Respiratory Therapy Cave

Blogging from work: the Unwritten Internet Code

2008-05-11T19:41:00.016-04:00

The Internet is so amazing. All the information that's on here has probably doubled my wealth of knowledge, and places a world of resources right at my fingertips. So when I learned eight years ago that some computers here at work had access to it, I begged the RT Boss to put it on one of our computers. He obliged.

It's neat, because every time we have a patient with a disease we are not familiar with, or we simply want to do a review of a disease we already know about, the information is right here. It's also nice to use this World Wide Web as a resource of staying up to date on all the most recent respiratory therapy information.

It was right here that my co-workers and I did much of our research when we were putting together our protocols. And the information we didn't get off the world wide web we obtained through emails and even a few respiratory related chat lines. I've also used this to put together hospital policy among other things.

So, by far, this Internet has benefited this particular department a great deal.

Yet, there are times when it gets slow around here, and during these times some of us RTs like to get on the Internet and play around. I think that I'm the only one who blogs, but I know some RTs here check their emails, shop or read the news or latest sports scores. It's simply a great resource.

Now I have seen notes up in other departments that say something like: "NO DOWNLOADING GAMES," or "NO WATCHING VIDEOS ONLINE." But we all ignore those notes and do those things anyway. We do so even though we know the powers that be can watch every one of our moves on the mainframe in the basement if they so chose to do so.

I know this has been done before. In fact, I know one tech who worked in ER was fired because the powers that be learned he was watching porn. That was an isolated incident I am certain. However, I know in doing RT searches on Google, porn sites have popped up on this screen on rare occasion. I click off as fast as I can. That's one of the side effects of using Google, you can't control what might come up on a search.

There have been problems on occasion that have come up. For instance, this computer got bogged down about five years ago, and I was blamed for it. The RT Boss told me that I was downloading stuff onto this computer. So, for about two years, we lost the RT Cave Internet.

I never said a word. I let the boss blame me for the computer jamming up, even though I knew one of the new RTs was the one who was downloading non-respiratory related stuff. In fact, I watched my friend do it and told him not to. But he was arrogant and told me it wouldn't matter. Well, it did. And, soon enough, I had to go down to the computer lab to play on the Internet instead of doing it here where it is convenient. Like the old saying goes, where there's a will there's a way.

Since then we have our Internet back. And there have been a few problems here at work on occasion, but for the most part we all play on the Internet, including the bosses, so we all usually keep our mouths shut, including the bosses. Lord knows they play on the Internet too.

Now, the reason I bring this up is that before we had the Internet I used to read books when it was slow. I still do sometimes, but most of my free time now is spent right here reading the news, sports, or blogging. It's not like I'm on here playing games or looking at porn, or doing this in lieu of taking care of my patients. No, because the patients always come first.

I don't like to waste my time playing games, however, I would imagine that probably most of the time the net is used by other bees it's for this purpose. Personally, I think playing games is a waste of time. But that's just me. Still, so long as your work is done, and that you follow the unwritten rules that I will list below, I see no problem with using the Internet to play games.

I like to think of it this way, if I wasn't on here reading the newspaper for free on the net, I would be reading the newspaper I bought. If I were not on here reading a short story, I would be reading a book I bought. If I were not on here watching an NCAA tournament game I would be watching the TV in the waiting room. And none of those things are trackable.

There are some unwritten rules that we Internet users tend to follow:

No playing on the Internet for non medical purposes in site of patients. This makes us look like we are not respecting the patient. It simply looks bad.
No downloading, unless it is absolutely medical related. Or unless you are absolutely burned out and figure the hospital owes you this time.
No going online when there is other work to do, particularly work that involves the patient.
Get up and tour the hospital every hour and check up on all your patients. This is particularly important on those days when it's REALLY slow
If you are paged, get going right away, don't worry about finishing up what you are doing on the net. This is the same for those who read books: if you are paged, stop reading and take care of business.
Don't go on the Internet when there is someone around you don't trust. If they happen to be a spy for the bosses, you will find yourself in a predicament. And you all know who I'm talking about.
Don't go online when the bosses are around, even though you think you can trust them. You certainly don't want to provide them with an opportunity to cause trouble.
Do not check your emails unless it is from someone you trust. This is perhaps one of the most important rules.
If you print something, do not leave it on the printer or in the office.

I had to add #9 to this list for personal reasons. I had a really good freind who downloaded offensive jokes and left them on the printer. Someone on the day shift found them and put them in the bosses mailbox. The worst part about it was his name was on each page, and he was fired.

Personally, I think there is nothing wrong with reading the news and sports or even checking on your fantasy baseball team or even your email, so long as you follow these unwritten rules. If nothing else, this makes you smarter, and provides you with information you can use in a conversation with your patients.

Most RTs, however, probably don't have time to blog at work. The day shift RTs here certainly can't surf the Internet while the dragons and doctors are around. And RTs who work in large big-city hospitals probably don't have time either.

They have to wait till they get home. But some of us don't have time when we are home, so we'd prefer to blog at work. Yet, sometimes, bosses can be stingy, as was the case with Djanvk over at RT Driven. And he works in a small town RT Cave just like Shoreline, so he should have plenty of time to blog.

He wrote a post for the first time in a couple months yesterday, and explained his absence this way:

"My hospital started blocking personal (BLOGS) sites from viewing on the Internet so I wasn't able to log onto Blogger here and post anything because I usually did it from work. Home has been a bit busy and there just wasn't enough hours in the day to do much posting."

Why would a hospital go through the effort to block blogs? How rude?

In fact, one of the reasons I started my RT blog was because since I needed something to do during down times at work, this would allow me to spend my time actually reading medical stuff. And there is a lot I have learned from reading medical blogs. So why would the RT Bosses want to stop me from learning RT stuff.

So, that in mind, I see nothing bad about Djanvk working on his medical blog while spending time in his RT Cave, so long as he follows the Unwritten Internet Code.

If one of my readers is an RT Boss, or if you happen to see something here that I'm missing, please feel free to let me know via comment or email.

Congratulations to myself on 10 years served

2008-05-10T09:56:00.005-04:00

Can you imagine working for the same place for 10 years and still moving up barely one notch on the totem pole? Well, that's exactly where I stand right now after 10 years working at the Shoreline RT Cave: 2nd to the bottom on the totem poll.

Yet here I am, still working the same night shift hours, at the same hospital, with the same boss, and relatively all the same RT co-workers. I can honestly tell you that this here RT Cave has the lowest turnover rate of any department at Shoreline, if not any department in the country.

It is so that I have been next in line for a day job for eight years now. And, likewise, it was eight years ago that I managed to move up a notch on the poll. Yet, since five of my co-workers are either 60 now or closing in, I imagine when one domino falls, there will be several.

It is such that I might go from 2nd to the bottom on the poll to 2nd to the top in a span of five years or less.

Yet, my boss, I think, is only 52, so that means that I will have no chance to take up his job for another eigtht years. I'm not saying I'd want his job or anything like that, I'm just saying.

I approached the Country Club yesterday for the awards banquet not dressed in a suit, and not wearing a tie. In fact, I never even tucked in my shirt. I mean, why should I if my wife doesn't make me.

This is normally my weekend to work, so while I worked Thursday night, I had to take Friday off to attend this event. Despite getting a whole four hours sleep, I was quite exhausted and not necessarily in a social mood.

Thus, in the parking lot, as we were approaching the door, I said to my wife, "I pray I can get inside, get to the bar, get a drink, and to my table without anyone talking to me. I don't want to talk to any dragons."

My plan, however, did not work.

I got inside, went to the bar, got a drink, got my picture taken for posterity purposes, and then attempted to sneak past the dragons to my table. Yet I was waylaid by a swarm of dragons with their prettiest and most political smiles on, all dressed in their best suits. To run would be unacceptable, a cowardly move. I had no choice but to communicate.

I survived. In fact, I came out of the ordeal with one extra drink, as the RT Cave dragon promised to buy my second whisky and Coke. I managed my way through the crowd of familiar and unfamiliar bees (bees are co-workers and dragons, if you haven't guessed, are bosses) and found a spot way in the back.

