the patient. This is in contrast with blood analysis by the lab, where the major difficulty regarding the patient is whether or not you can get blood out of the person. (Sometimes it takes the lab tech who can get blood from a stone. Sometimes it takes four strong staff and five point restraints.) The most accurate results will only happen when a patient can understand my instructions, will cooperate and follow my directions, and when they try as hard as they possibly can.

They emphasize to us in school how important it is for us to coach the patient enthusiastically, since a major portion of getting the best effort out of someone is coaching them to try their hardest. It’s not uncommon for me to look at a patient’s results on the screen or watch a patient blow and go, “you can do better than that.”

Then there’s the interface itself: I’m trying to make a person do a very specific thing to a machine, and if I can’t make that person do what I need them to do, the test is nearly useless. This is a classic example of troubleshooting the patient. I made sure at the beginning of the testing day that my machine is working correctly, so unless something catastrophically fails, the problem is almost universally one with the patient. It’s my job to look at the output the machine displays, and try and explain to the patient I’m testing what I need them to do differently in order to get the output I want. This includes noticing things like air escaping the system at the mouthpiece (and therefore not being measured,) a lack of effort on the part of the patient (meaning the results appear as if the patient has terrible lung funtion to the untrained eye,) or some things the patient has no control over, like whether their dentures are loose, whether that stroke they had five years ago means they can’t make a mouth seal at the mouthpiece, whether they can’t understand what I’m saying but are smiling and nodding anyway, or whether they’re just not going to put the effort in and I’m wasting my time trying to teach a pig to sing.

I can’t stare only at the machine and ignore the patient: the forced exhalation maneuver can cause a transient decrease in blood pressure and a transient slowing of the heart rate, especially towards the end of exhalation, where the patient is forcing against airways that are empty of air and for the most part, closed. In this way it resembles a valsalva maneuver and I need to pay attention to my patient, because if they faint and fall off the chair and bounce their skull off the concrete floor, well, I have a bigger problem than poor test results. If I don’t notice that air is leaking out the side of the patient’s mouth, I’m gonna have a really hard time figuring out why I can’t get decent results. At the same time, I can’t only stare at the patient and ignore the machine. The whole trick to the success of the test is ensuring that the patient is interfacing properly with the machine. Ignoring the machine is to ignore half of the system.

The other major example I have, the ventilator, is somewhat the opposite sort of system. In this case, the patient is often, but not always, passive (rather than with the spirometer, where the machine is passive.) With the ventilator, I’m trying to make the machine do this very specific thing, and if I can’t get the machine to do what I need it to do, then I’ve got some serious problems. The confounding extra factor, for bonus fun, is that sometimes the patient isn’t passive. Sometimes, I’ve got this machine that’s supposed to be breathing for a patient that’s trying to breathe, and a major limitation to this is that they don’t share a brain (though they’re working on that.) Sometimes the patient’s trying to breathe and the machine is trying to breathe and they end up fighting each other, or what some people call “the patient fighting the ventilator.” The term we prefer to use is ‘patient-ventilator dyssynchrony’ or, more colloquially, “hypo-sedation-emia.”

In an ideal world, the patient would initiate a breath and the ventilator would detect this and deliver a breath in synchrony with the patient’s efforts. This is called ‘triggering’ the breath. Then, when the patient is done inhaling, the ventilator can also detect this and, depending on the mode of ventilation, can stop delivering the breath near the same time the patient stops inhaling. This is called ‘cycling’ the breath.

Being as, from a gas flow physics standpoint, the sensors that make these detections are a considerable distance from the patient, sometimes the ventilator isn’t able to detect what the patient wants the ventilator to do. Accordingly, the ventilator is more likely to have a harder time the sicker you are and the worse your lungs are. The ventilator is, after all, a machine, and one of the major downfalls of machines is they don’t think, they only do what we program them to do. Sometimes we can program them with complex algorithms designed to eliminate some of the thinking, but that does not obviate the need to think.

This is where I come in. I observe both the machine and the patient and try to tweak what variables I can tweak in order to get the machine and the patient to agree with each other. I try and see what the patient is trying to do and try and manipulate the variables I have to try and make the vent do what the patient is trying to get it to do. It’s a magical sort of alchemy, and sometimes I can’t make it work. Most of the time, though, I can manage to find the sweet spot between the totally passive patient who “rides” the ventilator and the dyspneic, agitated, desaturating, magical self-extubating patient.

