Excerpt for RT! - Reflections on a Career in Respiratory Therapy by , available in its entirety at Smashwords


Reflections on a Career in Respiratory Therapy


Jeff Maurer

Smashwords Edition

Copyright 2018 Jeff Maurer


Responsible nurses do try

to ensure that their patients don't die.

But though drugs and compassion

both work in their fashion,

when pressed it's “RT” nurses cry.

Let me explain.

Suppose you are a nurse caring for a patient on a ventilator (a “breathing machine”). Suddenly an obnoxious ventilator alarm sounds, demanding immediate intervention – a demand impossible to ignore because the ventilator alarm is even more obnoxious than the variety of other obnoxious alarms that seem to be constantly sounding off in Intensive Care Units. You know there is a chance your patient will die if you do not figure out and fix what is wrong – and soon. The first thing you do is make sure that the ventilator tubing did not become accidentally disconnected from your patient, which can happen during some patient care procedures. It appears to be securely connected. The alarm is still blasting. Instead of the rhythmic inhalation-exhalation sounds of a properly functioning ventilator, you hear a constant, disturbing “whoosh.” And your patient’s chest is not moving, so clearly he is not getting any air. Multiple potential explanations exist for why the ventilator isn’t doing its job, but your training and experience has been largely focused on other of the innumerable aspects of patient care. (There are only so many things that any one person can be expert at.) But there is someone in the ICU, probably not more than a few yards away, whose training and experience is entirely centered on respiratory issues and technology – the Respiratory Therapist. You grab the bag (a plastic hand-held breathing device which will hopefully enable you to take over for the ventilator until help arrives but which you really don’t want to have to use for very long because there are other things which your patient will need from you and besides, you’re not a machine) and yell for help.


Or, suppose you are on the night shift taking care of a baby who, though not on a ventilator, is significantly premature and therefore at risk for apnea (not breathing). You’ve been a nurse for a while and have seen this happen to several of your patients. And more often than not, all you had to do to get them breathing again was provide a little stimulation. But that isn’t always enough. You’ve bagged babies before (provided manual respiration with the plastic breathing device), but since that is only one of the many things you need to know how to do and since you haven’t actually done it all that often, it’s not something with which you are as comfortable or competent as someone who does it frequently and whose training is specifically centered on that kind of thing – namely, the Respiratory Therapist. Sure enough, your baby stops breathing. And simple stimulation is ineffective. You try using the bag but just can’t get the baby’s chest to move up and down as it would if air was actually moving into and out of the baby’s lungs. (Positioning a premature baby’s head in just the right way to get the airway open can be tricky.) The doctor (a new Resident whose anxiety level tends to aggravate rather than diminish the tension which pervades emergencies) is probably in the sleep room around the corner and down the hall. The Respiratory Therapist is someone whom you know has saved the day in multiple such situations. If the problem is more complicated than just apnea, calling for the doctor would be a priority. But even if that were the case, establishing adequate ventilation is the single most important objective in the neonatal population. So, who ya gonna call first?


You know those dreams when you suddenly realize, the night before it is due, that you have completely forgotten about a term paper accounting for half your final grade, or you’ve completely ignored an entire course you were supposedly taking for the last three months, or you find yourself on the way to a class without having any idea at all where it is? Maybe you don’t dream. But I do. And I had those dreams for decades even after I stopped going to school. The good news is I no longer have those dreams. The bad news is the school dreams have been replaced by work dreams – such as being confronted by a nurse who knows full well I have completely ignored one of my patients for the first 11 hours of my 12 hour shift, or, still worse, turning my patient’s ventilator off so I can suction excess secretions from his breathing tube without the dang disconnect alarm going off but then fatally forgetting to restart the ventilator after I reconnect it to my patient.

Trust me. My bad work dreams are worse than my bad school dreams. So if anyone is wondering why I decided to write this book, the primary reason is to hopefully exorcise that particular dream demon by manifesting my Respiratory Care memories in some medium other than my fragile and apparently self-loathing subconscious.

Before proceeding, I wish to point out that while all the stories told here really did happen, none of the individual characters (except for Steve and William) is or was a real person. Names have been changed. Also, I am distilling over thirty years of experiences into a few pages. Many of my characters are amalgamations of multiple individuals. The same could be said of institutions – I’ve worked in over 10 different hospitals. And though I will, at times, portray some individual character or institution in a way that could suggest they deserve criticism, please keep in mind that everybody has flaws. The intensive health care environment is a particularly difficult one to function consistently well in for even the most competent of us. We all make mistakes. And we all deserve forgiveness. Also, coping with potentially deadly mistakes is a challenge that not everyone is up to and is something that should be taken into account by those considering embarking on any profession that would routinely place you in a life or death situation.

It may also seem that most of the stories I tell involve bone-headed blunders. This does not mean that bone-headed blunders dominate health care. One of the reasons they are so memorable is that they are unusual. The usual is for everyone on the health care team to know their jobs and do them proficiently.

In my opinion, based on decades of experience, health care professionals are among the most caring, compassionate, competent, wonderful people ever. To every single one I have shared healthcare trenches with throughout my entire career, even including the ones I at times found myself in disagreement with and who might (or might not) provide some fodder for some of the stories here, it has been an honor and a privilege. Thank you.

Chapter One


My third attempt at a career found me taking a stinking, crammed like sour in a lemon bus from Haight-Ashbury to the financial district where, with a bunch of other faceless suits, I toiled away in my cubicle manipulating figures, charts, and computer programs to arrive at the most actuarially sound contribution levels to ensure appropriate pension funding for our client corporations.

