"I'm not sorry I have COPD," she said

"You don't know what it's like to sleep in these beds," Mrs. Patient said, and smiled. It was the first time I had seen her smile in the two days I had taken care of her.

"You might be surprised," I said, preparing my syringe to draw my a.m. ABG.

"How could you possibly know what it's like to sleep on these uncomfortable mattresses?" She was admitted with exacerbation of COPD, and had been requiring a bronchodilator at least every two hours until today. She was looking pretty comfortable all slouched down there on the bed.

"You might be surprised. "I grabbed her hand, knelt alongside her and held her hand, feeling for her pulse.

"Usually they get it on the other hand. They keep missing on that one."

" I feel a great pulse here." I uncapped the syringe.

"Okay, I'm ready." I'm not poking you yet. I'll warn you when I'm ready."

She relaxed and smiled again. "So what did you mean I might be surprised."

"Because I slept in this very bed in December. I know how uncomfortable it is first hand." The needle pierced the skin. She did not flinch.

"You did, really?"

As she pondered that, I watched as the blood flowed quickly and smoothly into the syringe. I pulled out the needle and held her wrist with a pad of white gauze. "Yeah. I know exactly what these beds are like."

"What was wrong with you."

"A bleeding ulcer."

"How bad was it that you had to be admitted?"

"I lost four units."

"Oh, I guess that's bad. How does a young man like you get an ulcer?"

"It was probably secondary to asthma medications, I guess. Or a bacteria. No one really knows for sure."

"Oh, you have asthma."

"Yeah, I've spent my fair share of time in hospitals for it, but not in the last ten years." I removed the gauze. She was still bleeding a little. I held pressure again.

"Oh, I'm sorry."

"I'm not. I wouldn't have this job, and I wouldn't have my wife, and I certainly wouldn't enjoy writing if I didn't have asthma."

"That's a good attitude. You know what, I'm not either. I mean, about my COPD. I'm not sorry I have COPD." She smiled. "There's people who have it a lot worse than I do."

I didn't say anything to that for a few minutes. I thought of the irony of that statement. Here she was knowing she may never breath normal again, and probably will spend the rest of her life thinking about every breath, and she says she doesn't feel sorry for herself, that there are people far worse than her.

Finally I broke the silence. "I love that attitude in a patient."

She smiled. "You didn't get bad lungs because you smoked, right?"

"That's correct." I plastered a bandage over the gauze and stuck it on tight. "All done."

"That didn't even hurt at all," she said, looking down at her wrist.

"Thanks."

I grabbed the capped syringe and got up to go. She said, "I made myself this way. I destroyed my own lungs."

"When did you start?"

"When I was 17. I quit for five years believe it or not, then I started up again and smoked for 40 years. How stupid was that?"

"To your defense, though, back when you started you probably didn't hear all the time how bad cigarettes were for you."

"On the contrary. You had doctors on commercials talking about how cool it was to smoke."

I chuckled. "On the other hand, kids today know of the dangers, and they still smoke. Most kids just think they'll live forever."

"True."

"You probably would have smoked regardless too, hey?"

She smiled. "You know what, you're probably right there."

I've have this type of discussion with a patient from time to time, almost to the point I know exactly what to say; what they want to hear; how far I can push them. Especially when I'm tired at five in the morning I'm not shy about sharing my experiences with my patients, and getting them to share their experiences.

Perhaps we both get some solace out of it.

"Is there anything I can get for you before I leave?"

"No," she said. "But you could take a picture of me as I lie here in this bed and send it to someone who's thinking about smoking. Maybe they'd think twice."

"I doubt they'd think twice,"I said, jokingly

"I doubt it too."

Chronic lungers and fans go hand in hand

When I was a child and having an asthma attack I would open my bedroom window and get instant relief. Sure it wasn't much relief, but it did make me feel a little better. As I grew older I found that I'd have the bedroom window open a lot, even in the middle of winter.

One summer my parents gave me a fan, and I ran that fan every time I was having trouble breathing too, and eventually I learned the soporific drone of the fan was a good sleep aid, and that habit runs to this day, even though my asthma is now under control.

I never thought anything of this, but when I went to RT school I had a classmate who also had asthma, and she too used a fan the same way I always did.

Then when I became an RT I found that many asthmatics and COPD patients have to have that fan blowing in their faces. It's almost to the point whereas when a patient comes in who's SOB I habitually ask them if they want a fan. "Yeah," many say, "I always have one at home."

They also more often than not have the window open and, especially if its humit, the air conditioner on. I've seen this with asthmatics, COPD and CF patients.

In fact, if you go into a room that is ice cold, chances are it will have a chronic lunger it it.

RT Cave #14: If you have a chronic lunger, expect that the room will be cool, a fan will be on, and/or the window will be open. You may find yourself looking around in all the dark ends of the hospital for a fan.

Is this a mere coincidence, or is there some reason people who have experiences being SOB like fans.