The opposite is also true: sometimes the patient is so sick and so short of breath that they consume so much oxygen trying to breathe (and doing so only ineffectively) that they’re better off anaesthetized so I can take over and make the patient’s lungs do what want them to do so they get some actual gas exchange going and they can get better.

The trend with new ventilator modes is to try and make it so the machine can adjust itself continually according to what the patient appears to ‘want’ according to a software algorithm. This seems like a good idea in theory, and it can work pretty good for some patients, but us RTs tend to hate these newfangled modes for one reason and one reason only: we can’t tweak them. “I can’t make the stupid thing do what want it to do” is what we think, trying to find that sweet spot. I can see what the patient is trying to get the vent to do and the software algorithm can’t.

It’s alchemy, it’s guesswork, it’s “let’s try this and see how that works”, it’s tweaking and a process of elimination. Half the time the process is a series of judgement calls and failed experiments until something works.

I’m the respiratory therapist, and when I troubleshoot a system, it’s got both a machine and a person in it, and I have to troubleshoot them both at the same time. It leads to a unique set of skills and challenges, and I don’t even think these systems are unique to my profession. I think these systems are visible in many disciplines where people interact with machines. I think most of us are just not used to seeing the person as a part of the system.

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learning to take it seriously

I’ve had asthma ever since I was a baby, I think. I won’t lie and say that it didn’t factor into my decision to get into respiratory, either — I wanted to have control.

I’d always hated games with running. I remember hating tag in elementary school — I could never outrun anybody. Eventually my chest would get tight and hurt, and I’d cough and feel like I couldn’t breathe. I’d have to stop and then I’d get tagged, and I couldn’t tag anybody else. So I just didn’t play.

Mom put me in soccer. I hated it instantly, with its constant running after the ball. Other sports seemed like more of the same. This continued until I was about 13, when I walked into the doctor’s office (by myself) and demanded some kind of testing. I got a Ventolin inhaler and a referral for some testing. The testing showed airway obstruction with reversibility — a hallmark of asthma.

I had a problem, though. My parents had never taken me seriously about this (“You’re just out of shape” is something I heard a lot) and I had some real misconceptions about severity and proper treatment. I ended up at one point taking a steroid inhaler but I ended up with a lot of hoarseness of the voice (I later learned this is a common side effect) and eventually stopped taking it. I had no idea how severe I was.

It wasn’t until I was older, several years older, and looking to get into respiratory, that I had a second spirometry and learned to interpret what it means. I was a bit taken aback by the degree of impairment it showed — I had always thought I was relatively mild, that my asthma was “well controlled” with just my Ventolin inhaler to take when I needed it. (The truth was, my asthma had always been poorly controlled, and would remain poorly controlled for years afterwards.) It was the first opportunity I’d had to print out a copy of the testing and show it to my parents — “See, I’m not making this shit up” — and interpret it for them. I showed my family physician a copy — he was a bit tickled and compared it to the one I’d had done before — and he immediately adjusted my medication to better control things, seeing that my lung function had declined significantly since the one I’d had previously. It would be a few more years before I would learn that this was a bad sign, a negative effect of poor control, that poor control would sabotage my lung function slowly until I ended up like somebody who’d smoked for years.

Even after I’d gotten into respiratory, denial is somewhat of a strong impulse. I see these people who are wheezing and struggling, I do PFTs on the asthmatics who have even poorer control than I do (and perhaps, still smoke,) and I get the groove carved into my brain that this is what ‘severe’ looks like. My daily symptoms, my inability to participate in any kind of real ‘cardio’ without symptoms, my exacerbations which would have me wheezing for weeks on end, those didn’t register as ‘severe’. I had had poor breathing for so long that attacks didn’t frighten me. I could breathe through them and limit my activity. I could suck on cough drops and take my Ventolin only when the coughing was paroxysmal, with me gagging, doubling over, seeing stars.

Beginning work as an RT probably was the best thing for my asthma. I had peer pressure from coworkers when my tight cough manifested itself at work. I figured out something that worked for my symptoms — and ended up taking a fairly large dose of it to remain in some semblance of ‘control’ — but wasn’t exactly compliant with it. (I’m not alone, rates of nonadherence to medication are really high and is the main reason for severe exacerbations in asthmatics.) It wasn’t until I sought investigation for allergy testing that I got appropriately slapped for this.