Maybe your reaction to that is, “Wow! How interesting!” But the reality of it, for me, was that I was losing my mind. It was San Francisco. It was the seventies, man. And there was love in the air – if only I could escape the vibes of the financial district. So by a series of events nearly as circuitous as those that led me to be an actuarial assistant, I became a Respiratory Therapy student.

In case you’re wondering, I would have been far, far better off financially had I stuck with the actuarial sciences. But I would have been a different, even more “eccentric,” less socially responsible me - might even have swallowed the whole loony, market worshiping, greed justifying Ayn Randian “philosophy.” So it’s not at all clear that the best choice financially would have been the best choice for me. Anyway, a Respiratory Therapist makes slightly less than a Registered Nurse. And nurses also have somewhat better career options. So Nursing might seem to be the wiser career path choice. But in deciding whether to pursue Nursing or Respiratory Therapy, there was one absolutely essential debate to resolve: shit versus sputum. Shit, you know about. Sputum, in case you don’t, is the potentially putrid slime hacked up by patients with diseased lungs – think rotting oysters. With rare for me insight, I knew even then that nurses were the kind of people who were grossed out by sputum but didn’t mind shit, whereas Respiratory Therapists simply did not want to have to deal with shit. So for me, the clear choice was Respiratory Therapy. And, though my RT career did not turn out to be as shit free as I had hoped, this remains my observation on a fundamental difference between the two professions even today.

Beyond my preference for avoiding shit, there were other, more altruistic motivations for choosing to pursue a career in Respiratory Therapy, especially as it compared to other, less “helping” professions. What I wanted, and what I got, was a profession that enabled me to actually feel like I was doing somebody some good. I can’t tell you how satisfying it is to be greeted by a family of two grateful parents with their beautiful, healthy young daughter who survived severe prematurity in part due to my efforts and skills. Whether a chance encounter on the streets of the city where I concluded my career and still live, or the result of their return visit to the hospital years after discharge just to say “thank you,” these reminders of our successes were what kept us going in an intensive care environment that saw far too many heart-breaking defeats.

My fourth career ended up being a keeper. Though aspects of it infuriate me still, I’m not sure I could have tolerated anything else even nearly as long. I am grateful that I found it. But the heartbreak is very real – at least for the kind of person who ought to be doing this kind of work.

After taking some prerequisite courses, I started my two-year Associates Degree program in Respiratory Therapy. After the first year, while still a student, I got my first job as a Respiratory Therapist. This would not happen in today’s world of stricter education and licensure requirements. But back then, the profession was still young. Some still referred to it as “inhalation therapy.” (I’m too embarrassed to say how long it took them to realize that inhalation without exhalation didn’t do much good – so “respiratory” really was a much more appropriate title.) Heck, because some roots of the profession lie in needing somebody to move oxygen tanks around the various parts of the hospital, when I first started there were still some who referred to us as “oxy jockeys”. (Round about 1986, somebody decided that the ever-expanding role played by Respiratory Therapists demanded yet another update to our professional designation. Thenceforward, it was decreed, we would be known as “Respiratory Care Practitioners.” Really rolls off the tongue, doesn’t it? Twenty-five years later, despite the officially preferred title, nurses in need of assistance were still calling out “RT!”)

That first “while still a student” job in RT had me providing low risk treatments on “the floors,” as opposed to the more highly intensive responsibilities reserved for the more experienced RTs in “the unit.” I did med nebs, IPPB, and CPT. CPT (chest physio-therapy) involved placing the patient in several positions (mostly with the head lower than the body) while striking their chest with cupped hands in such a way that made loud popping sounds while supposedly mobilizing pulmonary secretions so the patient could more successfully cough them out. To my knowledge there has never been any experimental validation to suggest this actually works. But there is plenty of anecdotal evidence from pulmonary patients who swear by it. I was once complimented on my CPT rhythm by a patient who had been a professional drummer. Med Nebs (medication nebulizers) turn liquid medication into a mist that is passively inhaled into the patient’s lungs. IPPB (intermittent positive pressure breathing) is a lost art. It used positive pressure to help the patient take a deeper breath so that the medication could get better pulmonary dispersion while also treating and preventing the hopefully minor regional lung collapse known as atelectasis. Properly used it was effective. But in the hands of the less capable or less artistic, there was potential for undesirable side-effects. Today, both the artistic and the incapable have been homogenized into a middle ground of proper procedure that does a fair job of minimizing both.

Jerry was one of the COPD (Chronic Obstructive Pulmonary Disease) patients I truly enjoyed treating with both IPPB and CPT. And I had the pleasure of providing him with those treatments on many occasions. He was a happy, engaging older gentleman who offered me a stick of chewing gum every time I entered his room. Our treatment session usually lasted about 25 minutes (which was shorter than it would have taken to do it “text book” correctly, but longer than he was sometimes willing to tolerate) and I probably did him twice during my eight-hour shift. So we had plenty of time to talk and get to know each other. He had been discharged a few days earlier when I heard an overhead page for “Respiratory Therapy STAT to the ER.” (The director of Respiratory Therapy at that hospital preferred his therapists be paged overhead instead of via personal pager because he thought it was good PR for the profession to be heard as being needed so often. STAT means “right now if not sooner because the shit is hitting the fan.”) When I arrived in the ER I followed the general hubbub into the room where a code (resuscitation of a possibly dying patient) was underway. One of the ER nurses already had a mask securely covering the patient’s nose and mouth and was providing ventilation with the “bag.” I took over responsibility for that just as the patient’s heart monitor went flatline. The nurse I’d just relieved started compressions and soon the defibrillator pads were placed to hopefully shock the patient’s heart back into a life-sustaining rhythm. At the “all clear” notification I removed the bag/mask from the patient and stepped back to expedite defibrillation. It was only then that I realized the patient was Jerry.

