Tag Archives: career

the n of 1

We’d like to think that medicine is entirely evidence-based, but it’s not. Some of what we do has a great amount of evidence behind it, but sometimes the evidence is a little more shaky. Sometimes there’s practically no evidence. As a paramedic put it to me in an ACLS class one day, aside from this short list of drugs, as far as the evidence goes, we could put mayonnaise in that IV and there’d be a similar amount of research to support it.

I mean, we try our best to operate under what we think to be the best. We read consensus statements from working groups, we go by clinical practice guidelines published by a committee of experts, and when we aren’t sure, we go by conjecture that we base on previous clinical experience and whatever tangentially associated evidence we happen to have packed away in our brains. We usually get pretty close, but the truth is that we could get a lot better. A lot of the time, we basically run on nothing.

In truth, we don’t really run on “nothing” — clinical experience isn’t irrelevant, and recommendations from those with more experience than us, while not exactly evidence, isn’t exactly nothing. But there’s lots of situations, especially with the sort-of new-frontier type medicine, where the answer to the question of what the best thing to do is honestly that we don’t know.

So imagine my joy when I find a document on a subject that I know has gotten little research. Somebody (in this case the Canadian Thoracic Society) has compiled all of the best available information into one document and made recommendations based on it. I skipped off to the printer (sorry, trees) and pulled out my highlighter and began swiping away at passages I found most relevant. I got two swipes and three paragraphs into the actual recommendations before I found this gem:

“Unfortunately, each of these techniques suffers from the lack of well-designed prospective trials. As such, recommendations were informed by observational studies and professional consensus.”

Professional consensus and observational studies. So clinical experience (times a lot of clinicians) plus tangentially related evidence (with a small sample size and no controlled conditions) are literally the best evidence we have. Like I said, it’s not exactly nothing, but when you consider the way things tend to fall apart under close scrutiny in this field, it’s about as close to nothing as you can get while still having a half-assed idea what you’re doing.

In school they teach us to operate on this version of ‘nothing’. They teach us models and give us context and try and assist us in developing the skills necessary to work outside the textbook. Very few patients are cookie-cutter. We operate like that a little bit when we’re brand new, but as we gain experience we learn things that are unteachable. We learn how much wiggle room we really have — that it’s not necessarily the end of the world if we try something and it doesn’t work. We learn that the limits we were given are margins of safety, and that there’s a lot of space between the margins.

Enter the patient. I’m lucky, I say — so many of my patients are heavily sedated and won’t remember what I did to them — I have a sort of list of things I can try in order to achieve the result that I want. It’s a common refrain in health care that patients don’t read textbooks, and it’s true. It’s exactly because no two patients are exactly alike that no two treatments are exactly alike. It’s the nature of what I do that I intervene and look for a particular patient response; when I don’t get the response I want, I change my intervention. In this way each patient is its own isolated experimental model: a kind of so-called n-of-1 trial.

I think if most people knew how much of my job (especially with regards to ventilating people) is “well, let’s try it and see what happens,” they’d be a little concerned. The truth is that that’s the essence of a lot of medicine. The beauty of ventilating someone with a piece of equipment that retails for more than a small condominium is that I get the benefit of immediate information about how my experiment is working. I don’t have to wait for days for antibiotics to work or steroids to kick in. I don’t even have to wait the minutes it can take for sedation to kick in. I will usually know in under 5 minutes if what I want to do is going to work or not, and because things respond so fast, unless I do something exceedingly stupid it’s actually very difficult for me to harm somebody with an experiment of this kind.

Sometimes I get another kind of immediate data: sometimes my patients are awake and talking. The home ventilator stuff I linked up there is so interesting precisely because of that. 99% of the time when I ventilate a patient, they’re out cold and I’m left to do the guesswork based on some animations and a few fluctuating numbers on an LCD screen. When the patient’s awake, they can tell me what they want and how they feel, and if they’re articulate about it and it’s a problem I can solve, in a way this gives me far more fine-grained control over what I end up doing.

He asks me questions, and the answer I have is an honest one: we don’t know, there’s not a lot of research to support this, we don’t have a lot of good models for what we’re doing, it depends on how you respond. It sounds terrifying to somebody who wants the patriarchal model of medicine to hand down a pronouncement from on high about what their therapy will entail. Sometimes we do that, but we try not to. Care plans shouldn’t be about what I think is best for you. I don’t live in your body for 24 hours a day and once you walk out those doors the life you live is your own. If I’m going to come up with something that you’re going to be able to live with day in and day out, it’s far better if we can come up with something together.

It’s easy 99% of the time with my heavily sedated patients. The tube comes out, they come to, (sometimes not in that order,) and what I’ve done is something that was profoundly uncomfortable and yet saved their life. They don’t have to live with the therapy on a day-in-day-out basis — it was a short term thing and once over, it can be forgotten.

With someone who’s vented at home, it’s an entirely different story. Their life is my therapy and without it their life would be shortened considerably. They can’t ignore what I’m doing if it’s uncomfortable and they can’t forget about it because it’s ever present. I need his feedback to do my job properly: the equipment I use in the home is 1/10th the sophistication of the equipment I use in the ICU. I lose my raw data and get subjective information and I have to glean a course of action from that.

The benefit to this is his subjective response is just as quick oftentimes. He knows his body and I can trust that. He gives me far better data than I can get off of an LCD screen and it allows me to individualize his vent settings in a way that I would never dream of doing with an acutely ill patient. Admittedly it helps that most chronic ventilator patients have healthy lungs, and I’m using settings that are far gentler than anything I’d use on someone really sick, but an experiment is an experiment and it can still go awry.

It depends heavily on the patient too. Some people become very uncomfortable if they think you don’t know. Some people are anxious and when you say “we’ll have to try it and see how it goes” they hear you say that you’re not confident in what you’re doing. (Those are times you have to be part salesman.) But most people actually respond really well to an authentic voice, when you tell them we just don’t know and in a lot of ways we have no way of knowing. I tried hard to be honest without being wishy-washy, and I think they appreciated my lack of fatalism and my willingness to be flexible.

Even inasmuch as the n of 1 is a terrible way to conduct scientific research, it’s a great way to conduct patient care. We are all individuals and what works for one of us will likely not work for the next, and applying cookie-cutter approaches doesn’t always work. At some point a really good clinician will be willing to go beyond the textbook, to look at the data they have, to try new things and to see how they work out. The ability to think critically in this way is what separates out those who really know what they’re doing from those who use the paint-by-numbers or recipe-book method of healthcare, and not just for their critical thinking skills. Some of the most valuable things to come out of such an experiment is the experience of having done it in the first place, of learning those things that are unteachable. We shouldn’t fear experimentation. It’s how we become truly great at what we do.

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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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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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