Little did I know, the allergy specialist I was booked to see is also an asthma specialist. I didn’t expect my (terrible) spirometry to be put on display in his office, but there it was. I also didn’t expect to have to detail, in mortifying detail, my lack of adherence to my prescribed medication regimen.

I endured, hanging my head, my scathing lecture about how I should know better, about how my spirometry was all chronic changes, about how he should not have to belabour this point, about taking it seriously. I don’t know if it was internalized ignorance, I don’t know if it was mostly denial, but I do know I took this guy seriously.

I went home with a renewed conviction to take this seriously. I was adherent to the medication regimen properly for the first time since ever, and around about six weeks of this I had an epiphany. I could breathe. I could breathe and I was simultaneously amazed at how used to not being able to breathe a person could get. I had always thought that constant symptoms were normal, and I had a high tolerance for feeling awful all the time.

During this time, I took up running. I had always resigned myself to never being able to run. I amazed myself and conquered running, and found that after a small uphill battle training period I began to enjoy it. I began to become very sensitive to changes in how I felt and I learned to respond quickly to symptoms instead of suffering through them. When I had a significant exacerbation, I went to the doctor and went on Prednisone, instead of digging my heels in, instead of deciding that a month of feeling terrible was worth not having to take five days of oral steroids. I was shocked at how fast I felt better from the bronchitis that had me exceeding the recommended dose of bronchodilators.  I found the side effects were not as terrible as I had been led to believe.

I know now that I was playing with fire. I don’t entirely know why I did it, if it was denial or if it had more to do with not wanting to be seen as malingering. I do know that if I hadn’t done something about it, it very well could have killed me or left me critically ill. Now, I make it my mission to knock some sense into those like me, those lulled into the fog of thinking they’re not as severe as they really are, those that think they’re in control when they’re really not. Somebody saved my life once, by making me take this seriously. I feel the need to pay it forward.

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on being called “a hero”

There’s a hazard to having a friend that’s a sociologist: she forces me to think about why things are the way they are. In this particular case, she’s turned me on to some interesting reading material that seems never to fail me for something to think about.

I am not unaccustomed to risky jobs, and the people who work in them. I work with paramedics, firefighters, prison guards,  the most commonly thought-of “life is on the line, he’s such a hero” sort of stuff. The book they’re talking about is right on the money: for the most part, they don’t think of themselves as anything other than ordinary people in control of an extraordinary situation. Any mishaps that laypeople consider to be risks inherent in the job (a cop getting shot, a firefighter dying in a fire) are not seen as particularly risky to the people engaging in them. I’ve spoken to cops about going into buildings armed against people who have gone totally butternuts and are armed to the teeth — the risks they talk about aren’t that they might get shot at — it’s the fact that butternuts in the shed over there isn’t predictable. They’re trained to predict what the rest of us think are unpredictable.

This, of course, thanks to the grooming of my friend the sociologist, makes me think of the times when I’ve been told I did something “heroic.”

Usually what happened is there was a very sick person in a very bad way, and I was part of a team of people who predicted the unpredictable and then responded. The response is to perform a number of different interventions in order to change the course of their illness or injury. I don’t think what I’m doing is heroic. I don’t think about how people are going to die if I screw up. I don’t feel the pressure, really. What I am is in control.

I can see the signs. I can measure and quantify how bad the situation is using specific parameters which allows me to manipulate those parameters with drugs or pressure or gas. I can control the oxygen or the respiratory rate. Sure, there’s a bit of a scramble trying to get to the point where you’re in control, when you’re on the move from prediction to execution, but you know what to do, so instead of being stressed about how it’s do or die time, you just stop thinking and do.

I find us RTs especially tend to think in “the worst thing that could happen is” sort of parameters. When others are afraid to extubate the patient we’re shrugging our shoulders going, “the worst thing that could happen is she/he gets reintubated.” To us, it’s no big deal. We’re trained to predict what the worst possible scenario could plausibly be, and then be prepared for it. We controlled the airway by putting in a tube, we did it once, we can do it again. If I can’t do it personally, there’s someone close by who can.