It is a major side effect of working nights to be out of the social loop. It's not just that we are working while every one else is socializing, but when we are not working we are usually trying to recuperate from working the nocturnal shift.

So I sat there, drinking my whisky and cokes. Hoping to be buzzed just enough before that moment approached when I'd have to walk up through the swath of bees to the swarm of dragons up on the stage to collect my reward for years served at Shoreline.

The food was excellent as usual, and unfortunately it shaved off some of my buzz, so I had to order another one. I didn't want to be drunk per se, but just buzzed enough.

And, finally, after waiting for all the five year awards to be handed out, my turn arrived -- three whisky and cokes later.

Once again I survived.

Back at home after socializing for a while, I looked over my package. Inside was a plaque with my name on it that states "10 years of Service at Shoreline." I cannot wait to hang that up on the wall over my TV for all my household visitors to see.

Well, actually I don't know what the hell I'll do with it. I don't know what they expect us to do with it. It seems it's something more to hang on the wall of the RT Cave than on a wall in my home. But either way, it was a nice gesture.

The other thing we got was a booklet to choose any gift we wanted. My wife googled the gifts and learned they priced between $100 and $200 a piece. Needless to say, this worker bee is going to pick something of the higher price range, as I don't want them getting off on the cheap.

Well, congratulations to myself on ten years served at Shoreline. And here's to another ten, at which time I will have an opportunity to choose a nice TV as my prize.

RT Cave Lexicon

2008-05-09T22:37:00.008-04:00

Dragons: These are the bosses or hospital administrators. If you want to learn more about these unique individuals click here, click here and then click here. These individuals all where suit coats, and will usually present with smile and, of course, they will want a hug or a hand shake. They love money. Everything is all about money. They want every i to be dotted and every t crossed so as to make as much money for the hospital as possible. They want to keep the worker bees just Happy enough so they want to keep working, they also want to make sure money keeps flowing in.

Queen Mother Bees: These are all the supervisors. They take the heat from the worker bees so the dragons don't have to deal with piddly little things; like things that don't involve money. One of their biggest responsibilities is doing the schedule, and they often get pounded by unhappy bees if the schedule is not to the respective bees liking. While they get paid just a smidge more than worker bees, they get paid way less than the dragons. Yet, while these are usually aspiring dragons, they do not complain. Now, it also must be noted that Queen Mother Bees are often in a money mindset just like dragons. For example, you are not allowed to have overtime, because the farther under budget she keeps the department, the bigger the dragon's bonus at the end of the year. This is probably the most stressful job in the hospital and the least respected, as while the worker bees come at her with their problems, the Queen is also getting constant "heat" from the dragons to keep the department under budget. This is actually a lose lose job. But someone has to do it.

Worker Bees: These are all the Peon RNs, RTs, environmental experts, computer whizzes, x-ray techs, lab staffers, and all the other individuals who swarm around the hospital making the place look good so the dragons can make their annual bonuses.

RT bosses, admins think on different level as RTs

2008-05-08T22:10:00.022-04:00

I can kind of understand why the administration here at Shoreline has been having conniption fits lately, and why they have been clamping down on on us lately, as I come to work today to learn there is an entire patient floor closed due to lack of patients.

As I wrote in a previous post, the size of this hospital is too small to be considered a large hospital, and too large to be considered a small hospital. As we are too small, we don't make enough money to be able to have extra staff on hand, which should explain to you why I have to work alone on nights regardless of whether I have eight patients on my board, or 22.

We are too large to receive government grants. Which is funny, because when I used to work at Death Line Medical Center, which is about 40 miles from Shorline Medical, I never could figure out how they could afford to have two therapists during the day. The RTs there never got called off, even if there was no work. When I worked there I was told, "If you are scheduled, why would the place call you off?"

Well, here at Shoreline, when it's slow, people get called off work. So how could these two hospitals so close together have such a different view on when to call workers off? I'll tell you the answer, Shoreline is located in such the perfect (or imperfect) location where we have just enough more patients than Death Line that we are over the line that would classify us as a small hospital. And, since we are over that line, we do not qualify for government grants.

So I suppose when the patient load is down, like it is today, workers get called off. The surgical floor and the step-down unit have both been closed, and, of course, all the staff that usually works over there are getting called off. While over at Death Line, even though their census is down too, well, they continue to make their paychecks.

That's just the way the medical field is. In September and October, if you remember from my posts, we were so slow for so long I wondered if it would ever pick up. Then from November through May we were so busy all the staff here was getting burned out. Now the cycle has come full circle, and we are excessively slow again.

So, I can see why the administration would make a big deal about a few miss charted treatments. If we were busy all the time like some big city hospitals, then I don't think the administration would have the time to worry about the minor things. If we were small, and the hospital received extra money from the government to cover its debt as is the case with Death Line, I don't think it would matter either.

But, since Shoreline is not small and not big, the administration spends that extra time looking at all the statistics. They get bored and instead of taking care of more important matters, they sit around double checking all our charting to make sure we dotted all the i's and crossed all the t's. The get nit-picky. And sometimes they make decisions that they see as for the better of the institution, yet they forget to involve us in the process.

And that, my friends, is why some RT departments might develop a low morale from time to time. The admins don't intend for morale to dip, but it just does. It does because the staff feels like the admins are making a big deal out of spilled milk. And, quite frankly, they are making a big deal out of spilled milk. But, as more and more smaller hospitals are merging, or closing their doors, Shoreline has managed to stay afloat -- alone. So, perhaps, this little nit-pickiness is a necessry component of independence.

Now, whether this battle to maintain as an independent hospital works to the advantage to us RTs or not I have no clue. Part of me thinks it would be bad. But, the other part of me thinks that if we merged with Aero Medical Center, that we would all get nice hefty raises so our staff would be paid as well as their staff. As, being a smaller hospital (not small enough, not big enough), the administration here will not even consider the idea of giving us all hefty raises.

But why would they give us raises? All the RTs in this department have been here so long we are all complacent. We have worked here so long, have so many friends here, love it here so much, are comfortable here, that we wouldn't go anywhere else to work. In a way, that's true. I am comfortable here. I love it here. I have many friends here. I'm complacent. And, while I could go somewhere else, I don't. It's far easier to stay here. Besides, if I decided to take another job, at Death Line for example, I'd have to drive. That's wear and tear on my car, and, hell, with gas prices at near $4.00 a gallon, I'm better off staying here, where my drive is only five minutes.

And, with 10 RTs here, and all of us in relatively the same boat as me, the administration can afford to push us a little bit. And this, what I write today, is some of the mentality behind the administration forcing our RT bosses to crack down on our charting, making a big deal of little errors, and make an attempt, as my fellow RTs and I like to put it, to make us perfect.

While I do have a bachelor's degree in business, and an associates in respiratory therapy, I still don't know as much about hospital administration as some of you guys. If I am ever to move up the ladder and become one of them, there is a lot I have to learn. However, I would imagine that my analysis here is not too far from reality.

Usually here at Shoreline the morale is high. Usually, all we little RTs and RT bosses and administrators get along. Some of us get along in close little friendship type relationships, and some of us in good little business relationships. Some of us, like me, have a combo of the two. But on occasion the administration pushes our buttons just because they can. And slowly but surely the morale will decline. The morale will decline until someone gets tired of it all and mossies on into the RT bosses headquarters for a little chit chat.

Then, once the RT bosses realize that they pushed us a little too far, they back off. Then morale starts to climb. Then things get back to normal for a year or so until someone in the administration gets another idea, and the RT bosses, or the administration itself, pushes us over that line again. They will wait just long enough so they think we forgot the last time they tried to cross the line. But we are smarter that: we don't forget.

I've worked here long enough now to know this is how it goes at a hospital that's too big to be small and too small to be big. That's just how it goes.

Tonight I came to work with a self diagnosed acute exacerbation of chronic laziness. I feel this way not just because I had too many days off, but because the patient census is so low again. Now, I'm not making a big deal about this, because I love it when its slow because I get paid to blog, as I'm doing now. And perhaps I blog too much, but you guys can be the judge of that. But the downside of a low census, as I've already explained, is that the admins get all stressed out. And when the admins get all stressed out, so too will the RT bosses. That's just how it goes.