I can't remember where I read this, but some magazine about ten years ago had an article about how your face has receptors that are responsive to the wind. When the wind hits these receptors your lungs dilate ever so slightly.

I have never seen any information about this since. However, it would seem to make sense. It's a nice theory of mine I like to share with my patients who "have to have a fan."

Medical Helecopter Crashes

Just learned that Aeromed helecopter crashed into Specrim Health in Grand Rapids, MI. The top couple floors are being evacuated to different hospitals in the area, and the ER has been closed.

Wow... Just learned Pilot and passenger both survived, and escaped serious injury. Great news. The copter was apparently on a training mission.

This is where many smaller hospitals send their most critical patients. For all the good that these people do, and the risks that they take, we have to take a moment to appreciate what they do.

Here's the story in ther Grand Rapids Press, and here is a better link to the same paper.
Developing...

Cell phones as deadly as cigarettes???

Here is something to think about. We all know that the government got an entire generation of people addicted to cigarettes by 1917. They did this despite warnings way back then that smoking was deadly. Yes, they knew way back then the hazards of smoking, but they never said anything.

Check out this timeline of smoking, and you will see that the Fed might not have been completely honest with us.

For example, the "Federal Food and Drug Act of 1906 prohibits sale of adulterated foods and drugs, and mandates honest statement of contents on labels. Food and Drug Administration begins. Originally, nicotine is on the list of drugs; after tobacco industry lobbying efforts, nicotine is removed from the list."

Because of the fear that cigarettes are hazardous, and not wanting to be seen as a person who endorses the idea that children start smoking, Major League baseball player Honus Wagner insisted that his baseball card no longer be provided in cigarette packages. This ultimately resulted in his card being the most valueable care all time.

In 1912, the "first strong link (was) made between lung cancer and smoking. In a monograph, Dr. Isaac Adler is the first to strongly suggest that lung cancer is related to smoking." That was the same year many were concerned about the addictive quality of cigarettes.

Then, in 1914, Henry Ford and Thomas Edison talked about the dangerous effects of smoking cigarettes, and that Thomas Edison said it "has a violent action on the nerve centers, producing degeneration of the cells of the brain, which is quite rapid among boys. Unlike most narcotics, this degeneration is permanent and uncontrollable. I employ no person who smokes cigarettes."

Then, in 1917, an entire generation of young people comes home addicted to cigarettes. That was where the problem began.

The Fed never said anything because... why???

Here I have been telling my patients the past few years that people who have bad lungs now because of smoking didn't know any better in the 1950s when they started, and that today's kids do. Thus, today's kids have no excuse.

But, is it possible that kids back in the 1950s should have known better, and the government didn't say anything just because the cigarette industry was so good for the economy.

Cigarettes have been positively linked to various cancers, heart disease and COPD.

Now there have been theories and some vague studies the past few years that cell phones might also be linked to cancer. Do they know more than they are telling us? Should we be careful? Should we keep an open mind about this???

Or is this just poppycock?

In the days to come, we'll review this further.

Oh, and here's something in the timeline I found interesting. In 1920, " in Atlantic Monthly says, 'scientific truth' has found 'that the claims of those who inveigh aginst tobacco are wholy without foundation has been proved time and again by famous chemists, physicians, toxicologists, physiologists, and experts of every nation and clime."

Is it possible that cell phones will be the new cigarette? That cell phones are linked to brain tumors.

Johnny Cochran, O.J. Simpson's lawyer, was diagnosed and died of a brain tumor. It was widely known that he was on a cell phone all the time. And, while scientists don't know why smoking causes cancer, they just know that it is linked to lung cancer. The same can be said of cell phones and brain tumors. Or no???

Ear piece down to holster on belt is the industry recommended use of cell phones. If you dont' do this, will you increase your risk of brain cancer?

I don't know, I'm just as curious as you? Just something to think about.

RN Cave Rule #62

I've been posting RT Cave Rules on this blog as I think of them, but there are some RN Cave Rules I've alluded to from time to time that involve us RTs. One of them is RN Cave Rule #62,

RN Cave Rule #62: Whenever there is a stinky, dirty, disgusting, puky, gross, obscene, unruly patient, RT must be somehow involved in the care of that patient. Tell me you don't know what I'm talking about.

I thought of this tonight because I was called down to ER to do a routine EKG. As I walked into ER I immediately was hit with this rancid smell. It was one that I was familiar with unfortunately, as it was the smell of a human who hadn't taken a bath in a loooonnggg time.

I had this feeling in the pit of my stomach that it was in that patient's room where I was headed. And, lo and behold, I was right.

He was a young, gruff guy with tattoos covering his body, and was in his mid-30s, but his clothes were filthy dirty. His hands were callous, dry, rough and dirt filled like those of a mechanics. His boots sat at the side of the ER cot, and his filthy socks loosely dangled on his feet.

Last night I walked into a room of a patient whose skin appeared to be falling off, and she had little white flecks in her thinning hair. Why she needed an EKG I have no idea, but I had to touch her up close, and I didn't want to. But, because it's part of my job, I had no choice.