I remember a couple of these do-or-die situations happening to me and there was a lot of muscle memory in that st0p-thinking-just-do. A sick neonate thrashes a bit on the overhead warmer and self-extubates, and there’s no pediatrician within a shout’s reach? I’ve been trained for this. They taught me how to intubate precisely so that I could respond to this situation. Paralyzing myself with fear and waiting for the pediatrician to haul his ass into the room is an option, but the worst thing that could happen is I try and I miss. I’m also trained in what to do in that case: the patient would be no worse off for me missing. Besides the fact that I’m qualified and trained and skilled in intubation — the patient needs it right bloody now. If I waited for the pediatrician I’d feel like I had chosen the wrong line of work and would probably quit soon and go become an accountant. What I did was grab the (conveniently located) necessary equipment and make with the intubating. I know what has to be done, and I’m qualified to do it, so I do.

There are those times when despite your best efforts you lose control of the situation. Just like the firefighters do, I find we look for something to blame. Somebody screwed up, somebody didn’t notice the alarm, the monitor was malfunctioning, I gave up too soon and should have kept trying, we didn’t get there in time, they waited too long, and so on, and so on. I failed to predict the outcome. I failed to respond accordingly to the situation in the way in which I was trained. I look for how I could have gained control, therefore, I don’t really fear the loss of life that happens due to variables that are beyond my control.I learned very long ago as an RT that there’s some parts of the clinical situation that you just can’t change.

I’m scared of screwing up or missing something, I’m scared of missing the prediction or failing to respond. I’m also confident that the longer I spend in control and the more I refine my muscle memory, the more I lift the mental weights that allow me to consider more of the situation, the more that muscle memory allows me to automate simple tasks so I can spend more mental energy being observant to other signs, the less likely it will be that my simple screwup results in somebody’s death.

It’s happened in the past: I’ve failed to notice a sign that the patient was in cardiac arrest and then the patient died. That said, so did everyone else in the room fail to notice, and given how sick the patient was prior to going into cardiac arrest, the chances of us being successful even if we’d caught it were pretty slim anyway. No one person killed that patient. The culmination of many factors did, and some of them were beyond our control. Did I learn a hard lesson? Yes, I did. That one’s a notch on my proverbial shield that I’m not ever going to forget — and the next patient will benefit from it.

Therefore, by the same token, no one person involved in saving another’s life is “the hero.” The collective sum of our teamwork and brains and muscle memory and situational awareness and skills are the heroes. We just predicted the unpredictable. We executed our plan for how we were going to gain control. We gained control of the situation quickly and effectively, and then we held on to it. It holds no mystery to us.

We are comfortable.

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equipment monkey

It’s all at once an amusement, a pain in the ass, and a blessed distraction to be one of the only direct-patient-care health professionals that keeps a toolbox in her office.

I feel a certain sense of pride and accomplishment when I’m walking down the hall past the ICU, packing a two pound crescent wrench, or a pair of pliers, or an assortment of screwdrivers and hex keys. I work in this normally sterile environment and here I am getting my hands dirty, hauling tanks, spinning nuts and bolts, tightening connections, taking apart malfunctioning equipment to fix it, replacing bulbs and batteries and sensors and analyzing cells. Some equipment is less dirty than others; tanks are by far the dirtiest job. Some equipment is bigger and heavier than others; the blood gas machine is by far the tiniest and most finicky.

On the other hand, being the only person in the building besides the biomed (and the one who keeps the more extensive hours) I end up being the one getting phone calls about “why is this leaking” or “this isn’t working and I need you to come take a look at it” for pretty much any piece of equipment I lay my hands on in my scope of practice. It becomes somewhat frustrating when I have people to deal with (people can’t lay broken on the counter for a month and then be fixed at my convenience) but at the same time I rely so much on the equipment in order to do my job that it becomes just part of the job to ensure that what I rely on is optimally tuned and ready to go.

At the same time, while it can be grating to get multiple phone calls to come fix a piece of equipment that can wait, it’s absolutely lovely during times of “office” drama to be able to disappear with my toolbox and let them all hash it out.

I think the tendency for us to be the fixers comes from several sources. There’s first, the fact that my entire job revolves around equipment. Oxygen equipment, pulse oximeters, the ventilator, suction equipment, intubation equipment, that damned blood gas analyzer, and on and on and on. Then there’s the fact that since so much of my job is equipment, a significant chunk of my training is troubleshooting equipment. When you’re keeping a patient alive with equipment, you’d better know how to troubleshoot when things start to go awry. (Significant in this training: “is it a problem with the equipment or a problem with the patient?”) Lastly, and this is just a loose theory, there seems to be this predilection towards mechanical inclination that’s common among RTs, and combined with all of the above, when there’s one of me and between two and twenty nurses watching me do my job, it becomes common knowledge among the healthcare team that I’m the one who just knows how to fix things. I imagine that’s how I get roped into performing a 3am-on-a-Saturday resuscitation on the printer, anyway.