We bagged and compressed and shocked the heck out of him. But he didn’t make it. Jerry’s was the first death I ever witnessed.

As you go through the mouth or nose and down the throat, you arrive at two openings. One is the esophagus, which leads to the stomach, and the other is the trachea, which leads to the lungs. It is possible to position the head of a coding patient in such a way that air delivered from the bag/mask will preferentially go into the lungs instead of the stomach. But there are times when, no matter how hard you try, air just keeps filling the stomach instead of going where you need it to go. If this happens in the hospital, there are physicians (and sometimes RTs) trained in inserting a tube directly into the patient’s lungs so that the bag/mask will then be delivering air to only the lungs. But, at least back then, there was another device available to be used in a similar situation outside the hospital where putting a tube directly into the lungs was less feasible. This device was called an esophageal obturator. Here’s how it worked. The mask that goes over the patient’s mouth/nose had a short tube attached to it that was designed to go into the esophagus. At the far end of that tube was a small inflatable balloon. So with the obturator in place and the balloon inflated, the esophagus would be occluded and the air would therefore have to go into the lungs instead of the stomach.

In Jerry’s case, there was no trouble positioning him in such a way that air from the bag/mask entered his lungs. On a different occasion, however, I arrived in the ER for a case where the esophageal obturator had been placed out in the field and was still in place. On this occasion, the entire team (including me) was assembled and ready when the patient arrived. I had been asked to do the compressions. I don’t remember who was doing the bagging (using the resuscitation bag). It could have been another RT, or a nurse, or an MD wanting to get some experience doing that. The patient they wheeled into the ER, with an esophageal obturator in place, was blue, and her abdomen was severely distended. When we got her onto the ER table and I started compressions there was a sickening crunching sound, and relatively little chest wall recoil. The ribs were broken clean through – in multiple places. And the esophageal obturator had been placed in the patient’s trachea, which meant all the air from the bag had gone into the stomach, not the lungs. The patient had been dead for a while, and we all knew it.

Perhaps because the profession was still young enough that things were evolving faster than they could be standardized, there was an open-minded curiosity about all the changes and about how to identify and address the new problems that accompanied new technologies. Even as a mere student, my insights and opinions about the practice of Respiratory Care were given a degree of respectful consideration by other RTs, including the department head, which was much less forthcoming late in my career, even for as experienced a RT as I had become at the end of my career. On that first job, during one of the times I was allowed (with a chaperon) into the Intensive Care Unit, I discovered one such problem.

Early ventilators were very basic. They started with a baseline pressure of zero and then increased the pressure periodically so that during those periods of increased pressure air would be forced from the machine, through a plastic circuit connecting the machine to the patient’s breathing tube, then through the tube and into the lungs. Then they dropped the pressure back down to zero again, which allowed the air to be exhaled. We could adjust how long each breath lasted and how big each breath was, but once those things were dialed in, every breath was exactly the same. Normally, however, not every breath we take is exactly the same. Once this dawned on us, the ventilator manufacturers tried to come up with a way to allow patients to take variable kinds of breaths beyond the basic minimum of standardized breaths the ventilator was set to provide. One way they managed to do this was to provide a supplemental plastic circuit that could be hooked up in-line with the regular ventilator circuit. This supplemental circuit had one-way valves in it that maintained the positive pressure during inhalation but (during times of no pressure while the ventilator was waiting to deliver it’s next mandatory breath) allowed the patient to get whatever kind of extra breath he might want by simply sucking in enough to open the one-way valve. It worked. But, another thing we learned is that the normal baseline pressure in the lungs is something like three – not the zero our ventilators had been using. And we learned that increasing that baseline “Positive End-Expiratory Pressure” (PEEP) was a very effective way to improve how much oxygen got from the patient’s lungs into his blood stream.

So the problem I discovered as a student in the ICU was this. They had a patient on a ventilator that had a PEEP of 10 and one of those supplemental circuits to allow spontaneous breathing. But since the supplemental circuit was separated from the main circuit by the one-way valves, the PEEP in the supplemental circuit was still zero. So in order to open the one-way valves to get any extra breaths, the patient would have to suck the pressure out of the main circuit from ten all the way down below zero – not an easy thing to do even for a healthy person. When I pointed this out, I was not met with skepticism, or doubt, or dismissal, or annoyance at some inconvenient truth. They simply wanted to hear what I had to say. That none of the respiratory therapists in that hospital were aware of the problem is actually understandable. Like I said, things were changing very fast. And the patient-ventilator interaction is not quite as simple as I have described here. One could debate how likely it should have been for a conscientious therapist to notice that the supplemental circuit was not working as it should. But the point I wish to make here is how fluid the profession and its relationship with technology were in those early years, and how that resulted in an openness even from upper management to input from any source (even a student). In a way, “rocking the boat” back then was seen as a good thing. That is not the case anymore. I should probably add that in discussing openness to input here, I am referring to the Respiratory Therapy community. The openness of physicians to input from Respiratory Therapists is something I will address later on. Oh, and there is a solution to the problem. We as RTs just had to figure out a way to deliver and maintain the same PEEP to the supplemental circuit as the ventilator was maintaining in the main circuit- a bit of a pain, but certainly doable. In those days, more so than today, we did a lot of rigging stuff up.