Yes I wore gloves.

I told you guys once about the time I walked into ER and was slammed with the most God-awful smell ever. I walked past a room with several nurses and knew the smell was from there. And, I thought, since that man smells that bad, somehow, some way the nurses will make it so that I have to go in there.

And I was right.

This man had his legs wrapped a month earlier for whatever reason by his doctor, and the wrappings were supposed to be changed every day. But this homeless man never did anything, and there were maggots in there. Maggots I tell you.

There is nothing worse than rotting human skin. Nothing.

But if someone comes in that way, an RT is automatically indicated. It's king of a well-if-I-have-to-take-care-of-this-gross-patient-you-should-too rule.

Same is true on the patient floors. We once had a patient who had gangrene, and man if that rotting skin doesn't stink up the whole floor, and there's nothing you can do about it. But, even though the patient is breathing fine, the doctor just has to order nebs.

Why, the patient stinks, thus in accordance with RN Cave Rule #62, we have to get RT involved

Is the patient in isolation? Well, then they too need to be on nebs.

Fair is fair, I suppose. But I hate this RN Cave Rule.

RRT saves another; new use for Ventolin

Here's an interesting situation. A patient who was admitted several days earlier suddenly has an SpO2 of 72%.

Thus, the rapid response team (RRT) is called. Upon entering the room the RT finds the patient in no respiratory distress and he adamantly denies any trouble breathing. The rest of the RRT has now arrived.

By RRT protocol, the RT opted to do an EKG and found that there were changes: elevated ST in various leads. Per RRT protocol, the nursing supervisor orders cardiac enzymes, and the patient's RN rushes to call the doctor.

Hold the phone. After a quick ABG draw the patient was placed on a 75% non-rebreather. The doctor was called, and the patient was promptly transferred to the critical care.

Upon the arrival of the doctor, a breathing treatment was ordered. The RT grumbled about this because he couldn't see a purpose for doing this. What is Ventolin going to do for an MI?" the RT thought. But like a good boy he did his job.

Then a second treatment was ordered. He grumbled to himself, but did the treatment again like a good boy. Then, as both the RT and doctor were standing beside the bed, the doctor says, "Let's get a second EKG."

That's fine. An EKG I can understand.

Lo and behold, this EKG was back to normal. While the underlying cause was still undetermined, it appeared to this humble RT that the EKG changes were due to hypoxia, and the oxygen boost helped the patient.

After examining the EKG, the doctor said, "We better do a another breathing treatment."

What are you thinking, Dr. Mast? What in the world are you thinking? You can't possibly think your frivolous breathing treatment actually...??? NO!. Couldn't be.

Nonetheless, we now have discovered another use for Ventolin:

By some magic power, Albuterol now is capable of dissolving a clot in the coronary arteries and fixing an MI. If Ventolin is not the greatest drug of all time, I don't know what is.

Coronoryolin? MI-olin?

Now, on a side note and being serious again for a moment, the RRT came to the rescue and saved another life. I love it when we RNs and RTs are allowed to use our skills to help someone.

On a similar note, if I had access to a scanner I'd put those EKGs up here for you guys to look at. It was pretty neat seeing the changes on the EKG and then the change back to normal after the heart was oxygenated.

Pneumonia is NOT an indication for Albuterol

Click here for the real indications for bronchodilator therapy.

One of my favorite things to do is educate. I always thought it would be cool if either all doctors went to RT school before they went to DR school, because that would teach doctors some good assessment skills, and how to know when a breathing treatment is indicated.

Either that, or perhaps it would be good to have an RT teach at DR school the indications of bronchodilator therapy and stuff like that. That in mind, this I am starting a new subject I will return to from time to time here at the RT cave: DR wisdom. And that is what this post is: Dr. Wisdom.

This will include information that I think doctors could use to become better doctors, or little things doctors can do to improve the DR-RT relationship. Heck, this will not only benefit the patient, it will make RTs happier, and make it so you doctors don't have to be bothered all the time.

First, let us consider RT Cave Rule #13

RT Cave Rule #13: In order to know that a breathing treatment is needed, you have to actually assess the patient.

So, that in mind, here is RT Cave Rule #12:

RT Cave Rule #12: Just because a patient has pneumonia is NOT an indication for a breathing treatment.

You came into the hospital, you assessed the patient and you saw the same thing that I saw when I assessed the patient, that he is in no respiratory distress and he even denies SOB. So why do you insist on ordering breathing treatments. Why?

Here is what you need to know. Ventolin is a particle size of 5 microns. That's a perfect size to work down into the bronchioles, bind with the beta 2 cells receptor cells, and relax the muscles of the bronchioles.

Now, note that pneumonia is not in the bronchioles, and therefore Ventolin will do nothing for pneumonia. Ventolin will not magically shrink to 1-2 microns and get into the alveoli and scrub the alveoli clean of pneumonia. That will not happen.

