Monday, September 26, 2011

My Nose is Itchy.

I worked only one day out of the last set up in the ICU, As such I fell victim to the phenomenon that I like to call - "You will have the patients no one else would like to care for." This included a quadriplegic who is actually quite nice but is a lot of work. In fact, if you take this patient (let's call him Simon) as one of your patients for the day, you will actually only have to take on one or two other patients - just because he is so damn time consuming. Also, since you end up spending a lot of time in his room you end up doing several non-RT functions. So. At 9 AM Simon's day begins with cough assist which is coordinated with physiotherapy. In case you have never heard of cough assist, it is basically a vacuum which blows air into lungs, then sucks it out - which sort of simulates coughing in a patient with no ability to cough. Usually 3 breaths are done (in, two, three, out, two, three), patient is suctioned, and then this is repeated 3 or 4 times. Physio co-ordinates care with us in order to do exhalation vibes.

After cough assist is done physio gets to leave the room. I swear to god they think this is the easiest patient in the entire hospital. Then we do some TLC breaths with the bagger. Phew. Almost done. Ok, so now administer some Ventolin and Atrovent in preparation for the next step. What Simon? Your eyes are itchy? Ok, so now get a cloth and scratch Simon's eyes. Ok. So the cloth isn't wet enough. Get the cloth wetter. Soak the eye. OMG. Wrong eye. Ok. The cloth isn't the right temperature. Fix that. Neck is itchy. Nose is itchy. Ok. Solved the itchy problem. Almost done right? No.

Simon has an antibiotic nebulized through the vent circuit. Easy peasy, pop it in and go? You wish. Ok. The antibiotic is a powder. It needs to be re-constituted right before you give it. So you mix it up with the normal saline. Now you need to exchange the exhalation valve and flow sensor on the vent so that doesn't get gummed up with this sticky mixture. Ok, done and done. Neb mode started on the vent. Now you get to sit around and wait 30 minutes while it runs. Fantastic. Itchy neck. Itchy eyes. Can you put some lotion on my face? Can you put some eye drops in my eyes? Yes, yes, and yes. Increase the volume on the TV. No, too loud. No, not loud enough. WHAT? You want some ginger ale?! Right. So we let him suck up some ginger ale, swish it around in his mouth and then we suck it out with a yankeur. Fantastic. 20 times. Then Simon starts telling me about how he misses coffee, and pringles (which I misinterpret as "pickles" and he turns purple with frustration trying to make me understand), and beer. I feel terrible for him and also feel terrible for not wanting to scratch his eyes or the inside of his nostril. Sigh.

So, the antibiotic finishes and then I have to switch back to the original exhalation valve and flow sensor.

Repeat at 1600 hours.

Oh. Also, I forgot to mention that this patient is on the vent - so you have to bag him between sets of cough assist. With your free hand. And he is fully on isolation - don't forget your gown and mask. And finally? Simon can't really vocalize - better get really awesome at reading lips.

Wednesday, September 21, 2011

Off to India!

No - not me. I wish I were going to India.

We have had a patient in our hospital for months and months. He came from India to visit his daughter - with very poor lungs. Yet, his Indian doctor said it would be ok for him to travel. He was here one day when he went into respiratory failure. He has been in the hospital multiple times. He has been intubated multiple times. He has had multiple trachs. His health insurance ran out a long time ago. As a result his daughter has had to re-mortgage her house in order to pay for his medical bills. Yes - this can happen in Canada too. Numerous medical professionals have been donating their time to his cause since his insurance ran out.

The past few weeks have been focused on getting him well enough to travel home.  That day was yesterday. I was preparing him for travel - which mostly just involved some last minute suction and sending emergency trach supplies with the transport team - when the Dr came in to say that she wasn't sure that he could travel. I couldn't believe it, but eventually he was cleared and when I came back from lunch he was gone.

The transport team came from Taiwan. I can't even imagine how they found a transport team in Taiwan to come to Canada, collect this incontinent man with a trach and travel first to Frankfurt and then on to India. Seriously. I can't imagine the cost of four first class seats the entire way.

This is the second time I have seen this already in my time in the hospital. Elderly family member travels overseas, and either insurance runs out or doesn't at all cover a previously existing medical condition. Both times this involved a patient with COPD and greatly decreased lung function. Both times resulted in financial destruction for the families involved.

Seriously - think twice before having your elderly family member travel overseas to see you. Maybe you should go visit them instead.

Monday, September 19, 2011

What's Wrong?! What isn't Wrong!

We have a laryngectomy patient who is having some complications. Last time I saw him, he was still in the ICU, and he has moved out to the wards now. I saw him twice yesterday. The first time I had a student with me and, lets be honest here, she did the bulk of the work. So the issue is that due to bleeding there are many blood clots that need to be cleared out of his airway. We do this using sterile swabs, tweezers, gauze, and finally instilling saline and suctioning the crap out of his lungs. So. That went well the first time. When we arrived he was on the phone with his wife. Except he can't talk - so he would listen to the phone and then hand it back to the nurse who would listen to what the wife had to say and then convey what the patient was trying to say. Very frustrating. For everyone. At one point the nurse said, "Your wife would like to know what is wrong." I laughed to myself. This poor guy has had so much trouble in  hospital - What's wrong??? What isn't wrong. Anyway. She wasn't interested in coming down to the hospital so he was going to have to wait until morning to see her. And lucky us would get to continue to care for his laryngectomy site.

Later that evening, after my student had got home for the day, I had to see him again. Now the poor guy was vomiting up copious amounts of bile. Luckily for me, because I wasn't that interested in irritating a vomiting patient, the ENT resident was there with her little scope and she said it looked pretty clear in there. I just cleaned up some superficial clots and got the hell out of dodge.

Wednesday, September 7, 2011

Short Change Over

Due to some sort of scheduling mix up... I imagine it went something like this....

Scheduling lady - "Do you want to work such and such a shift?"

PeonRT (without looking at schedule at all) - "Yes! I am short on shifts! I will work anytime possible!"

So... I ended up working until 7 am and returning to the hospital at 3 pm. Never again.

Saturday, September 3, 2011

The grossest thing I have ever seen...

First a moral lesson. There are 2 very sick people in our ICU right now. One developed a Legionalla Pneumonia after going in a hot tub. As someone about to face a long cold winter, the thought of never going in a hot tub ever again is horrifying and sad. But I am definitely considering adding that to my list of DO NOT DO EVER's. This person is currently proned and oscillated. The second person (who this post is about) was wrestling with a buddy, broke some ribs, developed a pneumonia and now has multiple chest tubes, and well.. I don't want to ruin the surprise. So to summarize kids - do not go in the hot tub and do not wrestle.

Back to the grossest thing I have ever laid eyes on. Our friend in the ICU had a necrotizing pneumonia, which left some empty spaces in his lung, which then abscessed and collected large amounts of fluid. In the meantime he developed an infection of the pleural fluid which loculated into several separate specific areas. So the doctor thought it would be beneficial to have multiple chest tubes inserted under the guide of CT and Interventional Radiology. Chest tubes 1 and 2 went in without much trouble at all, and drained what appeared to be normal looking pleural fluid drainage - what we normally see in a chest tube. This is where things get truly fantastic. The Doctor was not wearing a mask, or goggles, or a gown. He inserts the last chest tube and a GUSH/EXPLOSION of grey, foul pus erupts out and all over him. I have truly never seen/smelled anything like it. Also. The Doctor was wearing fancy shoes. Fantastic.