This time around, it was my turn to let the RT bosses know they went too far. I had my little chit chat with the head RT boss. I had to tell him that morale was down. That it was so bad that even people in ER were asking me about the "tension" in the RT Cave.

"What?" he said. "I didn't know tension was that bad?"

Well, guess what? There ain't no tension anymore. While the RT bosses still want to improve our charting, improve the little things, they have backed off. It's like clockwork. I know these guys like the back of my hand.

Sometimes, as I sit here thinking about it, I think I could do that job and better than those guys. I think if I were the RT boss, there would be no lack of communication, particularly because I've worked here on nights for 10 years and I know what it's like to be on this end and I'd have empathy.

Then again, both RT bosses were RTs once upon a time. They are both dragons now.

Then again, I think that once I cross over and become an RT boss, I will slowly but surely turn into one of them. I will slowly turn into a dragon. I will slowly forget about simple RT mindset, and start thinking in terms of money. For RT bosses, money is the bottom line. And money can do a lot of damage to ones mind. Hell, just look at Hollywood for some good examples of that. RT bosses aren't' far removed from that crowd. They get a little wacky sometimes. They don't think rationally. I'd like to think I'd be different if I were an RT boss, but would I?? Who knows.

Now, getting back to the size of this hospital. Death Line has remodeled all its rooms so that all patients now get a private room. They have remodeled all the OB rooms so there is a hot tub in all the rooms -- and they are all private too. And they have a brand new ER. I've decided they get to do all that because of the government grants, which they get because they are just a little less busy than us and are qualified by the Fed as a small hospital.

Here at Shoreline, well, we are stuck with an ER that is just too small, especially in the summer when all the visitors flush into the region, and an OB that is way too old for modern times, and patient rooms that are too small for all the modern equipment and two patients per room.

Yet, even while we have this old facility, the admins have managed to keep it looking pretty sharp. While we have an old ER, we have a damn good staff. While we have an old, rickety OB, we pride ourselves in knowing we have a far better staff than Death Line. We take care of our patients as good as the best big hospital, the best small hospital, and the best hospital that is too large to be small and too small to be large.

And, for the most part, except for a few bumps in the road, the morale is high here. We are all one big happy family. All the units work well together, and I know it's not like that at all hospitals, as I've worked for some where there was no click between departments. And since we all know oneanother on a personal basis, because this IS still a small town no matter how the Fed wants to define Shoreline.

So, while the admins at this too big to be small and too small to be big hospital can sometimes get a little anal about little things, things that would be totally ignored in other hospitals, they still do a pretty damn good at keeping this place together.

Hell, all they would have to do is go down into the basement and look at the main computer to see that I've been blogging here all night, and they could make a big deal about it -- but they won't. They won't because I hold this RT Cave up while they are away. I make this place look good (except for my little piddly mistakes).

And besides, because I'm complacent here, because I have kids in the local schools I'm trapped in a way in this small town of Shoreline. I come to work every day not just because I want to, not just because I'm a great RT, but because I have to. I have to because the alternative would mean moving my kids to a new school again, and I don't want to do that.

The admins know this. They know this because this is how it is for about 80% of the people who work here. Because of this, and because they know I love the aura here at Shoreline, an aura the admins helped to create in those many periods of high morale, they know they can get me for a cheap wage. The funny thing is I know this, and yet I'm still here. I know their game. I'm just smart enough to know their game.

So they won't say a word to me any more about this little game they have been playing about being perfect. Because, as I told the head RT boss the other day when I approached him in a civil manner, "I do not have to stay here. None of us have to work here. We work here because we love it here, but we do not have to stay here. So let's move on."

And we will. For the next two or three years the admins will not try to push us over that line. And they better not, because I could just as easily go over to Death Line and work for a better looking yet inferior institution.

Then again, they might call my bluff.

New strategy for change in the RT Cave

2008-05-07T09:37:00.006-04:00

In my past few posts I emphasized the problem that has caused low morale in this RT Cave, in this post I will state the proposed solution to improving morale.

Yesterday I told my supervisor I was going to quit. I was serious. In fact, as soon as I got home I downloaded an application to another hospital, filled it out, and then went to bed. However, by the time I woke up I had a more level head on. I was ready to tackle the problem head on. The time had come. I had nothing to lose.

At first I thought my bluff wasn't taken seriously. But, when morning came about, and the hour of 4:00 rolled by and I didn't hear from my supervisor, I knew something was amiss.

And, as I was just about to wrap things up for the day, the head RT boss approached me and wanted to see me in his office. Apparently, the supervisor had told him I wanted to quit, and he asked me what the problem was.

"The problem is simple", I told him, "that I have gone home miserable the past few days, and while I had planned on working another 22 years at this place, I refuse to be miserable for 22 years."

"Well," he said, "How can I make it better for you." Wow. Is that all I need to do to get some attention -- threaten to quit. I suppose the squeaky wheel gets the grease. I'm taking advantage of this.

"The answer to that is simple," I said, "Communication. I think that we all seek the same goal of improving the department, but you guys decided you were going to do something and didn't' tell us about it, and then all of a sudden you expect us to be perfect in our charting. That's simply poor business. Thus, I propose, simply that you better communicate."

I could have sat in his office complaining about how poor of a communicator he is, or how stupid the administration at this hospital is, which is what the RT Complainers may do anyway, but I didn't want to stoop to that level. I wanted this meeting to be productive.

"What do you mean by communicate?" he said.

"Exactly like you are doing right now. You are listening to me, and allowing me to speak. And, I am sure, you will explain to me why you are all of a sudden cracking down and expecting us to chart perfectly."

"That makes sense." And he proceeded to explain to me why the crackdown. He explained economic hard times. While the hospital might be really busy today, it has had many slow days. So, when random procedures don't get charted, that amounts to money that is not made for the hospital.

He said, "Okay, any other ideas."

By golly I did. I rattled off a list off the top of my head:

I would like a 12 hour leeway in which we can do our charting, or fix any errors in our charting.

At the end of the day, I want to be able to print off a sheet that lets us know what we charted, so if we didn't chart something, double charted, or didn't chart something at all we'd be able to see it right then so we could fix it. He thought we had this list already, and I explained we didn't. There, one communication problem fixed.

Another co-worker I talked with proposed that instead of leaving notes every day that we made a mistake, that we create a monitoring system where this data is recorded, and at our monthly meeting we can monitor progress or lack there of. If a certain person has more charting errors than the average RT, then he should be set aside and a plan should be worked out to determine how this might be improved. If the department as a whole is making the same errors, then perhaps a new strategy for charting should be implemented.

After I left his office, I coincidentally picked up a book I had in my basement and read it, considering it was only 174 pages long and pertained exactly to the situation at hand in our RT cave. The name of the book was The Effective Executive by Peter Drucker.

In this book he talks about a model for effective executive leadership. It shows a way to turn a failing model around into a successful model. And, considering the new policy in our department that attempted to make us RTs perfect on a dime, and that resulted in excessive complaining, animosity and low morale, this situation was on my mind as I read the book.

According to Newt Gingrich in his new book Real Change, Drucker's strategy goes something like this:

What do you VALUE?

What VISION of success do you have for achieving what you value?

What METRICS would tell you whether you are making progress toward your vision?

What STRATEGIES would enable you to achieve your vision?

What PROJECTS would enable you to implement your strategies successfully?

What TASKS have to be done well to complete each project?

Before I left his office I cracked a joke to lighten up the atmosphere, and then I told him I felt better now that we communicated, and I thought it would be a good idea to communicate like this with the rest of the staff as well. I was impressed when one of my co-workers called me to inform me she was to have a meeting with the boss later in the day, as has every other RT in the Cave.

"What the heck did you tell him," she said.

"Everything," I said, "What did I have to lose."

We value more communication and good morale in our department. We want back what was stolen from us when this new policy was enacted. Our vision of success is involving the entire department in the decision making.

Jane Sage is the one who thought of a strategy for metrics, and this is her idea was to create a monitoring system that showed us what we were doing wrong and whether it was the entire department or if some of us were more more prone to making mistakes than others, and what exactly were the mistakes.