And even if the ventolin could somehow get into the alveoli, it would basically bounce off the alveoli and be absorbed by the body, because B2 receptor cells that it attaches to are not in the alveoli, they are in the bronchioles.

Thus, bronchodilators do nothing for pneumonia. In fact, I can tell you if that I never did one treatment on that guy you just ordered treatments on in CCU33, he would still eventually go home.

Please don't waste my time and make me wake up that poor guy every four hours round the clock for some stupid quacky uneducated theory you have.

Better yet, here is DR wisdom #11, of which I will be referring often in this class. So you better know this rule upside down and backwards:

RT Cave Rule #11: NOT everything pulmonary should be treated as bronchospasm. Ventolin does not work like Scrubbing Bubbles bathroom cleaner and scrub the lungs clean of all that ails them. It is for bronchospasm only.

We'll touch up more on this rule in our next session of DR wisdom.

That concludes today's class.

Note: I am aware that most doctors do not order bronchodilators for stupid reasons. And most who do are simply not aware of the real value of bronchodilators. That's exactly why we will hold these classes from time to time. Remember, we here at the RT Cave are leading the charge for bronchodilator reform. Thank you.

Nasal cannulas belong in the nose

As an RT, I'm certain that all of you guys, like myself, have come across the elderly patient with a nasal cannula stuffed into his mouth. We probably find ourselves explaining why the cannula does not belong in the mouth more than anything else.

This brings me to RT Cave Rule #10

RT Cave Rule #10: Nasal cannulas do not belong in mouths. Not only is this not necessary, it is unsanitary. The nasal passages and sinuses act as a reservoir for oxygen entering via the nasal cannula. Even if the patient is a mouth breather, or has a stuffy nose, the patient will still entrain oxygen via a properly inserted nasal cannula.

I find that most of the time I only have to explain this once, and the practice stops. However, we have our repeat offenders who insist that in certain situations that nasal cannula belongs in the mouth.

What one must be aware of is that a nasal cannula is a low flow oxygen device, which means that it will not guarantee a certain amount of oxygen gets to the lungs. As respiratory rate and tidal volume change, the amount of oxygen entrained increases and decreases.

Let's take one specific scenario that occurs often. You have a patient whose sats were consistently 93% all day on 2lpm. Now it is midnight, and the nurses assistant finds the patients sat is 89% on 2lpm. She relays this information to the nurse and the nurse assesses the situation and determines one of the following:

1. The patient is in a deep sleep


2. The patient is mouth breathing


3. The patient is has a stuffy nose

Thus, she decides that the nasal cannula should be placed in the mouth. Then, an hour later, the RT comes around and does one of the following actions:

1. He takes the cannula out of the mouth and places it back where it belongs, and leaves it at that.


2. He takes the cannula out of the mouth, and proceeds to educate the RN as to why this is not necessary and not sanitary.


3. He does nothing. He's tired and doesn't want to deal with it at the moment. Or, he's explained it so many times already he doesn't see what the point would be.

I have found myself in all three of these scenarios. Most of the time if it is a new nurse I explain why the cannula should not be in the mouth, but if it's a habitual offender, I might do action 1 or 3.

Okay, so the patient has a stuffy nose. The oxygen will find a way to work its way around the stuffy stuff, and make it to the patient's lungs.

Okay, so the patient is a mouth breather. The oxygen will still be entrained into the nasal passages and to the nasal sinuses and will still be entrained.

Okay, so the patient's sats have dropped. Check the connections. Turn up the oxygen. Assess the patient. Consider the patient's age and history and decide if it might not be normal for that patient to have a slightly lowered sat while from time to time, and leave the oxygen where it is.

Consider this too: it is normal for aging patients to have lower sats. It is also normal for elderly and chronically ill patients (like COPDers) to have decreased sats when they are sleeping. And, in the case of some COPD patients, sats in the high 80s can often be normal. So know your patient's history.

If the patient is in respiratory distress, or if you continue to be perplexed or concerned about the low sat, call RT. That's what we are here for. But -- please -- do not place the cannula in the mouth.

Think of it this way: would you want something that was stuffed into your nose in your mouth. I wouldn't. If a patient needs more oxygen, there are other options.

What's it like to die?

When you work in a hospital you see death more than the average person. It's almost impossible not to think about it. And even though you've seen it, you still have no idea what it is like to die.

Yet, still, I have been asked on more than one occasion the one question no RT, RN or Dr. ever wants to be asked: "What is it like to die."

The patient who asks this is usually one who knows he is dying, yet still feels so alive. If you've worked in a hospital long enough, you know exactly what I'm talking about. One time I had a young patient with terminal cancer, and he'd sleep most of the day only to wake up and say, "Oh, I'm still alive."

That would be a sad way to go.

Once I had a middle-aged lady with end state Pulmonary Fibrosis and her lungs simply had no compliance, or had become too stiff to oxygenate her body. She would smile through choppy sentences and ask, "What's it like to die?"

