5 top tips for Sputum - Harvesting the Prairie Oyster

Finishing the cardio placement tomorrow... and it has been good. For some reason, cardio seems to be lower stress, even though some of the patients have been a lot closer to death's doorstep than any I saw on the neuro prac.

One of the arts that I have learnt by doing is that of getting the patient to 'cough it up': 'harvesting the prairie oyster'. Here are my top tips for harvesting good gob:

1. Adapt the ACBT:
At school, we were taught a standardized version of the ACBT; but in practise, it gets modified quite often. For instance, if a patient goes through the first cycle of TEEs and you can hear the rattle of a good goober in the pipes, why would you go through another set of TEEs, huff and cough? What is the patient going to do, balance the little jewel on his tongue while he goes through the rest of a standard cycle? No, she will swallow it! And what a pity, you lose the chance to see how the lungs are doing (is it like pea soup?... infection! White & frothy?... possible pneumothorax!), to say nothing of that satisfying entry in the notes: "E/ pt produced 14 Tbsp.s thick++ creamy golden" (it is all about volume...).

2. Listen for the loogie:
You can hear when a patient is hiding treasures in the airways (even without a 'scope). Just think back to how L.R. , a 26y.o. female PT student, presented in the first year of the programme: you knew she was packing. So when you hear that rattly, 'chunks-are-coming' tone to a pt.'s exhale, skip the rest of the ACBT and go straight to the cough. (it's funny, thinking back to visiting the Dr. for a sore throat and being asked to cough, you wondered 'Why?' - now it is so obvious).

3. Grease the wheels:
To move anything, you need lube. If a patient has a dry throat, you aren't gunna get anything out of her. Imagine my chagrin when they put A.S., my top producer, on thickened fluids - he went from being an easy Tbsp. per-session-man to "np" (that's 'non-productive' for you musculo-heads). And then the Doc wants three sputum samples! The solution was easy. A.S. is a compliant, reasonable man: he understood that he wasn't safe to swallow water, but given how dry his throat was, he happily promised not to swallow in exchange for a sips of water to wet his whistle and then spit. Sure enough, the Doc. got three specimen jars of premium caramel custard.

4. Watch for the swallow:
Early in the prac, I often found that patients who had a moist++ cough and audible secretions on Ausc. would not produce. After a while, it seemed obvious that they were swallowing the goods. Many patients won't admit it, thinking it is too disgusting. So the trick is to watch their throat after a cough - you can see if they are swallowing.

5. The secret weapon:
Apple juice. For some reason, a sip or two of apple juice and the pt will double their production. The once thing you have to watch for is that it changes the colour of the final product.

Which brings me to my reflective question: more than one pt. reported that they always have more secretions after eating or drinking. What have the rest of you found? Is the after-lunch harvest better?

(dedicated to T.G., GEM 2008's very own sputum queen).