Metrics is more than just the statistics that are pounded on us at each department meeting, statistics that show ups and downs in the monthly financial status, or how well the hospital is perceived within the community, or the RT department for that matter (as a side note, we are viewed as excellent on a regular basis).

While the statistics can show some trends, statistics cannot show morale. Likewise, statistics can become stale. Thus, having good metrics is a far better means of solving a problem.

By my meeting with the head RT boss I listed some of my ideas for improving the problem. And, as he plans on talking with other RTs, they will list some of their strategies, projects and tasks, and then we will get together in our next departmental meeting an analyze all the information accumulated and try to implement a plan.

Newt Gingrich, in his book Real Change writes that "Albert Einstein had a firm rule for thinking about new solutions. He asserted the following: thinking that doing more of the same will lead to a different outcome is a sign of insanity (Emphasis added).

Thus, even before any of us had read any book on the subject, we were on the right track.

Thus it only makes sense for the RT bosses to implement a new strategy to achieve their goal. This meeting I had with the boss was only the first step, I'll keep you guys updated on how things progress from here.

You can control your own health care costs

2008-05-06T21:52:00.004-04:00

You are responsible for your own healthcare costs. That is why I hereby link you to an excellent post on The Respiratory Report, "Cut your Health Care Costs. This humble blog post will provide you with a few personal weapons you have at your disposal at battling the high cost of medicine, and the importance of battling those who wish to resort to governmental or "universal" health care.

It's your responsibility to make sure you have control of your own health. Please check out the link above. A great post.

Tension in the RT Cave

2008-05-05T21:43:00.008-04:00

What I wrote in my previous post, "New policy enacted to make RTs perfect," was my facetious interpretation of some of the rules the administration has laid down on us RTs in an attempt to improve our charting.

Personally, I think the RT bosses and the administration are well intentioned in their attempt at making us better at charting. Here, allow me to highlight two very important reasons why RT bosses might require their RTs to clamp down and at least try to do a better job of charting.

First one must realize the following:

1) All of our charting is now electronic, and billing is automatically done when we hit file. For example, if an RT does CPT, and forgets to click on CPT when he does his charting, then that is one procedure that is not billed for. Even though this doesn't happen on a regular basis, it still happens. According to the RT bosses, even these little mistakes have amounted to $30,000 in un-billed procedures over the past billing period alone. Especially in these hard economic times, these little errors can be very costly.

2) If an RT is called to court, accurate and complete charting can be of a major benefit to the hospital. We had an instance lately at Shoreline where a case went to court mainly because one nurse did shoddy charting. However, the RTs did excellent charting, and this resulted in the case getting thrown out. (I will write about this later.)

So, these two situations amounted to the administration clamping down on this particular RT department. They simply want us to pay more attention to our charting.

However, the major problem with this was not the general idea, but the way it was communicated to us by our RT boss. The general feeling among us RTs was that the bosses no longer cared about patient care so long as we charted accurately. I must add that this was not true, it's simply how it came across.

I understood the animosity of the department, I listened to the complainers, and even found myself complaining myself. After all, I am not perfect. In my opinion, perfection is a flaw in itself.

However, when I was left a note last week that I forgot to pull a file on an EKG, and my supervisor told me this was "unacceptable." I came back with the following line in my humble attempt to explain to her that perfection is not possible.

"Say, for example," I said, "We RTs do 100 procedures, and our charting is perfect on 99 of those 100. That's a 99% rate of success. Do you consider that unacceptable."

"Yes," she said, "I do."

"99% is unacceptable."

"Absolutely."

"Well, then, what can I say. I guess you'll have to fire us all, because we are all going to make mistakes from time to time."

In a rare occurrence, I found myself arguing with my boss. It's not that I tried to fight with her, I was merely trying to explain to her why the animosity; why the low morale.

Later, in discussing this with my good friend and fellow RT Jane Sage, she explained it this way:

"I have worked here for 20 years," she said, "and for 19-and-a-half of those years no one ever said anything about my charting being unacceptable. Now, all of a sudden my charting is unacceptable. So, what that tells me, is that I was unacceptable for all of those 20 years and no one told me. I've always been an awefull charter, and no one said a word."

Hell, I've even heard complaining from RTs who never complain, so obviously there was something wrong here. So when I approached my supervisor again to inform her of the problem, and that some RTs were already talking about quitting if the RT Boss starting writing RTs up for not being perfect.

As I was approaching her for the third time on this matter, she emphatically told me I was being ridiculous. "This all wouldn't be a problem if our billing wasn't dropped right from our charting. As with many hospitals, we have had some financial bla bla bla bla...

So, in rare form, I told her I was going to quit.

New policy enacted to make RTs perfect

2008-05-04T16:34:00.010-04:00

Shoreline is not run by JCAHO as most hospitals are, but ISO. If you think JCAHO is incompetent and out of touch with reality, consider this new policy ISO pretty much forced the administration to put pressure on the RT bosses to crack down on random errors. The ultimate goal here is to make RTs perfect:

Date: April 28, 2007
To: RT Staff
From: RT bosses
Regarding: New Departmental Policy

To prevent any further wasting of our time trying to deal with pesky RTs and all their demands, we RT bosses have created the following list for the further good of our medical institution:

An RT supervisor will be assigned the responsibility of double checking every single treatment and order to make sure all the i's are dotted and t's are crossed. If there is any mistake, a note will be given.

No matter what the note is for, after every seven notes the RT will get a write up.

All incentive spirometer instructs must be completed within an hour of the order or there will be a note given to the RT notifying him or her of the error. We demand thorough documentation as to why the IS was not done. Failure to document appropriately will result in a note

EKGs, ABGs, Holter monitors, incentive spirometers, treatments are all equal priority therapies and must be completed in a timely manner regardless of how busy the RT is. If any of these are not completed in a timely manner, a note will be left for the RT.

A SOB patient does not take priority over a patient who is not SOB. The excuse that such and such patient needed my services at that time more than the patient who has been here for three months and is still on treatments will no longer work at this facility. If an RT complains this is ridiculous, the RT will be called an idiot and sent home for the rest of the day. He will also be given a note.

All EKGs must be done within 10 minutes of the original page. There will be no allowable excuses such as, "I was busy with a SOB patient," or, "I was at a code."

All Q4 hour treatments must be done exactly every 4 hours. There will be no exceptions. If a Q4 treatment is done at 8:15, the next treatment should be done at exactly 12:15. We will no longer allow a 30 minute leeway on Q4. We will allow a leeway of 10 minutes and no more.

All Q6 hour treatments must be done exactly every 6 hours. We will allow no more than a 30 minute leeway. Q6 hour treatments done 20 minutes late will result in a note.

We will no longer tolerate complaints that therapy is not indicated. If the doctor ordered it, it is needed. Period.

Regarding #11, this includes Q2 hour breathing treatments on a patient who is not having bronchospasm and is in no respiratory distress. If the doctor ordered it, then it must be done exactly as ordered.

If you can't get a treatment done when it is due, you must not ever chart "unable to do," even if this may truly be the reason. It does not matter if you had a code. It does not matter that you had a pt. who was laboring. If a treatment was due, and you truly can't get to it, you must call in help.

You must call in help if unable to do a treatment even if the treatment is not indicated, and even though we know it takes most help 45 minutes to arrive and the treatment must be completed no later than 30 minutes late. When charts are reviewed the following day, a note will be left if the treatment is more than 30 minutes late.

Call in help will not receive time and a half for coming in and helping unless the RT is over the 40 hour mark, even if they would be going above and beyond the call of duty by coming in and helping out the business.

All overtime pay must be pre-approved. It doesn't matter if it is on a weekend or late at night, it must be pre-approved regardless of the reason.

RT Bosses are not to be called after 5 p.m. or on weekends.

If a patient is SOB or appears to have the look of impending doom, your responsibility as an RT is to stay with that patient until he is stabilized. This only makes sense.

There will be no excuses for late therapies. Late therapies will result in a note.

Q4PRN treatments must be assessed and charted every four hours. If you forget to chart why treatment not given, you will receive a note.

For every seven notes, you will receive a written warning.

All notes have the same priority, whether they were because you forgot to chart a med or whether you forgot to chart that a prn treatment was not given.