Perhaps you know already," I would think. Yet I'd say, "I don't know. I wish I could answer that."

So, what is it like to die? I have no idea. But most of the time I imagine that people lose consciousness before they die. Usually your organs start to fail, your kidney shuts down, and you simply lose mental awareness. Then you die.

But what about if you have the big one while awake. Would you not feel agony a moment before you lost consciousness, just before you died?

What about the terminally ill, or those in chronic pain, or those who have no lungs left. There are ways to make the transfer easy, and it often involves comfort measures only and some morphine.

After I finished my round of midnight treatments I sat in the patient waiting room and watched Red Eye on Fox News. I really didn't plan on watching this show, it just happened to be on when I clicked on the old boob tube.

I have no idea the name of the host nor the guest, but the conversation essentially revolved around the death penalty.

The host asked what the worse way to die was. The guest said probably stoning. It was very common in the old world, and is now only common in some far out countries. He said the electric chair has been banned in many states because it's so gory.

The shooting squad might result in instant death if the shooter hits the heart with the first shot. But I simply couldn't imagine the anxiety. I'd probably die of a heart attack before I made it that far.

Perhaps the worst way to die was the Pilgrim way. They used to place people they didn't like in water. If they sunk to the bottom they were innocent, if they came to the top they were guilty and they chopped off their heads.

Nobody accuses anyone else of being witches anymore, but I suppose it's possible that we could execute innocent people from time to time. However DNA testing makes this more and more unlikely.

Now the most common method of execution is by lethal injection. But the saying goes that this may not even be a humane way to go.

Penethol is used to put the person to sleep. Actually, the dose given here is enough to be lethal in itself. Pavulon is then used to paralyze the person so the executors don't have to watch the person squirm. Also, since the person is paralyzed, he won't breath. Then, to top it off, potassium is used to stop the heart.

So how do we really know the person went peacefully or not? Seems convincing to me, but how do we really know?

Is there a humane way to kill someone? How about if we hang them. When we used to hang people, according to the guest on Red Eye, they would have a bowel movement,urinate and ejaculate all at the same time because the muscles all relax. But that happens in all people who die, he said.

Anyway, just something to look forward to.

Still, what is it like to die? Does any living person really know? Well, we watch people die. We can say, "Usually people die peacefully in their sleep." But do they really die peacefully?

A conversation on Red Eye went something like this:

"What's the best way to die?" the host asked.

"In your sleep," the guest said.

"So if someone is sleeping, you don't know if they really felt pain before they went out."

"No."

"I mean, it's not like a person ever woke up after dying saying 'It sucked."

Whenever someone in my family has died, this question was always asked by someone: "How did he go. Did he suffer?"

"Nope," someone will say, "He went peacefully in his sleep."

Oh yeah. How do you know?

But when you are the RT or RN or Dr. and you have to talk with the family, and make your humble effort to ease their pain and suffering, you will find yourself saying those same words:

"He died peacefully in his sleep."

Respiratory Acidocolin

He's awake alert and orientated, and joking with the nurses and RT. He was placed on a BiPAP not necessarily because he was SOB, but because he had a CO2 of 90 and pH of 7.29, HCO3 34.

He was already given a series of treatments in the ER, but the patient stated to the RT the treatments didn't make him feel any better, "because I'm breathing fine." Yet, Q2-3 treatments were ordered nonetheless by the Internist.

An ABG was ordered in the a.m., and the results were similar to the previous, except the pH decreased to 7.20. Again, he declined any respiratory distress and otherwise showed no signs of distress. In fact, he continued to joke with the health care staff.

On the phone, the doctor decided the patient must be having an exacerbation of COPD, "and we're going to have to knock it out of him. So, I'd like to order a continuous breathing treatment."

No big deal, the RT decides as he sticks the neb inline. Then he decided this doctor made him aware of a new type of 'olin: Respiratory Acidocolin.

As the RT expected, the patient told the RT he feels no different after the 30 minute long treatment.

However, this therapy made the doctor feel better, because 24 hours later his patient's pH was back to normal. "It must have been the ventolin," the Internist chimes to the RT. "It must have been the Ventolin."

The difference between a WANT and a NEED

I was called the other night to ER to do a tx and EKG on three patients at the same time. Plus I was also paged to the patient floors too. So, upon entering the ER and starting all the treatments at the same time basically, I asked the nurse if the EKGs are needed or wanted.

"THE DOCTOR ORDERED THEM," she yelled at me, "OF COURSE THEY ARE NEEDED!"

Dog gone it, that's not at all what I meant. But thank you for getting all worked up and screaming at me. Now we all feel stupid don't we. Well, I don't, because I just take things in stride.

My point in asking her that question was not to tick her off, but because there is a difference between a need and a want. If a patient NEEDS an EKG, then I would do it right now. If the doctor simply WANTS the EKG just to be on the safe side, then I can move on to other priority therapies before I do the EKGs.