By the way, the Respiratory Therapy community was much more “intimate” then than today. In 1980 there were less than 12,000 Registered Respiratory Therapists (RRTs). Because at that time there were still some folks employed as Respiratory Therapists who did not have the RRT credential, that 12,000 slightly underestimates the total number of RTs in 1980. But even taking those uncredentialed RTs into account, the size of the RT community then is overwhelmed by the almost 160,000 RRTs of today (2018).

While in the RT office on a break from providing med nebs and CPTs, one of my fellow RTs asked me for an update on a patient we had discussed earlier. “How’s your patient?” she said.

Though remaining cool as ever on the outside, on the inside I was… moved.

My Patient. Not “a patient,” or “the patient.” Not a diagnosis, or a treatment modality, or a room number. And not some merely abstract notion of wanting to do somebody some good.


This may have been the most important lesson I ever learned about health care. I am fortunate to have learned it so early. Those two words suggested a level of personal involvement, responsibility, and ultimately empathy that I believe had, until that moment, simply not been an active part of my professional consciousness. I didn’t know it yet – but I was becoming a different person.

Chapter Two


During my second year in Respiratory Therapy School, we started doing clinical rotations in the Intensive Care Units of various area hospitals. These allowed us, as students, to get actual hands-on experience helping out and learning from Intensive Care Respiratory Therapists. During my student rotation through the PICU (Pediatric Intensive Care Unit) at Parnassus University Hospital I was offered a job. They wanted me to be the weekend night shift RT in the PICU. Remember, times were different then. Probably everyone in my class was working as a RT before they graduated. So this may not be as big a deal as it might seem. But PUH was one of the two premier teaching hospitals in the region. They had world famous physicians on staff and were about as cutting edge as it got. So yes, it was kind of a big deal. Plus, by taking the PUH job, I could give up my job in the community hospital I had to drive way down to the peninsula for and instead simply walk to PUH from my San Francisco apartment. But to be on my own as the RT in the Pediatric Intensive Care unit of a major university hospital – while still a student? Was I ready for that? Well, they apparently thought I at least might be. And because of my student rotation there I had some idea of what I might be getting into. And there would always be back-up available for me by simply paging the RT supervisor. So heck yeah – I went for it.

I do not remember a lot about my time as the PUH PICU RT, which is probably a good thing as it suggests I somehow managed to avoid the disasters that might have resulted from my inexperience and ignorance. I do remember a young child with a severe case of Reye’s Syndrome. Reye’s Syndrome is a frightening and potentially fatal disease that even today does not have a cure. It happens most often in children with viral infections (like the flu) who take aspirin. Fortunately, since the link with aspirin was discovered and publicized in 1983, it has become rare. Unfortunately, Janey came down with it in 1981. The parents first became concerned when she started acting tired all the time and then had some vomiting and diarrhea. On the way to the doctor’s office, Janey seemed confused and started acting aggressively. In the doctor’s office, she had a seizure. So she ended up in our PICU already a very sick little girl. She had to be intubated (have a breathing tube placed), ventilated, and sedated. Because the disease progressed so rapidly, the parents should not be faulted for any delay in seeking help. That truth, however, did not keep them from blaming themselves, and very likely each other. Sadly, that’s often just the way these things go. The disease is characterized by swelling in the brain and liver, and by blood acidity. Though there are more direct ways of treating both blood acidity and brain swelling than with a ventilator, the ventilator is one way of doing both. And we got to the point where we were doing everything we could. So I was very involved with her care. This was the first time I ever saw an ICP (Inter-cranial pressure) monitor. What it is, basically, is a hollow screw inserted into a hole drilled through the skull, which then enables us to keep track of the pressure building up inside the skull. As you can imagine, the brain needs a steady supply of blood to keep functioning. As the pressure inside the skull increases, it prevents an adequate blood supply from reaching the brain. So we needed to keep her ICP down, and her systemic Blood Pressure up (because that’s what keeps blood flowing from the body to the brain).

We did everything we could.

It wasn’t enough.

So that was the first time I ever saw a child die. It was, of course, difficult. Sadly, I’ve seen many more. And it never really got any easier.

A few short months later, I completed my RT degree and was offered a full time job at PUH, which I gladly accepted. As a full time employee I would no longer be working in just the PICU. I might also be assigned to work in the Neonatal Intensive Care Unit, or the Adult Intensive Care Unit, or the floors. They would honor preferences if they could, but at least in that institution at that time we all had to be able and willing to work anywhere. My preference was the NICU because babies are different from adults in such interesting and hopeful ways. But I would also be happy to work in the adult ICU because there was so much for me to learn there. Working on the floors would still be providing a valuable service but would likely be less interesting for me because I would be doing pretty much the same things I had been doing in the community hospital down on the peninsula. Plus, since patients on the floors were more spread out, there was the potential for having to run my ass off on the floors even more than if I was working in one of the units. So that was my third choice. The PICU was last on my preference list. I’d had enough of pediatric tragedy for a while.