If you complain about notes you will be given a note.

If you complain that you are burned out because of all the new demands set for you, you will be told that you have forgotten how to work and then you will be ignored for your stupid comment.

If you go over the RT bosses head to complain about stupid useless treatments, you will be ignored.

If you go over the RT bosses head to complain about all the stupid notes, you will be ignored.

If you go over the RT bosses head to complain that all your notes were for silly things like forgetting to chart PRN treatments and it's stupid that you now have a write up, you will be laughed and mocked because we expect perfection.

If you get home and remember you forgot to chart something, too bad: that note with your name on it is already on the bulletin board.

As you might have guessed, this new policy has created quite a bit of animosity in our department. When I got wind of this policy a few months ago I warned the RT bosses this would back-fire on them, and I was right.

I'll let you guys consider the above, and then I'll discuss this in more detail in the coming days. In the mean time, I have a question for my fellow RTs: are your RT bosses cracking down like this, or is it just here at Shoreline?

No Vent, DNR, or full code: what's your choice?

2008-05-02T14:16:00.023-04:00

The decision of whether or not you want to be placed on a ventilator, or whether or not you want to make a decision for your loved one, is one of the most difficult decisions one can make. In fact, this is the basis of some very deep ethical discussions, and one of which may never be answered by society, only by the person who has to actually make that decision.

First let us note here that a majority of patients who go on a ventilator do so only for temporary purposes. If you have surgery, if you have severe asthma, pneumonia, or failing heart, you may need to be placed on a ventilator short term.

If a person is involved in a trauma, or if CPR is performed, then a person may be intubated and placed on a ventilator.

Those are easy decisions, especially when we are in emergent situations and are trying to save a life. However, there are also times when the decision to intubate or not to intubate can be complicated as complicated can get, and very stressful, and often disappointing if not discouraging.

In some cases you can plan ahead and write in your advanced directives that you do not want to be placed on a vent, however, sometimes I have seen this declaration over-ruled at the point of impact when a person is in the emergency room and the person has to decide, "Do I want to risk dying now, or do I want to let these good people here in the emergency room help me breathe by placing a tube into my airway and assisting me with my breathing. Do I want to do that? Do I want to allow them to place me on a ventilator?"

Here I will provide some examples for you. All of these come from real life examples as I have actually seen them in my eleven years as a registered respiratory therapist.

One of the most frustrating examples to me is when a person has decided they do not want to be placed on life support because "I don't want to spend the rest of my life on one of those things," or "because I don't want to become a vegetable." In thinking this way, many people choose the following in their advanced directives: Full Code, Do Not Vent, or Do Not Intubate.

I have to cringe when I see that. I cannot believe any lawyer or doctor or advisor would recommend that option, because when a person's heart stops, and we have to do CPR on the patient, we also have to pump in quite a bit of medicine, and 99.9% of the time the patient does not survive a code breathing on his own: he has to be placed on a ventilator. Thus, if we do CPR, we have to put you on a vent -- there is no other option.

What might confuse people is what you see in the movies. There was one episode of "Walker, Texas Ranger," where Chuck Norris's character was having CPR performed on him, and his friend who broke his arm was watching on. Then Chuck woke up, the ambulance arrived, and the person who was taken away on the ambulance was Chuck, but Chuck's friend with the broken arm.

It does not work this way in real life. The majority of the time when CPR is done on a person, that person buys himself a ventilator. That is, unless you are a DNR. In short, DNR means Do Not Rescucitate. That means if your heart stops we will not try to restart it. And, if you stop breathing, we will not place you on a ventilator. We will let nature take its course.

However, if the people working on you don't know you are a DNR, you will end up on a vent regardless. Not only is that the ethical thing to do, it's the law.

However, I do think the decision not to become a vegetable on a vent is a valid issue for most people. Yet, one also has to consider the definition of a vegetable. Are you a vegetable when you have no body, but your brain is fully functional as would be the case with ALS (Lou Gehrig's Disease) or multi-system atrophy, which is a disease my grandma suffered from at the end of her life, and is a disease like ALS in that the person loses control of his muscles and basically becomes a brain without a body.

Some people value life so much that they would want to live so long as they have control of their brain. That was my grandmas wishes, and I totally understood those wishes. However, there is also the issue of depression and humiliation as you are fully aware that you have a tube up every orifice, and some strange person wiping you every time you have a bowel movement. Not only that, but you have to have someone assist you every time you move anywhere. Basically, you are a mind without a body. Do you want to live like that? Do you value life that much? Some people do. And we medical workers respect that.

Then you have the people who have Alzheimer's. These people will have fully functioning bodies but no mind. No mind no matter, no matter no mind. I would imagine that this might be the best way to end your life on a ventilator, if one had to choose between the two. If I were an elderly person diagnosed with Alzheimer's, I would simply make a wish to be a DNR just so that I wouldn't become a ward of the state, a useless blob of skin on a bed taking up space and absorbing taxpayers money. However that would be my decision, I have to respect the wishes of others who think otherwise. Thus, life is very precious no matter how fragile, and each individual has to decide for himself.

Then, let us consider the COPD patient who decides that he does not want to be placed on a ventilator. He is not necessarily end stage, but he is to the point that he cannot go without using his oxygen. However, he has a quality life to the extent that he is not one of those people who simply sits around and feels sorry for himself. He loves life. He loves living. However, he was also scared by the prospect that he might be placed on a ventilator and have to stay on it the rest of his life. So he makes the decision one day that he will make himself a d0 not vent patient.

Then one day he is having trouble breathing. His wife drives him to the hospital and by the time he arrives there he is severely short-of-breath; his work of breathing is labored. The doctor looks the patient straight in the eyes and asked the question no one wants to ever hear, "If something happens to you, do you want to be placed on a ventilator?"

Of course now the patient is not in the planning stages. He is actually miserable, gasping for every breath. His oxygen levels are falling. His CO2 levels are rising. He is pooping out. He has a feeling of impending doom. He, however, does not want to die; he is not quite ready.

Then again, he does not want to go on one of those things; he does not want to be intubated. So, he asks the naive question that is really not so naive because the only people who truly know the answer were standing in the bright room around him. Of course there were other COPD patients who knew the answer, but they were not in the room. His life, his destiny, was in the hands of the fine medical workers in the room.

"So," he says, huffing and puffing, barely able to get the words out, "How long would I have to be intubated for?"

"Well, the goal would be a day or two, but we really can't guarantee," the doctor explains.

Of course she doesn't want to give false hope, but she also doesn't want the patient to simply give up hope at the same time. This is the ironic twist that we often face in the emergency room. "The goal is basically to rest your lungs and allow them a chance to heal. That's the goal. I can't guarantee anything, but that's the goal."

I stand there thinking, as I am getting my intubation equipment ready just in case the patient makes the decision, that the doctor made a good presentation. In fact, I couldn't have worded it better myself. The key words there were "help you get over the hump" and "I can't guarantee anything."

By these short phrases the doctor threw the ball completely in the patient's corner. And, if the patient were to pass out, into the wife's corner. And if the wife were not there, the medical staff would have no choice but to make the patient a full code and do everything for the patient, unless they were 100% positive the patient was a DNR.

Another case I've seen is the elderly man with a chronically failing heart come into the hospital in respiratory failure secondary to the failing heart. The patient is non-responsive, and he is also not a declared DNR. The wife now is forced to make the decision of whether or not to allow nature to take its course, or to allow the medical staff to intubate her husband and place him on a vent.

"What should I do?" the patient's wife asks the Doctor.

"Well," the doctor says, "I know this is a difficult decision. Since you are in a very stressful situation right now and you want to make sure you don't make the wrong decision, perhaps it would be best to let us intubate your dad, and you can see how things progress, allowing yourself some time to spend with your family and to think, and then in 24 hours you can see how things are going with your dad. Either way, I can't make any promises. It's your decision.

The doctor pauses, allowing the patient time to think, before continueing. "Technically speaking, the goal of going on a vent is short term therapy to allow your husband's heart and lungs to rest. If things work out, he might come off in a day or two. However, I can't honestly say those odds are very likely right now. But, if things don't work out, he very well could be dependent, that's always a possibility. But if it comes to that, you can make a decision to terminate the vent if you wish."