This brings us to another RT Cave rule #98:

RT Cave Rule #98: "Not all procedures doctor's order are really needed. Some are needed. But others are ordered just as a precaution, and thus are wanted. Thus, some are wanted. In order to prioritize, we RTs need to know the difference between a need and a want."

Pre-op EKGs are wants. EKGs done just to prevent a lawsuit are wants. If that guy is having toe pain, then the EKG is a want.

If, on the other hand, the patient is having crushing chest pain, the EKG is needed right now. Another way of looking at it: If the EKG falls within the guidelines of ACLS it is needed, if not is is a want and can be prioritized.

And that, my friends, is the thought of the day.

More on the agony of end of life issues

A few days ago I presented you, my faithful readers, the end-of-life story of one of my favorite patients. She had led a wonderful life, was terminally ill, was a self declared DNR, had a bad case of aspirtion pneumonia and, as per her families wishes, was set up on comfort measures only.

She was on a non-rebreather to provide her 100% oxygen in order to help her breathing, and she was even on morphine. She felt no pain. However, her breathing was mildly labored.

In my opinion, and the opinion of most people I have had the privilege to discuss this case with the past few days, this was the humane and ethical thing to do in this case. It was time to let nature take its course with this lovely 93 YO lady. It was time for her to go to her maker.

Yet, the doctor provided an option to the family, that he could have the surgeon do a bronch, and that this might buy her some time by cleaning out her lungs. And the family came to the difficult decision to allow the bronch.

So, yada-yada-yada, the surgeon sucked a bunch of brown crap from her lungs, and she was placed on a vent. This is where I left you guys off.

That first night her breathing was SO comfortable on the vent she wouldn't do any breathing on her own. The doctor had conceded she might be a major conundrum to get off this vent. In fact, he said something along the lines that she might be a terminal wean.

But he didn't know I was working.

Without an order I weaned the lady off 10 of PEEP and placed her in CPAP and PS. She did not fail the weaning attempt as I had surmised. After a half hour of the wean I did weaning parameters, and her numbers weren't good by any means, but probably good for her considering her terminal lung status.

Her NIF was only -17. We like it to be at least -20 to consider extubation. Her RSBI was 120, and statistics show 75% of patients with a RSBI under 100 do not get reintubated. Since she was over 100, her odds were not so good. Yet, despite these stats, the Internist on duty wisely decided to give the order to extubate -- after all, she was a DNR.

Now, 24 hours later, she is on BiPAP. She is miserable. She hates the mask. She looks so frail and unhappy. When I go into her room she wants me to hold her hand and talk to her. When I tell her I have to leave, her voice is muffled through the BiPAP mask: "Please, don't leave me alone."

She keeps asking me to take the mask off, but when I do her sats sink fast.

Now the Internist on the case does not want to give her too much morphine as to not knock her drive to breath out. And he doesn't want to put her on 100% oxygen because she is a CO2 retainer.

That ticks me off, considering she was on 100% non-rebreather for five days before she was placed on a vent and she did not stop breathing then. She tolerated the high oxygen quite well as a matter of fact.

Yet now, while her PO2 remains in the 40s, we are allowed to go no higher than 50%. Go figure.

Despite that, I was rather impressed with this doctor. When he was provided an opportunity to yank her tube, he didn't hesitate as some doctors have in similar situations I have experienced.

People, this is a perfect example of why sometimes it is NOT a good idea to take advantage of modern technology. Sometimes it is best just to follow the wishes of the patient, and let nature take it's course.

Not all smokers are irresponsible around kids

True story here, and this relates to my last couple posts.

I walked into the garage at my dad's house because I though he might be involved in a project I could help with. The project he was working on was a cigarette. "Oh, I better put this out," he said, "I don't want your boy to see me doing this."

Thankfully the boy didn't follow me into the garage. My point here is that I respect my dad for not letting my son see him smoke. Here it's his home, he can smoke wherever he wants, but he goes into hiding. How cool.

I was 18-years-old and I went with my dad and my brothers to hunting camp. We arrived before anyone else, and made a fire. Then I watched as my dad lit up a cigarette.

I swear to you I never had a clue that my dad smoked. He told me he quit for a few years a few times, but he had smoked since he was 17 or so. Still, I never once ever saw him smoking before; I had absolutely no clue he smoked.

Why? Because he was a considerate and responsible parent who never smoked in front of his children. He never smoked in the family car. He never smoked in the house.

And now, as a grandpa, he still goes into hiding when kids are around.

Warning: second hand smoke is harmful to kids

The sign said, "Kid Zone: NO SMOKING."

Yet the smell of smoke wafted through the air around me. I turned around and saw 30ish year old man smoking in his car, two toddlers jumping around in the backseat, and a mom leaning on the hood of the car holding a baby, who happens to be sniffling and coughing.

I move myself and my little girl so we are now standing on the other side of the soccer field, yet the wind is still blowing the smoke our way. I turn around and watch as the scruffy faced dad tosses his cigarette butt out the window, apparently unaware of the fact he is littering.

