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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he walks alone

Many of the stories I have to tell aren’t really my stories. They’re the stories of others. Sometimes it’s the patient’s story, sometimes it’s the family’s story, and in this case, it’s the surgeon’s story.

She had been told she had to have bowel surgery to resect a tumor. She was quite frightened of this because she’d seen it happen to other members of her family, and they had gotten quite sick and nearly died. She was terrified of what would happen, especially after the surgery, when an arduous recovery would not necessarily mean that she was cancer-free.

She procrastinated. Her procedure, while not exactly elective, depended on her consenting to the surgery, and so she put it off. As is wont to happen with cancers, and especially gastrointestinal ones, she became more wasted as the weeks wore on, her body unable to properly absorb the nutrition that she was able to keep down.

Finally, the day came where she reached the point of no return. She presented in emergency gravely ill, with suspicions that her bowel had perhaps obstructed and perforated. She was operated on by one of the best — I didn’t enter into that equation until after her surgery.

She’d arrived decompensated and in poor condition and required a lot of blood during surgery. As happens somewhat rarely, she had a transfusion reaction. This precipitated respiratory failure and my involvement. Sadly, due to multiple factors, including how truly sick she was going into the surgery, her body failed to rally. Her surgical sites refused to heal and broke down, requiring further laparotomies. Finally, after returning to the operating room for the tenth time, the surgeon threw up his hands. There was simply no more bowel left to resect. Either she would recover, or she would not.

I remember a conversation that I had with him in the hallway after he had discovered she’d have to go to the theater for the last time. He had taken very personal care of this patient, not handing her over to a colleague even over the Christmas break. He poked his head in on her every single day that he was physically able to.

“You know, you think you do a good job…” he said to me, shaking his head. Knowing only the little that I knew, I tried to offer some meager reassurance that he had done what he could with what he had, which was arguably not very much to begin with. He simply shook his head and walked, alone, down the hallway to get the patient on the slate for surgery.

He carried the entire weight of this person’s recovery on his shoulders. I can only imagine how he’d felt when she began the downward spiral towards her eventual death. Especially being as he’s South African, reading Bongi’s post about the graveyard made me think of him. There most certainly is a tombstone somewhere in this man’s mind, with that woman’s name on it.

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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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when the cure is worse than the disease

I read the chart. I read the notes from the cancer clinic. Call it morbid curiosity — I call it chart review. Either way, she’s fucked.

She’s young. In her 50s, she’s smoked for years, in a region where radon has only recently become something worth educating the public about. English isn’t her first language, and neither is it her family’s.

She was diagnosed sometime around 2009, lung cancer. It’s untreatable with surgical resection, they tried radiation, even though her type doesn’t usually respond well to it. They treated her with first, second, third-line chemotherapy. A recent CT scan told her cancer doctor it had spread… to bones, to other organs, to lymph nodes. There’s lumps growing she can feel herself, and tell the cancer doctor if they’re growing bigger. They try a fourth-line chemotherapy agent, something palliative. They tell her, and her husband, that the cancer has spread, despite a year of debilitating, nauseating treatments. They are, “understandably distressed.”

She comes into the emergency department with signs of infection. Her lungs are somewhat compromised by the fact that there’s a tumor obstructing part of one lung. Her infection plus, god-knows-what, affect her lungs in such a way that I’m MacGyvering various ways in which I can keep her oxygen levels in some range that is compatible with life. The point becomes clearly made to us, throughout the day, that if she’s not going to die tomorrow, she’s going to end up intubated.

The intensivist explains to the patient, and her family, what is necessary. Unfortunately, due to the nature of being the doctor-in-charge-of-everybody-sickest-in-the-hospital, the explanation is somewhat harried and unclear. The explanation falls to the rest of us, the so-called “healthcare team,” to explain what’s necessary for the next few days. “There is a chance,” I say, “and not a small chance, that she may never end up off of life support,” I explain. I ascertain that what she wants is to be supported in the short term. I ensure that I understand clearly her wishes regarding the long term — that her life not be artificially prolonged, should we give her her week-or-so’s duration of ‘rallying time’ and determine, after a week’s worth of life support and drugs and everything-that-can-be-provided, that things are not improving. I ensure that her family, her husband, her children, her mother, understand that this is a very difficult decision to be made in the week-or-so to come, should things not improve. I try and be clear — English is not their first language either. She is very clear, herself — she wants to be kept comfortable, should what is killing her today turn out to be her cancer, and not the infection that we can treat with powerful drugs in a week-or-so.