After another pause, the doctor solemly states, "However, if he doesn't go on a vent now, there is very little chance he will survive this."

In this case, the wife decided to place her husband on the vent and the patient came off two days later with full mental capacity. Of course he was limited in what he could do, and had to go home with oxygen. And while his heart remained severely fragile, he was able to spend another two years.

Thus going on a vent "to get over the hump" bought this man two years to say good-bye to those he loved, and allowed those he loved to say good-bye to him.

I talked to the wife a year after he died, she told me she was very pleased with her decision to place her husband on the vent.

One time we had a lady on a ventilator with ARDS, and as she was on the vent for the fourth week, it was becoming evident that she wasn't going to make it. The patient had already been given a slim 10-20% chance of surviving by the doctor.

But the family stood firm with their hope, and prayed the patient would not only come off the vent but have some quality of life thereafter. Even the family was starting to give up hope after a while, though. Then one day, as though by some miracle, the patient woke up and was eventually discharged.

I know that's a rare instance, but patients with grim chances of survival can survive. And while it might be fine to say, "I've seen people like this survive before," you still don't want to give a family member false hope.

Likewise, I have seen many cases similar to my above examples go in different directions. In the medical field, you just never know what's going to happen. And, when you are making end of life decisions, you never know what the right answer is.

There are times, though, where I would definitely recommend a DNR status. These would be elderly people over 90, and any person who has a terminal end stage illness. If you have an 80 year old lady dying of cancer, it would be kind of foolish to place that person on a vent, when all the vent would do is delay the inevitable, and cost the family insurance and taxpayers thousands of dollars in the process.

Yet, I see these people going on ventilators all the time. In many cases it becomes quite frustrating to see these people on the vent for weeks on end. And, this can quite possibly be one of the most frustrating parts of the medical field. Sometimes I even feel sorry for these people, especially when it appears to me they are trying to die, and their family members keep pushing for them to live.

Recently I placed a cerebral palsy patient on a ventilator. He is off now and back at home in the care of his family. The quality of life for this person was already pretty low, but the family loved this young man and truly valued the sanctity of life. We had to respect those wishes, and we took care of him as we would any other patient.

So, if you are wondering whether or not you want to be a full code or DNR should your heart stop, or whether or not you want to go on a ventilator should you stop breathing (and many times those two come together in the same package), you should take some time to consider the what ifs.

It might be a difficult thing to stop and think about, but it could save you and/or your family members a ton of stress in the end.

As you can see, this is not an easy subject matter for anyone, including us in the medical field. And this has been and will continue to be an important ethical discussion for years to come.

Another doctor sees things my way

2008-05-01T23:49:00.002-04:00

When I started out as an RT, I was told when I did an EKG to take it directly to the doctor, even if you have to hunt the doctor down. That was when I was a student.

Then, after I was hired here at Shoreline, and I continued to hunt doctors down, I was lectured by one doctor about how I didn't need to do that. So, for the next five years I did the EKG and put it on the chart, unless it was one that needed to be seen right away.

Ultimately, however, we had a massive Dr. turnover in the ER, and now we have two doctors who require that we RTs hunt them down, Dr. Krane, of whom I work with most often, is one of them. So here I am after doing an EKG, running around like a little kid hunting the doctor down to show him an EKG I know is normal.

However, last week a new doctor (Dr. Click) and the nurses kept ordering EKGs, and I kept handing them to the doc. Then, as I was handing her the 6th EKG in an hour, I observed she had a whole stack of EKGs on the table next to her. And she said, "Rick, you don't need to hunt me down every time you do an EKG. I trust you to know when a person is having a heart attack."

Wow. I was so impressed I thought I could shout with joy. After ten years in this profession, and five years of hunting doctor Krane down, this doctor confirms that I am smart enough to know what an MI looks like.

I would like Dr. Click to have a word with Dr. Krane and knock some sense into her.

What's it like to be intubated?

2008-05-01T00:58:00.006-04:00

As I was looking at my blog statistics, and checking the recent keyword activity that landed someone on my site, I noticed one person had typed in the query, "What's it like to be intubated."

I remember waking up from a surgery once, and this person pulling something out of my mouth. I had no idea until I went to RT school what had actually transpired at that moment: I was being extubated.

So because I was medicated, I had no memory of being intubated, and had no memory of my time on the vent during the surgery. Thankfully, I must add, I have no memory.

Fortunately, I think that is the case for most people who are intubated. I think that we keep them sedated enough that they do not remember much. However, on occasion, we do have to intubate people under emergency situations where there is no time to medicate the person, and usually that person gags and groans during the process. There is no doubting the this is not a pleasant procedure to have done.

Which is why Succiconine is such a great drug, because it paralyzes a person just long enough to get the job done. And then, while the patient is serving time with a ventilator doing all the breathing or assisting with it, a patient is sedated enough with some good meds to allow the person to rest comfortably. And, while the patient is often awake, the meds are good at causing amnesia.

Lots of times I have to communicate with a person on a vent. Of course they can't talk, but you get pretty accustomed to lip reading after a while. Then, a few days after the patient is over the hump and is extubated, you ask them if they remember being on the vent, and they will tell you they have no memory of it. That's not always the case, but most of the time it is.

Occasionally, a patient remembers everything. Some patients are awake, alert and orientated the entire time they are on a vent. It's these people where you can learn the most from of what it's really like to be intubated.

It doesn't always suck either. I remember this one chronic end-stage COPD patient who was extremely short-of-breath. She told me she felt like she was suffocating. The next time I saw her she was on a vent, and she looked at me with eyes of joy. She smiled. She took in a deep comfortable breath. That vent was her savior.

That patient did not want to get off that vent.

I like to explain to my vent patients, if they are at all comprehensive, that they have not been placed on a ventilator permanently, it's just short term until their lungs get better. It's more or less to allow their bodies time to get over the hump. That's the case most of the time. And, usually, the person is off the vent in a day or two.

While I can honestly say that I have experienced much of the things I do for patients on a daily basis, I have never been on a vent; and I have never been suctioned.

One of my co-workers and good friends and fellow asthmatic was placed on a vent once, and she said she remembers the whole thing. She remembers being awake and alert and looking out the window and seeing a Burger King, which sucked because she was starving. And, she said, that wasn't even the worse part. The worse part was getting suctioned. She said there is absolutely nothing worse than that.

That in mind, a fellow blogger who used to be an RT, and who is unfortunately a victim of severe persistent asthma, was placed on a ventilator recently. I thought his story was very inspiring, and I would like to link you to his blog: The Bay City Walker.

Finally a doctor who sees things my way

2008-04-29T23:41:00.007-04:00

For years my RT co-workers and I have been trying to change the EKG policy in the ER so that EKGs are only ordered on people who need them, as opposed to every person who walks into the door with CP, stomach pain, back pain, toe pain, etc.

However, our boss doesn't like to rock the boat, and he didn't want to have to go out of his way to try to convince the ER RNs and doctors that they need to be more specific on who they order EKGs on. Or, better yet, it's all about money, and the more EKGs we do, the more money we make.

And our medical director did a review of the EKGs ordered in ER, and the reasons why they were ordered, and he agreed that there were many frivolous reasons for EKGs being ordered, however he was also reluctant to overrule the ER EKG policy where the nurses get to order the EKG on any patients they think one is needed on.

Yet today I went to ER to do an EKG on a 24-year-old female with CP. To me it sounded like she had a little chest cold or something, but considering I was overruled on my attempt to get rid of these frivolous EKGs, I had no choice but to complete the procedure.

Yet this time, as I handed the EKG to Dr. Honk, he said, "I don't think we need to do an EKG on every 24 year old with CP."

"I just do what I'm told," I said. "The nurses order the procedure, and I do the test."

"Well, Ill have to have a talk with them, because I wouldn't have ordered this EKG."

Awesome, I thought. Finally a doctor who's anti-useless therapies. And now that I think of it, he doesn't order breathing treatments on every patient who comes through the ER doors complaining of a common cold either.