I should also point out that I was hired to work the night shift – 11 PM to 7:30 AM, five nights a week. (Hospitals use military time, so that’s 1100 – 0730. Also, for obvious reasons, hospitals do not use the “graveyard” shift terminology.) If you’ve worked the night shift, you know. If you haven’t, let me tell you. There are SOME who seem capable of living normal lives while working the night shift. God bless them. I don’t know how they do it. Sometimes I think they just don’t realize how abnormal they really are. (And, respectfully, not just in the hours they work.) I was thirty-one years old, so still young and resilient. And I believe I functioned at work just fine. But human beings did not evolve as nocturnal creatures. Trying to get a good night’s sleep while the sun is up and everybody else is active is neither normal nor satisfying. While working nights, I always felt about a half-step out of phase with the rest of the world. To hopefully compensate for their unhealthy sleep routines, many night shift employees at PUH would take a one-hour sleep break during their shift. This was unofficially more or less acceptable. Nobody was ever disciplined for it. In fact, if you walked into one of the hospital lounges it was likely to be filled nearly to capacity with folks trying to grab whatever little extra sleep they could to enable somewhat normal functioning. I tried it too. But I found that even if I could get to sleep there, it would just make it harder for me to get to sleep once I went home. So I ended up not doing it. But it was OK with me if my coworkers did. Nightshifters are trying to live life inside out, for chrisakes. They deserve whatever help they can get to make it work.

I do not know how widespread this was in other hospitals across the nation. I do know that a few years later I was working the night shift in a hospital that did not tolerate it at all – except among the Resident Physicians whom they had practically enslaved.

For an extreme example of night shift sleeping on the job, there was the NICU lab at PUH. It was staffed by two laboratory technicians who basically split the eight-hour shift. Workload permitting, each worked four hours while the other slept. As far as I know, nobody ever said anything about it. But again, this was San Francisco in 1981 – people actively pursued a mellow vibe.

Speaking of San Francisco in 1981, there was something completely different from peace and love that was beginning to worry, and even terrify some of our citizens. The first to know that something was horribly wrong were those who lived in or participated in the predominantly gay culture centered in the Castro district. Accelerating numbers of previously healthy young gay men were becoming terribly ill. Soon, the medical community recognized this disturbing trend. These young men were coming down with a rare lung infection identified as pneumocystis carinii pneumonia. They also developed other unusual infections, all of which suggested some failure of the immune system. But how it started, how it spread, and how to treat it or even if it could be treated was all unknown. What we did know was this: it had a 45% mortality rate. The term “AIDS” would not be coined for another year. And it would be another year or two after that before we knew it was blood borne and could not be spread by simple touch or by breathing the same air.

Jason was the first AIDS patient at PUH to have been caught early enough to hope that our medical interventions might make a difference. When I first saw him in the Adult ICU, he was relatively healthy – painfully thin, but still more or less robust. I provided him with med nebs that aerosolized medicines to ease his breathing and fight his lung infection. We talked some. I remember him as an engaging young man with a big, sincere smile that he readily displayed despite the suffering he courageously endured due to both the progression of his disease and our escalating interventions. Neither I nor anyone else caring for him was entirely comfortable being that close to someone who had a deadly disease that, as far as we knew, could be contagious enough to infect us. So I somewhat shamefully admit to not spending any more time with him than I had to. Also, because we had no idea how AIDS spread, everyone who entered his room was covered from head to toe with “personal protective equipment.” As his condition continued to deteriorate, he never saw the face of anyone who was caring for him. Appropriately, this is called “isolation.”

He ended up on a ventilator, getting ever worse. Trying to provide just the minimal life-sustaining levels of oxygen, carbon dioxide, and acid-base balance, we kept increasing the frequency of breaths, the size of breaths, and the PEEP. We adjusted the speed with which we delivered the breaths and the degree to which we controlled his breathing. Ultimately, the ventilator was pounding his lungs so hard that if his disease didn’t kill him, it seemed the ventilator would. I do not remember if he died during a code, or if they decided to just remove his life support and let him go.

Jason was not the first patient to die of AIDS. But he was the first patient to die at PUH despite receiving the most aggressive treatment available from the best physicians, best nurses, best Respiratory Therapists, and most advanced technology at one of the most cutting edge Medical Centers in the world.

Remember that dream I told you about where I turn the ventilator off so that I can suction the excess secretions out of my patient’s breathing tube without disturbing everyone in the unit with the obnoxious disconnect alarm? But then when I put my patient back on the ventilator I forget to turn it back on? Remember that? It actually did happen. Not to me (though I’ve certainly made my share of mistakes), but to Rob, one of the other RTs at PUH. He was caring for an infant on a Baby Bird ventilator, which was one of those early ventilators lacking all the bells and whistles of today’s ventilators. Rob was not the only person to ever make that mistake, a situation that resulted in later generation ventilators having safeguards built in to them to prevent it. But as is often the case, people had to make the mistake before it occurred to us that the mistake would be made.

One would think that even though the ventilator was turned off, some other alarm would sound in time to save the infant (like the bedside monitor heart rate alarm, or respiratory rate alarm, or oxygen level alarm though on second thought I’m not sure there were bedside oxygen level alarms back then). But whether those alarms had also been somehow silenced or turned too low to be noticed, or whether by the time they went off it was to late to save Rob’s patient, I do not know. In any event, the child died.

There can be no sufficient excuse for the loss of a child’s life. But even the inexcusable can be forgiven. Up until that time, Rob had been a good, conscientious therapist. Grievously tragic though his mistake undeniably was, PUH was not going to terminate him because of it, and I do not believe they should be faulted for that decision. But it wasn’t long before Rob resigned. I do not know what happened to him after that. I hope he was able to forgive himself.

Fun Facts.

Parnassus University hospital was constructed on the top of a hill. The Neonatal Intensive Care unit at PUH was on the 15th and topmost floor of the hospital. When it wasn’t foggy or raining, the view of San Francisco Bay from the NICU at sunrise was so spectacular that even the mere memory of it still brings me near to tears.