They understood me. In no uncertain terms, they knew that this may be the last time they ever got to see her awake, and talking. This gave her husband the courage to ask the intensivist — a gruff and imposing man — for some time so that her daughter could come and see her before she became unable to speak. The intensivist has other priorities — either she ends up on the ventilator now or in a couple hours’ time, it won’t make a difference really as to the outcome since she is not yet at the point of crashing. The intensivist will return, and in that time, we-the-ICU-staff will do our best to ensure that should these be her last moments of wakefulness, they will be as meaningful as can reasonably be expected under the circumstances.

We bend the rules — two people in a patient room max, nobody under the age of 16 years, nobody after 8pm. We call their spiritual guide of choice. We are spiritually rewarded, ourselves — treated, somewhat bittersweetly, to the sight of her entire family in that tiny room, hands joined, chanting prayers together in their language.

This is a story that I don’t know the end of yet. It was a hard thing to be close to that much pain. That said, I feel better knowing that even if the story has a really shitty ending, that at least she had a chance to tell her family how much she loves them before she died.

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showing her the exit

The saddest situations aren’t the 95-year-old grannies who’ve lived good lives. They’re not the people who’ve abused their bodies until the wheels fall off. They’re not even really the accidental stuff, the traumas that, in a split second, change a life forever. The saddest things are the young people with chronic illnesses, the healthy people whose bodies just up and betray them one day. Arguably, the worst of these illnesses is pulmonary fibrosis.

It’s fairly rare — the stats on Wikipedia say somewhere between 10-30 per hundred thousand people — but it’s devastating. It’s one of those diseases where you seriously wonder whose mom you ran over in another life to deserve it. Your normally very elastic lung tissue is replaced gradually with scar tissue — which doesn’t stretch. It’s like breathing with a belt around your chest, and every day the belt gets just a tiny bit tighter until finally, you suffocate to death. The treatments are generally just big-gun immunosuppressants. There’s no real specific treatment. Most people are dead within 5 years.

There’s no nice way to slice it. It sucks and it’s awful. Who can handle being given a death sentence and told “there’s nothing we can do”?

She’d been told that when she was in her 20s. She suffered through the shortness of breath, dragging an oxygen tank around with her. She was young and healthy otherwise, though, and so ended up on the transplant list. A lottery where if you win, you get to live. And lucky her — she won a pair.

I’ve heard it said that a lung transplant is trading one chronic disease for another — and it’s the truth. The antirejection drugs they give you after the transplant make you more likely to get infections that’ll wreck your lungs — it’s not uncommon to get colonized with something strange. Your new lungs aren’t connected to your nervous system so your cough reflex doesn’t exist. The drugs come with their own side effects — unpleasant ones.  And sometimes your lungs come with pathogens of their own that you didn’t know about until after the recovery period.

She lived for months inside a hospital, slowly and tediously recovering from an illness that lay waste to the landscape of her body. She nearly died of CMV pneumonia. Her new lungs ended up getting destroyed and her shortness of breath came back. Again, she felt like she was suffocating to death. And then, the transplant center told her she was in full blown rejection, that there was nothing they could do, and that she should go home and get her affairs in order and be with her family.

I first met her because she had asked her family to help he commit suicide. She had suffered for years at this point. She remembered acutely what it was like to feel like she was suffocating to death, and she was terrified to die that way. So terrified, in fact, that she had begged her husband to kill her.

I provided no real respiratory therapy. Respiratory wise what could be done was being done. Instead, I sat on her bed and we talked, over her breakfast, while her husband snoozed in a cot by her bed. She described to me what she was afraid of: suffering. The reason she’d asked him to help her die was because she didn’t want to suffer; I ended up spending my visit explaining to he the concept of palliative care.

I explained that with diseases where you’re dying of shortness of breath, what we do is give medications to relieve shortness of breath. Ordinarily with respiratory disease we would not want to give medications that suppress the so-called “drive” to breathe, lest we worsen the situation. When we are palliating respiratory disease, on the other hand, the drive to breathe is what causes the sensation of shortness of breath — so we will in fact very deliberately suppress the drive to breathe, so as to relieve the shortness of breath. These medications are often sedating, so we only give you enough to make your time tolerable, so you can enjoy your time left with your family without suffering. Instead of increasing quantity of life, the goal is to increase quality of life.

She cried, cried and cried, her relief pouring off of her with her tears. She had so anticipated suffocating to death that to be told she doesn’t have to suffer was very relieving. Now, instead of feeling like her only way out was an act of desperation done in secret, she instead could pass away in a safe place, in relative comfort, with her family by her side seeing that she didn’t have to suffer. I saw her again a couple of days later and she seemed at peace. She’d spent some time touring the palliative care ward, talking to the palliative care coordinator. It seemed the relief had settled on her.

I was not surprised to find out that she had passed away only a few days later.

I think about how I got into respiratory to save lives, but in all honesty, I spend a good chunk of time helping people end them. I can’t say I find this disagreeable… I feel much, much better at the end of the day knowing I helped give a very sick lady what she wanted — a good death.