Wow. If Dr. Krane, of whom usually works my nights, was working, not only would I be doing the EKG, but I'd be doing a breathing treatment "to ease that chest pressure." And I'd be coming up with a new name for a new 'olin for the bottom of this blog.

I'll have to have this Dr. Honk talk with Dr. Krane and have him knock some sense into her.

Reimbursement criteria going a bit overboard

2008-04-29T23:24:00.004-04:00

I had to laugh as my co-worker today told me that he was approached by the lady in charge of double checking charts to make sure we are complying with quality management.

The basic purpose of her job is to make sure that charting is as such that we will be reimbursed for therapy. She also has to make sure that the patient meets criteria for payment.

"Hey Dale," she said, "What is it with all these Q4 breathing treatments being given 10 minutes late or 10 minutes early.

Dale told me he looked at her with a blank face. What was he to say? He told her that we are a busy department, and because this is a job with many interruptions, we have to have some leeway in doing our therapies.

"But," she said, "In order for our insurance to pay, Q4 treatments have to be done every four hours exactly."

Dale said, "At first I thought she was joking, then I realized she was being serious."

What is the medical world coming to. Not only are we incapable of deciding who really needs breathing treatments, we have to do them exactly when we are told.

However, that's not going to happen.

Treatment plan for man with a lung tumor

2008-04-28T14:22:00.005-04:00

The following note was not found in the "Doctor's Notes" section of the patient's chart for reason that would be obvious to doctors who follow the "New Doctors Creed." It would create too many questions doctors do not want to answer if that were done, especially among RTs who think they know everything about medicine.

The following, my friends, is a note that was left on the coffee table in the doctor's lounge. Only us here at the RT Cave have access to this stuff; you will find this no where else. Trust me, you cannot make this stuff up.

Tx Plan for George GooGoohead (fake name for Hippa purposes):The mass is to be treated with CPT. This is a very delicate procedure that demands a unique approach. The idea is to percuss the mass to a manageable size, and then dislodge it so it may be safely coughed out. Great care must be taken not to dislodge the mass before it is percussed to optimal size. Any suggestion for aerosolized drugs that will help shrink the mass will be welcomed and immediately implemented (perhaps alternate treatments with Mucomyst and Atovent???). Please complete this task before I report to work Friday in the a.m.
Sincerely:
Dr. Bighead (fake name for purposes of protecting brilliant doctor from harassment from irritated RTs in case this note is not protected properly by you guys -- God forbid.)

The following is a response to this note by another distinguished doctor:

Dr. Strictler and I ordered Q2 Aerosols and CPT to go along with the alternating Atrovent and Mucomyst aerosols that you recommended. Brilliant idea by the way. We ordered the above therapies because we believed the mass shrinking wasn't progressing fast enough. George must have gotten wind of the benefits of this new approach to lung mass removal (perhaps he had been talking with the nurses), because he's been calling for his treatments lately instead of refusing them. He now should have a much greater chance of being cured and, hopefully, of being discharged by you when you return on Friday.
Sincerely,
Dr. Bonehead.

We here at the RT Cave hope you RTs heed this information and use it to your further understanding why such therapies on cancer treatments may be indicated and ordered by doctors of whom are definitely smarter than you, especially when it comes to respiratory therapy.

Dr. Krane discovers yet another use for Ventolin

2008-04-27T05:55:00.009-04:00

The infamous Dr. Krane has impressed me with her wisdom once again. If you guys remember, she is the one who discovered that Xoponex is more than just a bronchodilator, that it is also a humidifier of the airways.

She is also the same doctor who orders treatments in ER "Now, and again in one hour." She is so smart that she knows before the first treatment is given that it will work, and that the patient will be short of breath again in one hour. Awesome. Brilliant. All doctors and RTs ought to worship this lady as the Einstein of Respiratory Therapy.

Today, I must inform you (and I am very impressed I must add), that Dr. Krane (fake name mind you), ordered me to do a second treatment on a patient who has a cardiac history and renal failure, and who also had crackles in the left base, which is indicative of pneumonia.

As the treatment was going, I asked the patient, "Are you feeling short-of-breath."

"No, actually I feel better..."

"I ordered the treatment," Dr. Krane intervened, "because her sats were in the mid 80s and I thought the treatment might help with that, and open her up. I also think that she has thick sputum, and that treatment might loosen things up a bit."

I looked at her countenance to see if perhaps she might be smiling. I mean, she was joking right? Nope. No smile. She looked serious as usual.

She just informed me of a new 'olin that was not relayed to me via the New Doctor's Creed. I will have to add this one to the list of 'olins on the bottom of this blog. I will have to come up with a name for this. What do you think? How about Mucusolin, or thinolin or...

How about Mucobuterol: A new med that has the ability to thin secretions, and is far more effective than Mucomyst.

Cardiac asthma should not be treated as asthma

2008-04-26T21:07:00.010-04:00

I have spent so much time writing about and educating nurses and students about cardiac asthma that I have decided it needs a post of its own.

And, considering about half of all breathing treatments I do are either for pneumonia or cardiac asthma, I am hereby convinced that even doctors have no clue what the difference between true asthma and cardiac asthma is.

According to the Mayoclinic.com, here is the definition of Cardiac Asthma:

The term "cardiac asthma" refers to wheezing associated with congestive heart failure. It isn't true asthma.
As a result of congestive heart failure, fluid can build up in the lungs (pulmonary dema). This causes signs and symptoms — such as shortness of breath, coughing and wheezing — that may mimic asthma. True asthma is a chronic condition caused by inflammation of the airways, which can lead to breathing difficulties.
The distinction is important because treatments for asthma and heart failure are very different

Cardiac asthma is mainly caused due to increased pressure in the pulmonary vessels causing fluid to fill the air sacs, "preventing them from absorbing oxygen," and making the person feel extremely short-of-breath.

This same increased pulmonary vessel pressure in turn squeezes the bronchioles and causes the wheeze and other symptoms that mimic real asthma, and this is why this "problem" is quite often mistaken for asthma and treated with bronchodilators.

I was flabbergasted when I found this article a few years ago, because I knew I was correct in this, but have not found any evidence to support my claim other than what I learned one day in respiratory therapy school. However, even in RT school, one of my teachers mentioned cardiac asthma and cardiac wheeze, but did not give any further detail.

So, here we have it -- the further detail; the evidence that cardiac asthma and asthma have similar symptoms but must be treated as unique illnesses.

When Cardiac Asthma is treated as bronchospasm, all we are doing is putting in more fluid already fluid filled lungs. What we need to do is give a diuretic to get rid of the fluid and, if the heart is causing the pulmonary edema, perhaps provide drugs to increase the contractility of the heart to reduce the pulmonary pressure.

Other than the heart, there are other diseases that can cause pulmonary edema and, thus, cardiac asthma, and these include pneumonia, exposure to toxin, and high altitudes. It is the job of the nurse, the respiratory therapist and (ahem) the doctor to determine the cause of the symptoms and treat the symptoms appropriately.

RT saves life and then gets no respect from RT boss

2008-04-25T23:19:00.003-04:00

One of my day shift co-workers did an EKG on an out-patient and it was normal. Then the patient told him that she was fine when she was just sitting there, but got SOB and her heart felt funny every time he walked.

"Well, go run up and down the hall and come back and we'll do another EKG," my co-worker said.

The patient did, and my co-worker did the second EKG, which turned out to be abnormal.

So said co-worker called the patient's doctor and the doctor said, "Excellent job of thinking off the cuff there." The patient is currently admitted in the critical care.

Said co-worker told the head RT boss about this situation, and RT boss said, "WHAT! YOU DID WHAT?"

"I had him run up and down the hall, and then I got this EKG." My co-worker showed the boss the abnormal one. "If I wouldn't have done that, the only EKG I would have got was this one, and it looks normal. Would you feel comfortable sending this patient home with this normal EKG on file, when every time he moves he gets this abnormal EKG?"

"Well, you better chart the hell out of this," the head RT boss said.

Here you go out of your way to save a patient's life, and not even that is good enough to please the RT bosses. This is another example of how they have lost touch with everyday RTing.