With so much more equipment being software-controlled, there’s going to need to be an inclination towards computers moreso too, I think. Maybe not so much as the biomed needs, but it’s looking like it’s going to be more and more necessary to troubleshoot software problems as well as problems with the mechanics of it all.

All in all, though, I’m happy to be the one with the toolbox. And not only because when I’m resuscitating equipment, if my patient dies, with enough tools and time and parts and knowledge, I can pretty much always bring it back to life.

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“practicing” medicine

I have to chuckle at how much “being good at my job” in this field involves simple skills. Either muscle memory, fine motor control, or quick reflex. In school, they cram your head with facts and lab demonstrations. They try to get you to show that you can do what they teach you … it’s still not the same as doing it on a person. And then they throw you into practicum, and you have to poke ten (or so) people before you get signed off on the skill. You will miss a bunch. Theoretically, you could pass the course having only poked those ten people. (It never happens that way, of course.)

I don’t think I’ve met one person who freshly graduated who felt like they knew Exactly What They Were Doing. (At least, not anybody who I would let touch me in a medical sense.)  I was probably on the job for months and dozens of shifts before I began to poke people and assume I wouldn’t miss. This isn’t to say I missed a lot prior to that — just that prior to that point, I wasn’t confident in my skill.

It took months and months of practice before I began to feel confident — and months (and months and months and months) after that before I began to truly get “good”. Some of being “good” at it is individual. Experience, steady hands, a particular technique that works well for you, and even just having a good day. I’ve had days where I couldn’t hit the broad side of a barn.

Some of the skills involve where you work. I had never attempted an arterial line until I moved from the (not-so-affectionately-nicknamed) Center of the Universe to a little hospital in the boonies. In the Center of the Universe (University Center for Excellence I think was its formal title in some permutation) we were of the type that tended to believe that those country bumpkins? Those hicks in the boonies? Their experience could in no way ever compare to my experience, here in the land of too-much-money. Now that I am one of those hicks in the boonies, I realize that there is pretty much no way in which I could have been more wrong.

Prior to moving, intubation practice was a theoretical exercise, done in the OR under the supervision of an anaesthetist. You had your choice of: the gruff ex-military guy, who once barked at me that “putting the tube in is a bar trick, I am not signing you off unless you can tape it and throw him on the vent by yourself,” the lady from down east who hated you up until the point where she discovered you were intelligent, and only then could you be friends, the head of anaesthesia who I think was compensating for something, the tiniest skinniest woman I have ever met, whose capacity for niceness and overall cheer definitely outweighed her entire body soaking wet, and the various other anaesthetists who would rotate through all of the hospitals in the health region, a process I once jokingly referred to as “the rock stars going on tour.” You went through the OR and did your six or ten or what-have-you intubations and got signed off and then left, every year, without fail. You pretty much never intubated outside of the OR, because there were always 835 residents or ICU doctors or somebody who wanted to be a hero who wanted to secure the airway. I demured, partly because it was entertaining, and partly because I didn’t much relish, as a young RT, being the object of scorn to miss an intubation (because it was generally understood that even if an RT were to try, if you didn’t get it on the first attempt, you would be quickly elbowed out of the way by someone ‘more experienced.)

I will never forget the moment at the small-town hospital when, during a code blue in the middle of some department completely unfamiliar with code blues, the only doctor in attendance gave me a funny look from the foot of the bed. I, at the head of the bed, bagging my little heart out, had gathered my things and was waiting for him to come up to the head of the bed and assert his heroism. Apparently in the country they don’t believe in being Big Damn Heroes, because he kind of just gave me the eyebrow until it dawned on me: “OH! You want ME to intubate!” He laughed at me and nodded. I intubated. It felt amazing to get to use a skill I’d practiced nine thousand times and never gotten to use before. Without the nine thousand times of practice, however, I doubt I would have been even moderately successful. Those anaesthetists, when not chuckling at my struggle with bagging via the circuit on the anaesthetic gas machine, were a veritable font of tips and tricks. I have used many an anaesthetist’s dirty trick since.