In addition to hills, fog, and rain, San Francisco also has earthquakes – frequently. (You only hear about the big ones.) From the top of that building at the top of the hill, whenever there was even a relatively small quake, you could feel the building swaying back and forth. What a ride!

This was a long time ago, back when they still used whiskey to calm agitated babies. There was a bottle in the cupboard. It worked.

Premature babies are at risk for apnea because the normal systems that keep us breathing have not yet matured in them. Stimulation (hopefully gentle) is the primary way to reverse apnea. One thing we did to prevent apnea was to hook up a breathing machine to a rubber glove, set the machine to give a “breath” every few seconds, and stick the hooked up rubber glove underneath the baby’s mattress, thereby providing “stimulation” every few seconds. Until this very moment, I never wondered if there might be a correlation between this stimulation and the agitation that led to bringing out the old whiskey bottle. Maybe somebody should have done a study. (Actually, I suspect the whiskey was reserved for the older, non-premature babies.)

As I’ve mentioned, the Baby Bird ventilator we were using in the NICU in 1981 lacked all the bells and whistles of later-generation ventilators. It was also not as pretty. Some of the “guts” that would be hidden (and inaccessible) on later ventilators were right there on the outside of the Baby Bird. And we had to know what to do with them. Later ventilator circuits were relatively simple and disposable. Baby Bird circuits were reusable. So they had to be completely broken down and sanitized in between patients, which pretty much left them a tangled mess. What I’m suggesting here is this: to get the Baby Bird to function properly, we had to know that machine very well. Certainly some later-generation RTs have at least as much expertise with their machines as we did then. But it’s also easier to skate by when everything is put together for and hidden from you. And it has been my observation that on average, RTs late in my career did not know their machines as well as the RTs early in my career.

To prove (at least to myself) that I’m not simply an old fart romanticizing the good old days, I would like to point out two things. First, even if we were better technicians, that does not necessarily mean we were better therapists. Second, the later-generation ventilators were indisputably better machines – easier to use, more precise, more flexible, safer, and if properly adjusted much better tolerated by our patients. The Baby Bird did not even have any digital readouts to tell you what it was doing. Modern ventilators tell you what the pressure is with a digital display whereas the Baby Bird only had an analog meter with a needle pointing to roughly what the pressures were. The needle bounced around a bit so that two different people looking at the same needle at the same time might record seeing two different pressures. And there was no indication at all of what the respiratory rate was or of how long the inspiratory phase lasted. Therefore, we each carried a stopwatch around our neck. If the physician wanted to change the rate from 30 breaths per minute to 36 breaths per minute, we would decrease the amount of time between breaths (expiratory time) and then use the stopwatch to see what rate that resulted in before doing any fine tuning. Sometimes it took awhile to get it accurately set to provide the desired rate. If we wanted to decrease the amount of time the breath lasted (inspiratory time) but keep the rate the same (to perhaps allow for more time to exhale CO2), then we would have to both decrease the inspiratory time and increase the expiratory time. With more modern ventilators, you would simply turn one knob until the digital readout was what you wanted. Back in the good old days, however, we used a stopwatch to manually check the results of each adjustment we made. So if the physician wanted to change the inspiratory time from 0.30 seconds to 0.25 seconds, we would do our thing and then (with serious professional demeanor and completely straight faces) assure him that the ventilator was set precisely where he wanted it – based on our ability to reliably detect a difference of 0.05 seconds with a stopwatch.

After I had been there for about a year, PUH bought some next generation infant ventilators that did have digital readouts and simpler circuits. Some of the RTs were worried that the time these new ventilators would save might put our jobs at risk. It didn’t. Good RTs find productive things to do. And MBAs had not yet taken over healthcare in America.

Infant Respiratory Distress Syndrome (IRDS) is a disease of prematurity in which, among other things, the baby’s lungs have not yet developed to the point where they are capable of making enough surfactant. Surfactant decreases the surface tension inside the millions of tiny, balloon like air sacks (alveoli) that make up our lungs, thereby enabling those alveoli to inflate. We are able to suck in a breath by contracting our respiratory muscles to create a negative pressure around our lungs so that the alveoli expand, drawing in air. It is the movement of molecules between these thin-walled alveoli and the tiny thin-walled blood vessels surrounding them that enables oxygen to get from our lungs into our blood and carbon dioxide to get out. But if the alveoli won’t inflate, we die. A baby with insufficient surfactant will not be able to breathe well enough to survive. So they end up being intubated and placed on a ventilator, hopefully until they are mature enough to manage their own breathing.

Round about 1990, artificial surfactant became available. This could be injected into the breathing tube and would then disperse throughout the lungs, decreasing the surface tension inside the alveoli and greatly enhancing the baby’s ability to breathe – sometimes enough that they wouldn’t have to be put on a ventilator at all. Though there have been other advances as well, the development of surfactant is largely responsible for probably at least a ninety percent decrease in mortality due to Infant RDS. (Though I have researched this figure, the 1980s are apparently so long ago that good data is simply not readily available, which does not do my attempts to feel young any good. I did find one source which stated that the annual number of IRDS deaths in the 1960s was more than 25 times greater than in 2005.) In 1981, of course, we were not using surfactant. So not only did more babies require mechanical ventilation, but the amount of support they needed from the ventilator was also significantly greater. As I mentioned above, the way we normally get air into our lungs is by creating a negative pressure. But the way a ventilator does it is by creating a positive pressure to force air into the lungs – not at all what you would call “physiologic.” (There have been repeated attempts to use negative pressure ventilators – iron lungs being one. But at least so far, none have proven to be practical enough for widespread use.)