It's now time to examine the hypoxic drive theory, and determine if it is reality or simply a hoax

2008-04-24T03:02:00.008-04:00

One of the theories that evolved as the field of respiratory therapy evolved was the THEORY of the hypoxic drive. That is where if a patients oxygen level gets low enough, a patient's brain will signal the patient to breathe.

While CO2 is usually what causes people to breathe, when the levels of CO2 is chronically high, particularly in patients with chronic bronchitis who have developed a chronically elevated CO2 level "that cannot be lowered significantly regardless of patient effort," according to Egan, Fundamentals of Respiratory care, (page 336 volume 6, 1995), CO2 no longer effects a patients drive to breathe, and low levels of oxygen (hypoxemia) "drives ventilation quite strongly."

Due to this theory, it is recommended that people who are CO2 retainers not be placed on oxygen greater than what is absolutely necessary. Generally, the accepted wisdom is that a PO2 level of 50-60 torr is the target PO2 we reach for with these patients, which is equivalent to an SpO2 of 80 to 90%.

And, if a patient is given too much oxygen, the theory suggests, this patient will lose his drive to breathe, his CO2 becomes much higher, he ultimately becomes lethargic, and will at some point stop breathing. Therefore, we medical workers in charge of the patient want to avoid using FiO2s greater than 40% for the most part.

However, also according to Egan, (page 707, volume 6, 1995) while hypoventilation is a hazard of oxygen therapy, "this harmful effect should never stop us from giving oxygen to a patient in need. Preventing hypoxia should always be the first priority."

So far I've stated the obvious that all of you wise RTs already know, but what happens if you have a chronic CO2 retainer patient on 100% oxygen to maintain a PO2 of 40%? Will that patient lose his drive to breathe?

In my professional experience, I have seen maybe two patients who became lethargic when the oxygen was turned up, but I have also seen many patients in this situation be placed on a 60% or greater FiO2s and never have his drive to breathe suppressed.

The point of this post is this: Is the hypoxic drive theory a hoax?

As I reported in a previous post, I accidentally mentioned that I am not necessarily a fan of the hypoxic drive theory to an RT student. I did not go into detail as I caught myself. However, the following week she told me she "in passing" mentioned this to her teacher, who said, "What are they filling your head with?"

Yes, it is true that we have to be careful what we tell our RT students, but at the same time we want them to be aware that what they learn in school is not exactly the same as what occurs in real life here at the hospital. And, the truth to the matter is, the hypoxic drive theory is just a THEORY.

In the next few weeks I will review briefly why people breathe, and then I will share some information I have that challenges the hypoxic drive theory. My goal here is not to convince you that the hypoxic drive theory is a hoax, but to inform you of other theories out there that might more accurately describe your patient's condition.

Stay tuned.

WARNING: As I stated earlier, the hypoxic drive theory is the gold standard theory of respiratory care. Most doctors live by it. If a doctor says lower the oxygen level on a patient because he is a CO2 retainer, it is your job to do what he says, even though you have proof that a) the patient is not a retainer, and b) the patient is a retainer and the oxygen is not harming the paitent. You may try to convince him otherwise, and he may also grumble and gripe.

WARNING #2: Since the hypoxic drive theory is the gold standard of respiratory care, it is strongly defended by RT teachers. And therefore, for you RT students out there reading this, know that any material opposing the theory will more than likely not be on your RT exam.

The medical field is humbling -- like baseball

2008-04-23T22:24:00.005-04:00

Too bad we all couldn't be professional baseball players and play a kids game for a living. Too bad life couldn't be that easy for all of us.

Then again, professional players will tell you fast that, "baseball is a humbling sport." If I could have a dime for every time I've heard that I'd be rich.

Well, so is the medical field a humbling profession, or any other profession where you deal with a lot of people on a regular basis. If you are over confident, and your patient dies, the next time you won't be so confident will you.

According to dictionary.com, humble is to not be proud or arrogant. Some people in the medical field, and you know who I'm referring to, are so not proud and so not arrogant that they have lost all sense of personality. They are blunt, short and nearly impossible to get along with.

You know what? Sometimes parents can be humbled in this way. And that's why some poet wrote this really great poem that went something like, "sometimes you need to stop and smell the roses."

My point is that while it's good to be humble in every way, something that often comes with age, experience, stress, death, threat of losing ones job, etc., it's also important to be a good person to other people around you, and to have some fun.

In other words, don't be a stick in the mud.

We have to listen to our bosses and doctors, keep our mouths shut even when we disagree with an administrative decision or stupid doctor order, for fear that we might lose our jobs. If a major leaguer loses his job, so what: he's already set for life financially.

If I could be a humble baseball player, one who's greatest stress would be whether he'd go into a major slump and be booed at home, that would be a far better place to be humbled than the real world.

That, my friends, is the thought of the day.

The real RT world -vs- the RT student world

2008-04-22T12:48:00.005-04:00

I have an RT student who follows me every Thursday. She is in her first clinical rotation, but she's such a good worker that I'm actually able to allow her to do several procedures on her own. She even does EKGs.

While I do let her do some procedures by herself at this stage, most of the time I'm with her, and sharing with her my opinion on this and on that. This way it is more of an educational experience for her, as opposed to just sending her out to do my work.

Yes, I do have to slow way down when she is with me, but I actually enjoy it. To be able to share the knowledge I've obtained is something I like to do. I don't know if I ever wrote this before on this blog, but I actually had my choices limited once to either being an RT or a teacher.

And the only reason I chose to be an RT was because I could start working right away, as opposed to waiting four years before I could teach. The bottom line in me choosing to be an RT was that I needed money right now.

Thus, when I get the opportunity to teach, I really enjoy it. But I told her that she needs to be careful what we teach her, because what goes on in the real RT world is not the same as what occurs in the teaching world. And, while it is our job to teach our RT students how to be an RT in the real world, it is your RT teachers job to teach them how to pass the exam.

For example, I showed her ABG results from the weekend before where I had a patient with a pH of 7.10 and she said, "The patient was vented, Right?" I said, "No. The patient was placed on BiPAP for 24 hours and now he's fine."

In the real world, I told her, you don't treat the number, you treat the patient individually. However, in the RT student world, the one where you have to prepare for "The Test," you have to intubate any person with a pH less than 7.30. At least that's what I was taught when I was preparing for the test.

Likewise, the theories they teach in school are not the same as theories in real life. For example, I told my student that I'm not sure I really believe in the hypoxic drive theory. I told her I wouldn't tell her why because I didn't want to confuse her.

"But tell me," she insisted.

"After you take your test I'll fill you in," I said.

I almost felt guilty bringing it up. And, the next week she told me her teacher said, "What kind of junk are they filling your head with."

I said, "I didn't tell you why I thought it was a myth, only that it was my opinion that it was. And," I added, "You can even look in that book of yours right there, the one with Egan's name on it, and it's in there that some people believe that the hypoxic drive theory is a myth. I know it's in there because I read it just last night."

"Really?"

"Yeah."

Again I felt guilty for having brought it up, except that it wasn't five minutes later, back in the RT cave, that we were having a hearty RT discussion with Jane Sage, and Jane coincidentally brought up the "hypoxic drive myth."

"If you follow it to a tee," she said, "like you would if you were taking the respiratory exam, you might kill some patients."

"Why is that?" the student asked.

"Well, let's give an example," Mrs. Sage said, "Say you have a patient who is a known COPD retainer, and that patient has an SpO2 of 40. What do you do?"

"You put him on a 40% venti mask or a nasal cannula at 3-4 LPM."

"According to your test, the answer would be yes," Jane said, "But in real life, you would want to give 100% oxygen. Think of it this way, your heart needs oxygen, and if it's oxygen deprived, it will poop out at some point. If you only give that person 100%, he might lose his drive to breath in 20 minutes. But, if you give him 40% FiO2, he might lose his drive to breath due to pure exhaustion and Oxygen depletion in ten minutes."

"Wow, you guys make some good points," the RT student said. "I never learned that in school."

"Well, it's just something to keep in mind that you can apply when you are doing clinicals, but when you are taking your tests you'll want to stick with what your teachers tell you. That's just the way it is in the medical field."

I'm sure we can think of many more examples of the differences between the real RT world and the RT student world.