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Sunday, January 13, 2008

Albuterol a cure for annoying respiratory ailments

As part of my usual two week schedule I end up with 6 days off in a row every other week, and right now I'm on day three. To be honest, I'm still not recuperated.

It's not just the burning feet and eyes, but ridiculous doctor orders. It takes 2 days to recouperate from tired feet burnout, and 5 days to recouperate from doctor order's burnout.

I don't have a problem with doctors, but I wish they would actually assess patients rather than looking at them, determining they have no clue what to do, and deciding to annoy respiratory therapy by ordering a breathing un-needed breathing treatments.

I'm telling you guys, if you check out my post, "Physicians creed: how to take care of pesky RTs", you'll see that this is all planned out.

Just before I was called to intubate a patient I honestly didn't think needed to be intubated, I finished doing a second breathing treatment in ER on a 1 YO boy of whom the doctor stated "has obvious signs of RSV."

Upon finishing the treatment, I charted, "Patient happy and playful, no signs of respiratory distress, has audible rhonchi and congestion and runny nose, no observable difference with this treatment."

I had to leave to do an EKG in another ER room, and then, when finished with that, I just happened to walk by the room where the RSV boy was stationed. I overheard the doctor, "He's looking much better. I'll come by in a half hour to see if we need another treatment, and about getting set up for home nebs."

Home nebs? Since when does this child need home nebs. He's full of junk. He needs suctioning if anything. Home nebs? Where the bleep do we get these doctors from?

I rolled my eyes to no one but myself, and waited for the doctor to leave the room. When she did, I proceeded to assess the patient again. He sounded just as junky as the first time I listened to him.

He grabbed at my stethoscope and tried to put it into his mouth. I pulled it from him, and handed him the little blue corrugated tubing from the nebulizer, because I had already discovered he loved to play with it. He smiled at me and placed one end of the tubing into his slobbery wet mouth.

While he was so entertained, I placed my palm on his chest, and I could feel no retractions. With the blue tube, he smacked me on the back of the hand, and smiled at me.

I went to the nurses station, chose a seat in front of one of the computers, and pulled open a charting screen. I did this while two nurses stood behind me, and I made sure they watched what I charted.

"Re-assessed patient at this time. RT notices no signs of respiratory distress. Patient very happy and playful. No breathing treatment indicated."

I was tired, and I wasn't going to dink around. If the doctor is going to order therapy that isn't indicated, the insurance company can read about it via my charting.

Home nebs for this kid! How ridiculous! Why couldn't the doctor have asked me what I think. I've been taking nebs for 25 years; I've been an RT for ten. If I don't know who needs home nebs, nobody does.

Then again, I am bias. And, of course, I'm lazy. I'm lazy because I want to get out of doing work. I'm lazy if I tell the doctor a treatment isn't indicated. I'm lazy because doing the treatment involves actually doing something.

I would love to tell that doctor to look on the Albuterol insert, where no where does it say that irritating lung sounds is an indication for this medicine. But that would involve actually doing research. That would involve going into the room and actually assessing the patient for real signs of bronchospasm.

Then again, another doctor ordered a breathing treatment on the floor. The patient told me she was not short-of-breath and, upon assessment, her lung sounds were clear with good air movement.

She said, "Well, I did tell the doctor I had a little cold."

After doing this treatment I charted: "Patient denies SOB, NARDN, no signs of bronchospasm, no indication for therapy, no difference with therapy."

Read that, Dr. Astro. Read that insurance company, and think about why you have to put out $80 for this procedure.

I would love to tell that doctor to look on the Albuterol insert, where no where does it say that clear lung sounds is an indication for this medicine.

Later I had a patient in ER who was very short-of-breath. I noticed this while doing an ordered EKG, assessed the patient, and thought a treatment might benefit the patient. However, the doctor told me the patient didn't need one.

Whatever! I left the ER and went to my cave, where...

...five minutes later the phone rang. Oh, come on!

"Yeah, respiratory," I grumbled into the receiver.

"We need another treatment down here," the ER desk clerk said.

Okay, fine. So the doctor came to his senses on the patient I thought should have a treatment.

In ER I observed that there was not one order but two, and neither was for the guy I wanted to give a treatment to. Upon assessing the patients I learned that one was coughing too much, and the other was not coughing enough, and the doctor wanted a sputum.

Ah, I just want to go home.