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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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even when it’s different, it’s always the same

It’s funny how reading news stories bring back memories.

It’s always awful when a new mum dies. It’s usually such an awful death, too.

I remember the first time I ever was at a birth like that. An emergency section, an abrupted placenta. Baby’s heart rate frighteningly low, respiratory came for baby, and ended up with front row seats at the show. Enough bleeding for a horror movie. More bags of PRBCs and FFP than I had ever seen before. Fluids, fluids, fluids. I’d been at many c-sections before and they were all elective, scheduled, methodical things. The most tension in the room was an obstetrician demanding a student justify their presence or an anaesthetist calling someone out for making a mess of the OR with gloves covered in baby cheese. None of this wide-eyed adrenaline, the obstetrician and his assistant scrambling to get the baby out as fast as possible, the air thick with the sense of urgency. The jokes about us making him feel like a “real obstetrician” lighten the mood only the tiniest of margins. There’s a little person in there, and it’s not exactly scheduled to come out.

This story, however, is about the mum. When mum gets sick, or something horrifyingly bad happens. These scenes stick in my mind forever, not only because of the family, the husband, the tiny baby. The father and tiny baby aren’t there to see those last five, ten, thirty-five minutes. Just me, and the code team, there to witness what will later be described in one sentence.

Pick your pathology, really; there’s no shortage of pathologies that can cause this type of thing. The one that crosses my mind when thinking about these events is the amniotic fluid embolus. A seemingly normal birth, a happy fresh baby, an elated family. The endings of birth didn’t stop the bleeding. It continued and continued, and what began as a mild worry quickly escalated into a high-strung fear. The bleeding wasn’t stopping.

The infusions of blood products are really only a stopgap measure. By the time her heart stops, it’s already too late. We can only infuse so much. I have, arguably, the easiest job: stand at the head of the bed and watch, while I make her limp body breathe. Everyone else is scrambling and using their brain. I, I am standing there with one hand on the bagger and one hand on the yankauer, suctioning blood that flows freely from her lips, nose, eyes. It seems wrong, these young people coding in our ICU. As if the codes should all involve 90 year olds who were ready to let go. All I can think of, while watching this person die of DIC, is their husband, their family members, their brand new baby.

It’s been a long time since women routinely died in childbirth. These events are admittedly quite rare. But they happen. And when they happen, everything inside me twigs about how abnormal it is for a new mother to die in this place of western medicine and modern cures, of nothing other than having a baby.

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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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blinks of life

Relatively speaking, with consideration for the span of a lifetime, the amount of time I get with a patient is rather short. Days, weeks, even months or a year don’t accurately reflect the fullness of a life lived outside the concrete box that is a hospital.

I don’t realize this at the time, really. There’s other things that concern me when they are in the ICU with tubes down their throats. It’s sometimes kind of striking later when you read their obituary and find out they were an avid hedgehog breeder, a rabid hockey fan (with pictures to prove,) or even, in another life and at another time, a hugely important civic personality, a philanthropist, a businessman or woman, or a humanitarian crusader.

It’s easy to lose sight of this. The depth and reality of an entire human life is such an immense time of otherwise indigestible details… it’s inabsorbable, at least in five minutes, or at most, a week or a month or a year. I will never know you as your family or your loved ones know you. I will never know you as you know yourself.

I am, however, quite treated to these little glimmers of what you are as a person. Perhaps it’s your common-law husband, talking to us while you’re comatose, of your philanthropic ventures. Perhaps it’s the name you’ve made for yourself in the community, the fact that the other healthcare professionals responsible for your life know what you’ve done. Perhaps it’s how you treat us, these faceless agents of the system, in how you call us angels and/or assholes. Perhaps it’s even being able to experience you on a daily basis, and to have you declare that you have adopted us as newfound family.

I keep the happy little moments close. Even if things didn’t go as planned. Even if you ended up passing on far before your time. Even if I have to endure the march of family following after your downturn, ensuring with their own eyes that indeed, the truth is real, that you are closer to death than they’d ever want to realize. I like to think about your personalities in the best of times, how you taught, how you advocated for your isolated community that only you cared about, how your wife loves you so much she would be here to watch you struggle even to the detriment of herself.

I won’t pretend that all that I get is positive. Sometimes you’ve been out of jail only long enough for us to declare you dead due to a gang-related incident. Sometimes you have no family, and the only people who see your beauty are those of us tasked with poking you with sharp things and wiping your ass. Sometimes you’re an insufferable asshole, and even your family physician will not at all hesitate in telling us exactly so.

I think the thing that I have most intimately learned in this situation is that I am completely unable to judge a person. All that I get are the tiniest sparks of life, the most washed-out and grainy snapshots of a person. You are something to someone, perhaps everything to everyone, or nothing to no-one.

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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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