So we’re trying to ventilate these babies whose lungs just aren’t cooperating. And in our attempts to keep these babies from dying, we keep turning up the ventilator pressures, higher and higher. Even a healthy lung is not uniform – some parts of the lung will inflate more easily than others. These differences are magnified in unhealthy lungs. So what ends up happening is that the ventilator will push air into some alveoli while others remain closed. Then the ventilator reduces pressure and exhalation occurs – in theory. In reality, even if exhalation did occur smoothly, we’re trying to force a fraction of our alveoli to do the job all of them should be doing, which puts a lot of strain on those alveoli that are working. And the exhalation is not smooth. During the positive pressure inhalation, the diameter of the larger airways increases, which allows air to move past any secretions or other physiologic obstructions inside the airway. But when the pressure decreases for exhalation, the airway diameter decreases again, trapping air behind those obstructions. When this happens, every ventilator breath increases the amount of air trapped, which can ultimately lead to a rupture of the lung tissue in that part of the lung, which means there is even less “good lung” than there was before. But it gets even worse. When lung tissue ruptures, air that was inside the lung escapes into the “pleural cavity” between the lungs and the chest wall. This buildup of air in the pleural cavity (known as a “pneumothorax”) can end up compressing the lung, making an already difficult situation potentially deadly.

The fix for a pnuemothorax is to insert a “chest tube” into the pleural cavity, which allows the trapped air to escape and must remain in position until the rupture hopefully heals. I remember seeing six or seven chest tubes in individual babies weighing not much more than one pound.

Fortunately, this kind of horror occurs much less frequently now than in the bad old days. Working in the PUH NICU in the early 1980s, we saw many babies die. The aftermath of one such death stands out in my memory. I do not remember any particulars of either the child or the family. What I will never forget is the reaction of the physicians, nurses, and RTs, some of whom had been dealing with this awfulness for years – certainly long enough to have hardened themselves to it, or developed some other defense mechanism to spare themselves from the recurring sadness. Every one of us openly wept.

I don’t know that I can adequately describe how, along with the grief I shared, I could also feel honored, grateful, humbled, and hopeful. Honored and humbled to be one on a team of such devotedly compassionate people. Grateful to have found a profession that enabled me to work with such people and to develop and share some of the characteristics I found so admirable in them. Hopeful because of the above and because I knew that the same efforts which had on that occasion (and so many others) resulted in frustration and failure would also sometimes be successful.

As it turns out, I was correct to feel that way. All the various NICUs I’ve worked in over the decades were filled with wonderful people. And I have evolved as a person in no small part due to what I shared with them. However, there has also been what for me was a previously unimaginable level of overpowering, recurrent sadness – a sadness that has been made more bearable by having also witnessed miracles.

Chapter Three


After just two years at PUH, I left. It had nothing to do with the physicians, the nurses, my fellow RTs, our workload, our patients, or PUH itself. At the time, I told myself it was because the city had just gotten to be too much. And in a way, it had - San Francisco, like any big city, simply never got quiet. But in retrospect, I suspect the culpability laid more with me than with San Francisco. The city hadn’t changed – not much, anyway. But I suspect I had. Or maybe working night shift was more of a drag than I realized. In any event, I felt it was time to move on.

One thing about Respiratory Therapy – you can find a job just about anywhere. I can’t guarantee it will be a good job, and you might have to work night shift. But if you want to take advantage of it, the opportunity to explore living in different places is certainly available.

So I ended up at a hospital in Reno, Nevada. And yes, I did have to work the nightshift. But understanding how difficult that could be for their employees, they did an admirable job (for awhile, anyway) of easing that pain. In addition to the slight increase in hourly wages they paid for working nightshift (which is typical in all hospitals), they also decreased the total number of hours nightshifters had to work. Instead of working five 8.5 hour shifts per week (which, after subtracting 0.5 hours from each shift for a meal break, adds up to 40 hours), I only had to work four 9.5 hour shifts – but still got paid for 40 hours. This was a sweet deal. And that extra day off every week made a huge difference in both being able to catch up on sleep and being able to have a life outside the hospital.

I worked in the adult ICU and on the floors. They did have a NICU there. But in that hospital, all the NICU RTs worked only in the NICU – and there was a waiting list to be one of them. I put my name on the list but ended up not being there long enough for my number to come up a winner. The Respiratory Therapy department there, staff and management alike, seemed capable, caring, knowledgeable, and dedicated. Things ran smoothly during my three months there and I simply don’t remember any really cool RT stories. But I do remember this one incident involving an older married couple. Mr. and Mrs. Singer both had COPD and had caught a cold that winter which ended up compromising their chronic pulmonary disease to the point that they were admitted to the hospital. She had it worse than he did. So whereas Mr. Singer was successfully managed in a regular patient room on the floors, Mrs. Singer had to be admitted to the ICU and placed on a ventilator. After two days of rest on the ventilator, including suctioning the excess secretions out of her lungs, she had been successfully extubated several hours before I arrived to work my nightshift. She remained stable overnight, demonstrating sufficient ability to breathe for herself. So just before the dayshift arrived, we planned to move her out to the floors – to share her husband’s room. A nurse and I went out to make sure the room was properly setup to receive Mrs. Singer. Upon learning that we were about to move his wife in with him, Mr. Singer, who had been reading a newspaper, put the paper down, frowned, and emphatically stated, “That hasn’t worked in fifty years. What in the hell makes you think it’ll work now?”

