RT bosses, admins think on different level as RTs

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

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:

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


2. 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.


3. 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:

1. What do you VALUE?


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


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


4. What STRATEGIES would enable you to achieve your vision?


5. What PROJECTS would enable you to implement your strategies successfully?


6. 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

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

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

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:

1. 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.


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


3. 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


4. 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.


5. 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.


6. 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."


7. 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.


8. 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.


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


10. 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.


11. 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.


12. 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.


13. 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.


14. 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.


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


16. 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.


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


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


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


20. 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.


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


22. 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.


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


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


25. 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.


26. 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?

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.

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 when a person is in the emergency room and they have 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," 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 and not Vent.

I have to cringe when I see that. I cannot believe any lawyer or doctor would 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, and the ambulance arrived and the person who was taken away on the ambulance was Chuck's friend with the broken arm.

It does not work this way in real life. If you get CPR and live, you bought yourself a vent, unless you are a DNR. However, if the people working on you don't know you are a DNR, you will end up on a vent regardless.

However, I do think the decision not to become a vegetable on a vent is a valid issue for most people, 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 might 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, as she loved life and wanted to continue on as long as she could. 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?

Then you have the people who have Alzheimer's, people who 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 is 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 could 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 hands 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." He 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 who has a bad heart, and has had a bad heart for year, comes into the hospital with a severely failing heart and in respiratory failure secondary to the failing heart. The patient is non-responsive, and he 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 intubate her husband and place him on a vent.

"What should I do?" the patient asks the Dr.

"Well," the doctor said, "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.

"Technically speaking," the doctor continued, "the goal of going on a vent is short term therapy to allow your husbands 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."

The doctor pauses as to allow the elderly lady a moment to absorb all the information he just reported to her, and then he solemnly states, "However, if he doesn't go on a vent now, there is very little chance he will survive this."

In one case I remember clearly, 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 his heart remained severely fragile, he was able to spend another two years, and thus going on a vent "to get over the hump" bought him two years to say good-bye to those he loved, and allowed those he loved to say good-bye to him.

And, as 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 surviing 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.

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, if 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.

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), is a decision you and your loved ones ought to be thinking about, because it could save you 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

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.