I breathe in fresh, non-smoke filled air. It feels good. I figure we should have clean air from here on out. And, just as my daughter runs off amid the crowd of spectators, I smell smoke again. I do not turn around this time, though, because my son has the soccer ball and he's....

These people are so ignorant they can't even not smoke for one hour during a kid's soccer game. I wanted so bad to get up and tell this person to stop smoking. I never did, and neither did any of the other parents. I wondered if they were as annoyed by it as I was. I never asked.

I wanted to tell this person that I think it's fine that he chooses to put arsenic, acetic acid, acetone, ammonia, benzene, butane, carbon monozide, ethanol, formaldehyde, hydrazine, hexamine, hydrogen cyanide, lead, methane, mathanol, napthalene, nickel, nicotine, phenol, polonium, stearic acid, styrene, tar and toluene and 3,580 other substances into his body -- the contents of one cigarette.

But why make all these kids ingest these same toxins, which are poisons likely to cause cancer in humans, or cause one of the kids to have a flair up of asthma? Hey, second hand smoke is even known to cause asthma.

But that doesn't matter though, cause that guy is enjoying his cig.

After watching the game for a while, I notice I STILL smell smoke. Gosh darn it, I thought that cig would be gone by now. But no, he keeps lighting 'em up one after another. And then I notice the mom is no longer standing outside the car, she is inside with her smoker of a boyfriend. She has now joined him in smoking.

I was rather irritated. I thought again that I should go up to the open car window and tell that mom that a recent study found that infants are three times more likely to die from SIDS if their mother smoked during and after pregnancy. Also, infants are twice as likely to die from SIDS if their mother stopped smoking during pregnancy, and then started smoking again after birth.

I'm sure she wouldn't care, though. She'd probably just be annoyed that I was rude to annoy her.

That chronic cough, wheezing and excess phlegm your baby is coughing up is probably because of you, I wanted to say. And all your kids are very likely now, because of your ignorance and irresponsibility, to have a reduced lung function as they grow older, making them more susceptible to chronic lung and heart diseases, and therefore probably shortening their lives.

She would tell me I was just making this up to scare her. I'd tell her the facts, that 150,000 to 300,000 kids develop lower respiratory tract infections like pneumonia and bronchitis each year in children under 18 months of age.

When your baby develops bronchitis, you will get to know me very well, as statistics show that 7,500 to 15,000 of these children are hospitalized each year. If your child is the exception, it's only because you are lucky. Are you willing to play the odds game with your kids?

I suppose it doesn't matter so long as you are enjoying yourself. After all, it's all about you anyway.

I don't know if it's because I'm an asthmatic, have an asthmatic daughter, care about other people's kids as well as my own, or the health of my pregnant wife, or the fact that I'm an RT, that it bothers me so much that that guy continues to smoke and smoke and smoke and smoke some more in the span of a one hour kid's soccer game in the Kids Zone.

Yep, that guy and that mom have a God given right to do what they want in this life, but why they insist on endangering the lives of their children, let alone mine and all these other innocent kids running around this Kid Zone, I will never understand.

"Hey, there's a sign right there, can't you read it."

It's not just soccer but other kid events too that this happens. Last summer at baseball games I came across this same situation. There is always one jack-ass in the crowd who naively sits in his lawn chair puffing away, forcing everyone in his or her vicinity to breath in the second hand smoke.

Is it fair that I should have to keep getting up to move away from someone else's exhaled smoke? Or should I break the silence and become the bad guy who tells this smoker to put it out.

It's kind of ironic, isn't it, that I would consider myself the bad guy here, when the true bad guy is the one holding the cancer stick. Or am I wrong here?

Note: All the information and statistics provided in this post are compliments of a packet called "Michigan Smoker's Quit Kit," which was written by the Michigan Department of Community Health, 2006.

Stop smoking in front of your kids. Period.

Here's another issue that could be discussed in ethics class at some lengths. Or, better yet, a great topic for Stupid People 101. What do stupid people do? Stupid people smoke in front of their kids, that's what they do.

I'm so sick and tired of taking care of kids because their parents are too stupid to know better. Kids do not know any better, and therefore it is the responsibility of parents to create a safe, clean and healthy environment for their kids.

Smoking in front of your kids is not safe, clean nor healthy. In fact, it is just plane stupid and irresponsible. It may have been acceptable 50 years ago because people didn't know any better, but there is so much information out there, there are no more excuses for this kind of stupidity and ignorance.

The fact is, smoking in front of little boys and girls is hazardous to their health if they have healthy little lungs, let alone bad lungs already.

I'm not a fan of making a laws just because, but I'd be willing to make an exception for a law to make it illegal to smoke in front of kids. Then I could take half the mom's who bring kids to the hospital and put them away for 30-90 days for causing their kids to get sick. Maybe that's what's needed to knock some sense into them.

Tonight I took care of yet another little boy who was having an asthma attack. And I didn't even need to ask my usual 101 questions to know the mom smoked in front of her child, as they both smelled of smoke. Yet I asked anyway, and the answer was a nonchalant, "Yes."