I also remember that everyone who worked in that hospital (because word spread quickly about the frequency of certain kinds of cases that turn up in the ER) knew to NOT eat at The Big Show Casino. But as far as hospital stories go, that’s about it.

Reno, however, is something else again.

In some ways, it really did live up to its self-promoted title as “The Biggest Little City in the World.” The indoor shopping mall I sometimes visited, which seemed perpetually deserted, exuded the charming if perhaps overly optimistic commercial ambitions of small-time developers with big time dreams, while casino row stepped it up several notches by ostentatiously red-lighting anything you could possibly want at any time of day or night. (Not that I was able, hard as I might try, to confirm the ready availability of everything I could dream of in a mere three months.) In between the cute, shopperless mall and the bedazzled corporate casinos lay a legion of local, mom-and-pop bars, all offering their own gaming options and all competing for the same entertainment dollars. A common ploy to attract customers was free food. Had I wanted to, I could have eaten well and for free every day of the week.

For me, however (as I believe was the case for most of Reno’s permanent residents who did not actually work in them), the casinos were more like something to be tolerated or even avoided than something to spend your time on – kind of like wild-eyed second cousin Gus who, despite making your kids giggle, somehow always made you want to keep both your distance and your hand on your wallet. Living in Reno offered other, more desirable diversions. At almost a mile in elevation, it straddles wetlands and high desert at the base of the Sierra Nevada Mountains. Nearby attractions include skiing, world-class fishing, ghost towns, eerie rock formations, abandoned gold and silver mines… The view of The Sierras from my balcony was breath taking. Ten minutes after walking out my front door, I could be cross-country skiing on the slopes of Mount Rose. And another 20 minutes of relatively easy skiing took me to a spectacular view of Lake Tahoe. (I agree that both those time estimates seem low. But that’s how I prefer to remember them, which does not mean they are significantly wrong. Besides, in case you haven’t yet noticed, time can be a fickle companion.)

I did a lot of cross-country skiing that winter in Reno. There was a State Park just over the border into the California side of the Sierras that had a groomed cross-country loop trail with gentle enough elevation changes to allow for consistently fast skiing. And ski fast, I certainly did. Perched next to the start of the trail was a little ski hut that had a porch where folks could rest, or eat lunch, or just hang out. How I remember it is, I would zip past that hut so fast and with such proficient technique that the people on the porch would stop and stare – with admiration rather than amusement, I think. Certainly I was in the best shape of my entire life.

Here’s why I stayed in Reno for only three months. Remember that sweet deal they made me where I worked 36 hours over four days but got paid for 40? Two months after enticing me there with that offer, they yanked it right out from under me. I would have to work an extra day and four extra hours to get the same pay. The Respiratory Therapy department was not responsible for this decision. It came entirely from the hospital administration. Did the growing influence of MBAs on American health care have anything to do with it? I don’t know. But in my conversation with Human Resources, they unapologetically affirmed that whereas they felt no responsibility what so ever to honor their end of our agreement, I must honor mine, which made me feel disrespected – even defiled.

Some will say that I was over-reacting, that it was just an unfortunate circumstance that they really could do nothing about, and that I should just be meekly happy to have any job at all. Based on what I have observed over decades of evolving employer-employee relationships, I think that attitude is largely the result of the powers that be promoting a lowering of the expectations people have as workers from their jobs (and as citizens from our government). To me, both then and now, an individual, and an institution, is only as good as their word. And even worse than a broken word is a word broken with no remorse at all. And I think it is tragic how willing we have become to accept the disrespect of broken promises and insincere excuses.

The agreed upon relationship between me and that hospital was over – they ended it. And the new relationship they wished to impose on me was unacceptable. I called my friend Jake in Portland to see if he had a line on any jobs up there.

A few words about Jake. In the Respiratory Therapy School I attended, every first year student was assigned a second year student as their mentor. My mentor was Jake. After I graduated, we worked together at Parnassus University Hospital. One night when we were both in the PUH ICU, there was a very sick patient with a Swan-Ganz catheter in place (which allowed sampling of blood from the patient’s right heart – the part of the heart that takes blood that has returned from the body’s periphery and pumps it into the pulmonary system where gas exchange with the air we breathe can occur). They had been tracking this patient’s Cardiac Output (“CO” – the amount of blood pumped by the heart per unit of time), which can be a very valuable piece of information to have. But something wasn’t working right and the Docs were bemoaning the loss of their ability to keep track of the patient’s Cardiac Output. Jake pointed out to them that even though the technology they’d become accustomed to relying on to track CO wasn’t working, because the ports in the Swan-Ganz cath were still functional, they could get all the data they needed to calculate CO. There were a few moments of stunned silence while the MDs and RNs (some of whom no doubt still thought of RTs as “oxy jockeys”) wrapped their heads around having been taken to school by a RT.

When I called Jake, he told me that the hospital where he then worked (The Medical University of Oregon – MUO) was hiring RTs and was a pretty good place to work. So I arranged an interview, drove up there, and was hired on the spot. (This would not happen today. That process has now been greatly complicated by Human Resources professionals.) I drove back to Reno, worked the one shift remaining on the then current schedule, and moved to Portland, Oregon. I would have preferred to give at least two weeks notice. But HR in Reno made it crystal clear that even though they broke our contract, if I did not complete at least one year of employment, they would dock my pay to recover what they had spent to move me there – which meant I wouldn’t get any pay at all for the two weeks I would work if I did give them that notice. Screw me once – shame on you. Screw me twice – shame on me. So I only worked that one shift before leaving, knowing I would never get paid for it.

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