Lambs to Slaughter

On the limits of education

An elaboration on Paging Doctor Gorman.

I belong to a Facebook respiratory therapy group, which has a mix of old pros swapping war stories and RT school students looking for help and advice. Occasionally, somebody will post a practice question for students. Sometimes, these questions make me wince, laugh, or scratch my head. An example that sticks in my memory, some details vague with the passing of time:

An elderly male patient presents to the ER with severe shortness of breath, hypoxia, and cyanosis lasting the past several days. He is pursed-lip breathing, has retractions, and just generally looks like hot buttered arse. He has smoked a pack of cigarettes per day for the past forty years, blah blah blah … his PFT results were as follows: FEV such and such before the administration of bronchodilators, a better number after.

Some of that is maybe a wee bit exaggerated, but I distinctly remember the original mentioned cyanosis, which is to say this dude was turning blue at the extremities from lack of oxygen. The question then says we took this cyanotic old man—who in a real setting would be eyeballed for about two seconds and stuck on a BIPAP¹ so he didn’t code, diagnosis TBD—and subjected him to Pulmonary Function Testing.

What.

I have seen pulmonary function testing only a couple of times. It involves a very chipper RT, usually with a special PFT certification, sitting you down in front of a big machine with a tube you wrap your lips around and telling you to BLOW BLOW BLOW BLOW BLOW BLOW BLOW as hard as you can KEEP BLOWING KEEP BLOWING KEEP BLOWING and you give the RT a death glare because you don’t have enough air in your lungs to tell her you don’t have any more air in your lungs. That’s typically done with a basically healthy and stable patient, to diagnose their lung condition.

The idea of a patient in dire crisis actually doing a PFT is outright comical. This patient being a man, I envision him staring at it, uncomprehending, for a long moment, then looking at the RT and saying, “fu … hu … hu … huuu … huuuck … y … y … you.” Old COPD dudes be like that. If the patient were female, women generally being more agreeable, and ladies of a certain age being raised to be ladies at all costs, I would expect her to do her best because a medical professional was trying to help her, and then go into cardiac arrest in the PFT room².

Why does the “practice question” ask such an absurd thing? Because the goal of RT school is not actually to prepare you to be an RT. No classroom can do that. The goal of RT school is to prepare you to pass the Clinical Simulation Exams so you can be an RT and learn how things actually work. And the CSEs do not clinically simulate the work of an RT. They clinically simulate being the most unimaginative and anal-retentive doctor in the universe, running off a checklist at the Lake Woebegone Hospital where all the patients are above average. I passed the CSEs with the help of Kettering Seminar, where a lecturer walks you through a very fixed method of passing this test by selecting answers in a specific order. Don’t get me wrong, Kettering was good value and it vastly improved my performance on this test, but the test is infamously stupid and out-of-touch.

The practice question asks you about PFTs because its purpose is to shepherd scared and overwhelmed students through a diagnosis with every possible clue they can give, and PFT results are used to diagnose COPD so if they miss the part where he smokes like a steamship and his lungs are hyperinflated on X-ray and his ABG says his blood is so carbonated it fizzes like Coca-Cola, but they happen to still remember the thing about PFT results … they will select the right answer. Then they will feel more confident and clever and ready to face the test. That PFT results are realistically impossible to obtain, and that the average ER doctor might physically strike you for suggesting it under those circumstances? Beside the point.

The official test, of course, is written by people who may not have ever worked in a hospital, assuming no real-world friction or limitations, and assuming you will do things according to the most conservative and lawyer-proofed protocol imaginable³. CSE patients never refuse to cooperate, CSE doctors are always promptly available, ABG sticks never miss, your attention is always undivided, clues are never overlooked, the patient is truthful and has an excellent memory about their medical history and how they got here, and healthcare is generally administered as if sick people were busted cars waiting at the mechanic’s shop.

Then you graduate and go to work with actual responsibilities and drive home every day for six months trying not to cry because you went to all that work going through school and you studied hard and did flash cards and you burnt out working full-time at the restaurant and watching your kid the whole time and now you thought you made it and it turns out you’re too stupid and useless to actually do the job YOU MISERABLE FAILURE⁴.

This is not a rare thing. That Facebook group sees at least as many “please help, I think I wasted two years of my life” posts as it does asinine practice questions. I saw such a question just this morning, and was part of a mob of RTs assuring this person that really, they’d be fine. All this was just part of the customary baptism by cayenne-laced napalm that every new RT goes through. In some bizarre way, all that is the system working as intended.

Coincidentally, a lot of RTs will quit after a couple of years, if they make it that long. I know at least a couple of my classmates have gone back to nursing school—though I think they do the same thing to nurses. The grass is always greener, and all that. There aren’t that many RTs in this country, and the field skews old; at 42, I believe I’m maybe the third or fourth youngest person on day shift at my hospital.

This is far from the worst problem in health care, but a little mercy would go a long way.

1. I believe I’ve mentioned BIPAP before, but not gone over it in detail. It can be done for a couple of reasons, but in this context you can think of it as the thing we try to keep a seriously ill patient off the ventilator. It’s a breathing machine that works with a very tight mask instead of a tube down your throat.

2. This is a naive expectation based on typical results, assuming the old lady is the genteel sort who smokes Virginia Slims or Misty while playing Hearts with the girls after church on Sunday. If, on the other hand, she is an archetypal mean ol’ hag with shoe-leather tanned skin and a pack of Marlboros stuffed down her bra, she will be as salty as the saltiest old man, and may try to hit you if she has the energy. It all depends. I do not subscribe to simplistic gender essentialism.

3. Another example: if the patient survives his PFT to go on a BIPAP, his settings will invariably be 12/6. If you don’t know what that means, don’t worry, the guys who made the test might not either. They just know that everybody starts on 12/6, even if they weigh 350 pounds and that level of pressure will have about the same effect as the patient’s elderly wife at bedside nagging him, “Breathe deep, Frank. The doctor says you have to breathe deep, Frank. Do you hear me, Frank? Take nice deep breaths, Frank. No, deeper than that. Frank! Are you listening?”

If you really, really need BIPAP, I’ma take your phone, start up “Welcome to the Jungle” at the highest volume, strap down that mask like it’s A Clockwork Orange, do some insane settings like 24/5 with a rate of 24 and an i-time of zilch, and, time permitting, scream in your face together with Axl, “DO YOU KNOW WHERE YOU ARE? YOU’RE IN THE JUNGLE, BABY! YOU’RE GONNA DIIIIIEEEE!” I’m not playing around. I have too much work to be dragging you down to the ICU to intubate. I’ll know you’re better when you wake up shouting and rip the mask off.

4. I’ve had suicidal ideation exactly once in my life, on a drive home from work in my first year. I felt like I’d failed everything and maybe it would be better to swerve into opposing traffic. Fortunately I was still rational enough to realize that this was not how I usually thought and that I shouldn’t do anything rash. I’d skipped lunch that day, since I was behind on everything and it was too busy. I decided to keep going out of esprit de corps—a condition that far more frequently afflicts nurses, but it hit me that day—and tough it out to show my commitment to helping patients. I’m not diabetic, but I’m pretty sure my blood sugar was in a deeply weird place by the end of that twelve-hour shift as I drove home. I have “skipped lunch” since, but always in the context of shoving down some snacks in an odd minute here or there. Lesson learned: la feu tue, and there is no amount of dedication that can overcome the brute limitations of physics and physiology.