Pathetic, I say. Just pathetic. Pure stupid.

Is there any way possible that any parent in existence in the United States today can possibly not know how stupid it is to smoke in front of their kids, let alone a kid with asthma.

You sit there and watch your kid have an asthma attack. You love your child so much that you take him to the ER when he is having an attack, yet you don't know enough to not smoke in front of him. How stupid. How stupid you are.

Let this peon of an RT tell you something: If you want to ruin your own lungs and your own life by smoking, you have that choice. Your son doesn't have the same choices you have. He has to live in the atmosphere you create.

It's your job to protect him. Do not destroy his life too. Don't smoke in front of him.

That is the thought of the day. Thoughts anyone.

Are we prolonging life, or delaying death???

What I am going to write about tonight is something we need to have a major discussion about. Because I am convinced there is no solution to this conundrum. It's a conundrum because this terminally ill 93-year-old do not resuscitate (DNR) patient was placed on a ventilator last night.

In talking to her daughter, she led a wonderful life. She never held a job in her life, but her husband had a good job, so she didn't have to work. Instead, she stayed home and took care of the kids.

She has four kids, and all of them became successful in their own right. She was so proud that all her children turned out so well. And she's even more proud of her 12 grandchildren and three great-grandchildren. The flowers all over her room are a testament to how much she was loved.

When she was diagnosed with pulmonary fibrosis (PF) at the age of 88 she decided to make herself a DNR. Yet, even before the PF diagnosis she had become a regular fixture in the hospital with fluid overload, whereas her doctor said to me once, "Even a slight weight gain of 1-2 pounds quite often put her into pulmonary edema."

She was also a lifelong smoker. As a matter of fact, she smoked about a pack of cigarettes a day since the mid 1940s, when she started because it was in fashion to do so. As one of the negative and unexpected consequences of smoking, she has slowly developed emphysema, which has now progressed so that she has become a CO2 retainer.

Considering her grim prognosis, her doctor and family had decided to make her a comfort measures only patient, which justified placing her on a non-rebreather to keep her oxygen levels up despite the fact she was a retainer. But, despite the high levels of oxygen needed, she did not stop breathing (despite what believers in the hypoxic drive theory might contend. but that's a discussion for another day.)

The family had already been informed that their mother probably wouldn't live much longer without getting her lungs cleaned out, and that the best way of doing that was via a bronch. Yet, if the bronch were to be done, their mother more than likely would have to be intubated. But with her extensive medical history, she probably would need to stay on the vent at least over the weekend.

After a brief family conference, the family made the difficult decision to go ahead and allow the surgeon to do the bronch and risk the vent.

While the anaesthesiologist used a minimal amount of sedatives during the procedure, the patients sats consistently stayed low even on 100% FiO2, and the patient was not breathing over the vent when provided the opportunity. So the choice was made to send the patient upstairs to critical care, and to call RT to set up a vent.

As you know, when someone has to go to surgery they wave their right to a ventilator, at least temporarily. Even while a bronch is a simple procedure, it involved placing a tube in her throat, and the doctor peeking around her lungs with a bronchoscope.

As I was setting up the vent, the surgeon told me the right lung was completely filled with pneumonia, and he suctioned copious amounts of thick brown pneumonia not just from the right lung but from the left lung too.

The poor lady. My initial impression was that I'd keep her on the vent a few hours and wait for her to wake up and hopefully extubate her by morning, as I would any other post-op patient. But then I learned the story I just reported to you.

The problem with this case, as the Internist reminded me when he arrived on the scene to manage the ventilator, is that this patient is not weanable. He said, "How do we wean someone off the vent to respect a DNR order when she was on 100% to begin with. I know she's a DNR, but how do we ethically get her off the vent?

This lady was a true medical and ethical conundrum.

Did the family make the right decision? If they did nothing, there mother probably would have died soon. If they did the bronch, it might be possible to resolve the pneumonia, but still, the chance of her ever leading a normal productive life is gone. She is frail and has a terminal illness.

While the family assured me that they perfectly understand modern medicine cannot stop the inevitable, it might buy her some time, "so she can make it to her grandson's wedding in June."

Still, as one of the doctors said to me afterwords, "Are we prolonging life, or delaying death?" That is the question up for debate. What do you think? What would you do?

Blogging from work: the Unwritten Internet Code

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:

1. 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.
2. No downloading, unless it is absolutely medical related. Or unless you are absolutely burned out and figure the hospital owes you this time.
3. No going online when there is other work to do, particularly work that involves the patient.
4. 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
5. 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.
6. 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.
7. 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.
8. Do not check your emails unless it is from someone you trust. This is perhaps one of the most important rules.
9. 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

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

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

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.

Actually, the best way of improving morale is to have happy employees. If you have happy employees, everything else simply falls into place.

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 to obtaining better communication and, perhaps, better morale.

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.