I had never attempted an arterial line prior to coming here. I remember one anaesthetist here, regarded as a bit of a comedian, giving me the eyebrow when I said I didn’t think I was certified to do one. Apparently here, the certification procedure consisted of “show that you know how to do it.” I have since impressed him with my ability to put one in on the patients with blood pressures so low that the textbooks say they shouldn’t have a radial pulse. (Not gonna lie — some of them didn’t and the only reason I got it was because I’ve poked that artery 9000 times before, and know pretty much where it’s gonna be. I’ve also missed my fair share of those, so no hubris here either.) I have somehow earned myself a bit of a reputation as The One Who Never Misses, which is utter hyperbole — I miss occasionally — but the only difference, apparently, is practice.

It’s not just me, even. The residents and their (sometimes sisyphean) struggle with the subclavian line, out here in the middle of nowhere always positioned without the use of an ultrasound device, a device which, I feel, is a bit like a back-up camera on a small family sedan. Can you please learn to parallel park without the camera before you start to rely on the damn thing? Over-reliance on gear seems to me to be a handicap moreso than an asset — those who are excellent at the primary skill are often far better users of the gear anyway. (I will never forget the day I watched our comedian-anaesthetist intubate a lady with a fractured C2 — move her neck too much and you might be able to see, but you will also kill her — with practiced ease and proficiency with a glidescope. I declared myself a member of his fan club. He replied with a grin, saying he loved being African, because “I’m blushing, and you can’t tell!”)

The practice-practice-practice paradigm shows very clearly why the best are often the ones who’ve been around since dust was invented, and how old are you, again? They’re the ones who could get blood from stones, who could put IVs in even the most hardened IV drug user veins, who could intubate the guy you’re terrified to even try on, who can say, with confidence, “I will get it,” and then they do. They’re the ones with the dirty tricks. The ones who make us better, by making us into amorphous collections of piecemeal knowledge and dirty tricks. There’s an old joke about practicing medicine and “maybe someday I’ll get it right” … I don’t know if it’s possible. Much as it’s not like they come out with a new model of the human body every year, they come up with enough new information and new gear that that’s all we’re ever going to be doing … practicing.

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setting the tone

Tension is contagious. The job is stressful, what’s happening is scary, yes, but it’s sometimes in these situations that the most important thing you can do isn’t anything life-saving — simply put, you have to keep your cool.

Emergency is a department where you think you would meet some of the most resilient people in the world — people who are unflappable and good under pressure. Some, even the majority of them, are. Not everyone can be perfect, however, so it’s important that the unflappable stay calm, with an even tone of voice, without rushing. It’s precisely because tension is contagious that the naturally un-tense among us mustn’t get caught up in the tension.

Respiratory is a tense job, period. I’ve had moments I clearly remember primarily because of that squeeze of adrenaline burning the memory into my brain. The stress response is a strong thing: my hands shake, my speech is fast, pupils dilated, time dilated, memory sometimes not the most reliable. It’s a struggle in these moments sometimes to keep my tone of voice even, to not rush my words into an unintelligible mumble, to not get impatient to the point where I begin taking my stress out on other people.

It only takes one person to destroy the calm. Even when things are hairy and scary, voices don’t have to be raised, team members can ask for things (rather than demanding,) and tempers don’t have to be short. It’s when the one person who’s not in control, who lets tunnel vision take over, who lets their stress spill into their voice and their ability to cope evaporates in the tension. This person can be the most dangerous player on the team, simply because they stress other people out — those who don’t have iron fist control over their emotions — and it’s in this stressful state, with someone barking orders at you, yelling at you, that you begin to rush, and your judgment and decision making skills become impaired.

This is when experience helps — not because experience will tell you what to do, but because experience will make you harder to stress out, generally speaking.  The exception to that rule, of course, are those people that have a tendency to become flustered even with experience. It’s worse, because the less experienced team members pick up on this, and then end up in this situation of “if they’re freaked out, then I should be freaked out!” Things spiral into disorganized chaos from there.

I’m at the head of the bed most of the time. I have a very clear role to play and a specific job that is, truly, nobody else’s. Nobody in that room barks orders at me for the most part, and I don’t order anyone else around. Once I’m doing what needs to be done, everything else follows. In a sense, it’s tense at the beginning, but once airway is secured and air goes in and out, I am a spectator at the head of the bed. Maybe it’s what makes it easier to be calm.