It's amazing a world where the same medicine that can be used to make someone cough can make someone not cough. And the same medicine that can get rid of rhonchi can make clear-er clear lung sounds. And, yet, a patient that's really having bronchospasm has to wait.

You'd be proud to know I was a good boy and kept my mouth shut, but I charted "No treatment indicated," on all of them. Is this legal. I really don't care.

No wonder the cost of medicine is so high. I wish that doctors would look at my charting, at least then we could have a good debate about it. And, of course, I'd lose. I'd lose because these doctors are following the "Doctors Creed: how to take care of pesky RTs."

Doctors are not on a mission to annoy RTs. They are taught in med school that Albuterol nebs are a cure all for all annoying respiratory ailments. Understanding this should help us RTs who study research that shows bronchodilators are for bronchospams and bronchospasm only.

In other words, doctors don't think in terms of "does this patient have bronchospasm or does this patient not have bronchospasm." Heck no. That technique is simply too hard and would involve a full assessment and doing reasearch.

They don't think this way becasue bronchospasm is covered under "annoying respiratory ailment." There may be exceptions to this rule, but not very many.

This is why it's better to just keep RT mouth shut, however hard that might be to do sometimes, expecially when I'm burned.

For more information check out the list of 'olins at the bottom of this blog page. Even while docotrs order Albuterol, they have these 'olins in mind.


the anonymous therapist said...

You and me both lately, good sir. It seems like pedi docs are the worst with the inappropriate nebs, though ER docs surely come a close second. Maybe we'll both get lucky and JAMA will publish an article entitled "ALBUTEROL OVERUSE: The Sign Of A Lazy Bastard."

the anonymous therapist said...

To clarify the above, the physician would be the lazy bastard, not the RT. Pretty sure that's clear how I wrote it but I am tired and unsure.

Freadom said...

You were 100% clear. I think all us RTs are all in concordance here.

Djanvk said...

Nice one Freadom.

I also go through the same stuff here, but you forgot the one where they order a tx just to say they did something. And of course the nebs on a congested person, yea that just as good as trying to throw Baking Flour through a waterfall.

Asthma Mom said...

I'll chime in w/my perspective as a parent and non-medical professional. When my daughter was originally diagnosed and for YEARS afterwards, I was constantly told 2 things:

1. Give her albuterol when she has a coughing fit or trouble breathing.

2. Never give her ANYTHING else for the coughing fits b/c we shouldn't suppress her major flare symptom.

Of course, like all kids w/asthma sometimes my daughter coughs b/c she's flaring but sometimes she coughs b/c her throat is irritated. Or b/c of PND or other sinus issues.

Not ONCE did I get clearer advice until she was hospitalized for pneumonia at age 4. Guess who gave me advice about how to help her coughing and how to figure out when I could give her medicine as long her breathing was under control? The nurses, other asthma parents I met online, and......the RT's.

Keep up the good fight, guys. As a parent, I for one appreciate it.

snocrazee said...

Use the order for albuterol on a RSV kid as a chance to teach teh docs... Use this:

snocrazee said...

snocrazee said...

It can't take the long URL so try this:

Freadom said...

Yes, snowcrazee, that is an excellent article. And this is quite a coincidence, because I ran across that article at last weekend, and I posted it up on the bulleton board over where the ped docs sit.

Great article.

Anonymous said...

So what ARE the magic signs that point to asthma flare cough vs cold vs PND vs whatever? That's where I am right now with almost 4yo DS. Don't want to overdo the Albuterol, don't want to call the doc for every little cough and end up with wild steroid-boy again, but want him to breathe!

Anonymous said...

im an rt also and i just sat down at work b/c i was frustrated. i started surfing the web and found this blog. i think it is funny b/c i just had a doc order q4 nebs and cpt on a patient with pulmonary edema and pleural effusions. when i told her what i thought she told me to do it anyway.

Freadom said...

According to our hospital policy, CPT is absolutely contraindicated for Pulmonary edema associated with congestive heart failure and large pleural effusions. If CPT were ordered, I'd refuse to do it and chart my reason.

You should check your hospital policy.

The treatment, however, you'll just have to suffer through.

Anonymous said...

i didnt really know what to do and how to handle it but i didnt do the cpt and let my lead therapist know. im still a new therapist so im trying to get a handle on what is appropriate to do in situations that are uncomfortable. i think b/c im young the drs dont listen to me.

Freadom said...

You absolutely did the right thing, and you have the backing of the AARC.