This feature of the job allows me to fade in the background and observe people. I consider it a point of pride to remain collected and cool. While spectating, I take notes in my head — notes about the people around me and how they’re handling the stress. I think it stands to reason that the people I observe setting the tone, giving orders in even tones of voice, or focusing efficiently on the task at hand, tend to be the people I gravitate towards when the situation isn’t stressful and hairy. I find their resilience enjoyable, and for the most part, they’re also highly intelligent people who are exceptional at their jobs.

A lot of people start out with emergency medicine in mind thinking that they get to be a hero in those dramatized situations they see on television. The truth is that the best people for the job are the opposite — not trying to showboat their heroics, not making the situation into a dramatic cluster of chaos, but those who calmly go about the task at hand with focus and skill. The truth is, the best run codes are the ones where everyone in the room looks like they are just this side of bored. There’s nobody pressed with anxiety that things should be happening faster. The lack of tension means that it’s easier for everyone to take a second to think. And while in those situations speed is crucial, speed is useless if you haven’t had a chance to think.

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the one who doesn’t cry

An unanticipated death; some professional embarrassment in there for good measure. Difficult, due to the fact that the one who died was a child, and a sweet one; that, and the fact that it was likely our fault in some way. (The reader is left to imagine the multitude of ways in which one person in a team of probably hundreds could be possibly at fault. Trust me. We’re all wondering the same thing.)

A debriefing; listening to the vignettes of the family and the child from the circle of chairs in the playroom. Some tall people on some tiny chairs, wilted from night shifts, or the ones fresh from days off, with perfectly applied makeup. They had a long time with this baby, they laid down in his bed and hugged him, patted his tummy to comfort him in that way they had seen his dad do, taking him to the playroom instead of starting his feeds … interviews with mom … years of past history … perhaps wondering why they hadn’t intervened earlier.

If there’s anything I’ve learned through a multitude of shitty situations, a multitude of debriefings, it’s this: no matter what is your fault, it’s over. Learn from it, for it’s the only possible positive outcome of an entirely crappy situation. Beating yourself up about how it could have been better if you had the power to go back in time and fix your fuckups is ultimately a failed exercise in self-loathing, and the self-loathing is an obstacle to learning: what’s happened has happened, so learn for next time, and prevent it from happening again.

A lot of that happened in that debriefing. From the strong and silent among us semi-blaming themselves, knowing what they’d do different, to the ones who have what seem like the easiest jobs in that they are only so tangentially involved, nearly everyone seemed upset nearly to the point of tears.

Except me.

It came to be my turn near the end, and I spoke of equipment malfunctions, problems with sensors, recalibrating X and Y, and of being pissed at myself (not blaming) because I had been so absorbed in the equipment that for that critical minute, I forgot to look at the patient. I wasn’t upset at the death of the kid, I was more pissed at myself that I had immediately jumped to the conclusion that the equipment was messing up on me.

To be fair to myself, the rest of the equipment hadn’t exactly been working as intended, and I’d had problems from the get-go. Things were quiet and stuff that should have been watched wasn’t, but it’s hard to not feel a bit like an uncaring goon when the people who weren’t even there for the arrest seem significantly more shaken up than I am.

It’s remarkable to me because, I think, this is not simply because of respiratory or because of the sheer amount of times I’ve been there when somebody’s died. I don’t think it’s that I’ve become desensitized or somehow heartless regarding the whole incident. Indeed, I was upset about it — I just did all my crying immediately afterwards and not in the debriefing. So it goes.

I think, however, that last paragraph is a bit reflective of how RTs are. We have the face we show to the rest of the team, and then there’s the things we say, the stuff we complain about, the opinions we share, the discussions of what bother us, the planning what to do next, that we all do behind the closed door of the respiratory department. The reason I never cry at organized debriefings, the ones headed by a social worker or someone with training for crying people, is because in order to keep doing what I do, I have to do it every day, by myself, behind a closed door. More often than not, I do it with other RTs. Sometimes, like the particular instance that struck me this time, I end up doing it at 2am with other health professionals, like the nurse who gave me a hug before I cleaned my vent and went home to bed.

I think it’s healthier that way; that I know how to debrief so that I can sleep, that I do it automatically and without needing hand-holding or prompting. I think it’s what means I can do my job without having a nervous breakdown.

Long ago I used to worry that not crying about these things meant I was getting callous and gritty, jaded and bitter, all those things that they usually say about surgeons and cops. I don’t worry about those things anymore: I think I have a better understanding of grief and attachment as a result of having done it more times than I can count. I can survive without losing compassion. Maybe some would call it tough, but I hate that word for this. It’s not some kind of machismo bullshit need to appear all stiff-upper-lippy. It’s just self-preservation. I can sleep without waking up screaming, I can go to work the next morning, and I can still have fun at work. I still love my job. No matter how shitty it gets, I plan to. For a long, long time.

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what I am

I knew I wanted to help people, to be in healthcare. I remember being a small child, having medical textbooks and laypeople books on medicine taken away from me, because it was apparently somehow inappropriate for a child to be looking at electron microscopy photos of sperm and other such human structures. I ate all that I could find about medicine and such up. I have vivid memories of being a small child of less than 5 years old, desperately sad that I had lost my Fisher-Price medical kit. My mother always thought I would be a doctor, or somesuch. I chose respiratory therapy instead.

I remember being in the end of junior high school, the age when they made us take computer-based courses to see what we were most interested in. I didn’t need a computer based course to tell me what I was most suited to. I knew I wanted something medical, something with adrenaline, something exciting, something where I saved lives and fixed equipment and did a little bit of everything. I knew nursing was not it for me… I was not into the task-based system, I preferred very much to be thinking on my feet, solving problems, to be the one-of-a-few, the few like me.

I have worked in several different configurations. The one-of-none, the one-of-a-few, the long-term-care situation, the acute-care critical-care situation, the one-of-many, where I had years and years of experience to draw on, and the one-of-none, where it was just me, my pulse oximeter, my stethoscope and myself to survive throughout the weekend.

School, practicum, was gruelling and the hardest thing I’ve ever done. Officially the most difficult thing I’ve ever put myself through. That said, it was worth it, infinitely so, to be able to have the coolest job in the world.

I remember being a young kid — I didn’t understand the chest pain and shortness of breath that, to me, became associated with games of ‘tag’ and other things where I had to run (soccer, etc.) I grew to hate sports, gym class, all of these things, because I intimately associated them with chest tightness, burning sensations, a tight barky cough, the taste of blood, and feeling like I was going to die. I had a friend at the time who had asthma, and she encouraged me to get what she called an “asthma test.” I followed her instruction, and thus began my foray into the world of respiratory therapy.

My initial spirometry showed that I was indeed asthmatic, and that my parents’ claims that my distress had more to do with being “out of shape” than anything else were incorrect. I wanted to know, most of all, I wanted to know what else it was that they did not know, I wanted to know everything.

I joined a student shadowing program. I shadowed respiratory therapists. I found every single individual stitch of what they did completely fascinating. In the words of my supervisor, I “talked the talk”, and despite the fact I was being paid essentially minimum wage to restock gear, I was so happy I could have died.

I’m a few years out of school, but not so much as to be one of the 20- or 30-years-out crew that nothing ever flusters. I enjoy where I work, because the endless variety and complete independence I get kind of caters to my more cowboyish nature. I have been told by my manager (a nurse) that respiratory therapists tend to be introspective, self-analytical, very cognizant of their own failings, and 100% accountable. I don’t find this at all to be a bad reputation to have as a professional.

I enjoy my professionalism, my professional-ness. I enjoy having physicians come to me and ask me advice. I enjoy giving them advice, knowing that I (now) have the skills and ability to do so in a non-threatening non-intimidating fashion, to be able to teach the baby physicians, the noobiest of the noobs, to teach the nurses, to teach… really, whoever wants to learn. I love being able to show what it is that respiratory has to offer, that much as we may not come with eight or twelve year long university degrees, we do come with an incredible depth of knowledge, and we are more than willing to share.

I love being the ambassador of my craft. I find this to be a uniquely rewarding experience; helping professionals otherwise unfamiliar with what I do to understand that I am not here to usurp them, but rather, to offer guidance so that they may better perform their jobs.

I enjoy specializing. I enjoy being a specialist. I enjoy especially being a specialist in life support, specifically in ventilation, in this esoteric art that only an RT can appreciate. I enjoy, although less joyfully, the unique role I play in the ethical discussion of who is best suited to have their lives supported — to be a willing and robust participant in what is uniquely both the extending of life, and the prolonging of death.

I hope to blog in this place once a week, if not more. I hope to share my stories and the stories of friends like me, the stories of other respiratory therapists, the stories of the (arguably) most unknown health profession on earth. I hope to share the perils and pearls and pitfalls, the ethics and ethos, the ideology, the guiding principles, the heart and soul of the respiratory therapist.

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