An epidemic of Fake Pneumonia

It's spreading hospital to hospital, patient to patient, faster than any disease on the market. Would you believe the disease I'm referring to doesn't even exist. In fact, it's not even contagious.

I'm sure all nurses and RTs have seen it: it's fake pneumonia.

Fake pneumonia: Patients that are diagnosed with pneumonia, but there is nothing on the chart to indicate pneumonia. The x-ray and labs look normal. Auscultation reveals clear lung sounds. When the patient is asked, he or she indicates no trouble breathing. The patient says something like, "I've never been short of breath in my life."

(Click here to check the signs and tests that indicate real pneumonia)

So why the diagnosis of pneumonia. I can only make guesses here.

1. The doctor had no clue what was wrong, so he chose the most common diagnosis


2. Pneumonia is the most reimbursable diagnosis.


3. The pt looked bad, but otherwise didn't meet criteria for admission.


4. The doctor actually thought the patient had pneumonia.
5. The patient is a lot of work for a family member, and they need a break
6. There really is no reason.

And, in order to meet criteria for admission, all pneumonia patients must have Q4 breathing treatments ordered. If they are not sick enough to have breathing treatments, they are not sick enough to be admitted.

Fake pneumonia is very contagious. You cannot get it by person to person contact. You can only get it from your doctor. So be wary.

That is, unless you want to be admitted. If that's the case, see a participating* doctor near you.

*Note: Not all doctors in your area will paritcipate in this program.

A list of what I like about being an RT

Since I started this blog in October I have received occasional emails from students who are interested in going into the career of respiratory therapy. They tell me that some of the things I write about peek their excitement, and some of the things I write about make them wonder why I stay in this field.

I write about how doctors often order treatments for stupid reasons, and I created my list of olins at the bottom of this blog based on these stupid doctor orders.

Consider the post I wrote on Sunday, Dr. Krane knows all, hates us RTs, where I wrote about a particular doctor who doesn't have much respect for RTs.

AllClear, an RT student wrote this response: "I find postings like this everywhere on the net - the whole disrespect thing, cave thing, underdog'ish atmoshphere, yet many people -myself included- are drawn to this field. What keeps you in this field and going strong when up against the elitist attitudes you encounter?"

To be honest, there are a lot of good things about being a respiratory therapist, and I probably should spend more time writing about these -- but complaining and satire makes for much better reading.

Here is an extemporaneous list of what I love about being an RT:

1. I love educating people about what they can do to prevent themselves from ever coming back to the hospital again.
   
2. I love it when someone comes in with an asthma attack and the breathing treatment I gave makes them feel much better.


3. I love it when I have a patient who is SOB and I am able to empathize with that person because I have asthma myself.


4. I love it when a doctor asks me for a recommendation, and I have the answer.


5. I love it when I can use my knowledge and experience to help a person who "just doesn't look right," especially when a doctor is not immediately available and something needs to be done "right now."


6. I love meeting people and getting to know them. I love it when I learn about their entire lives in a short period of time.


7. I love working with critical patients, and the feeling that I am the only person in the hospital (I usually work alone) who can do what I do. No one else knows how to run a BiPAP, including our doctors. No one else knows how to set up a vent.


8. I love it when I tell the doctor what vent settings are best for the patient based on the cheat sheets that I made for myself, and the doctor says "that looks good to me."


9. I love it when I have all my work done I can socialize with my co-workers, read, or play around on the Internet.


10. I love learning about asthma and COPD and sharing my knowledge here.


11. I love writing about my experiences as an RT (good and bad)


12. I met my wife while working as an RT. She was an RN student following RT for the day.


13. I love talking to family members about their loved one who is on life support, and explaining to them in simple terms what's going on, and what to expect from here.


14. I love explaining to my vent patients what to expect from here.


15. I love it when an extubated patient comes up to me and says, "Rick, I was really scared until you came into the room and explained what I should expect to happen, especially when the doctor said he was going to wean me today."


16. I love it when people walk up to me in stores and say things like, "You're my little angel," or, "You saved my life."


17. I love it when I am called even before the doctor because of the magic medicine I carry in my pocket.


18. I love it when I am called "STAT" to ER because of the "ACLS" service we are proficient in.


19. I love being an expert in a difficult and invasive procedure like suctioning and ABGs.


20. I love it when I know the results of an ABG even before I draw it based on my experience.


21. I love it when I can tell just by my initial assessment what's wrong with the patient.
22. I love it that I know more than doctors about when a breathing treatment is indicated because I'm the one who assesses the patient before and after EVERY treatment.


23. I love it when doctors and hospital administrators decide to approve RT driven protocols because they have faith in our knowledge and experience.


24. I love it when a nurse calls me because she can't figure out why a person is SOB.


25. I love the Rapid Response Team that allows me to use my whit to make a quick decision to save a person, or to help a nurse.


26. I love telling a nurse thanks for helping me out.


27. I love it when we all work together as a team to help a person.


28. I love learning more about respiratory therapy.


29. I love having students, and sharing with them the wisdoms I've obtained.


30. I love my fellow RTs


31. I love the nurses I work with


32. I love the doctors who respect my ability to do my job, and allow me to do it.


33. I love when it's slow and I get to sit in the waiting room and watch the Tigers or Lions.


34. I love sharing my asthma knowledge with an asthmatic.


35. I love talking with a COPD or asthma patient about quitting smoking.


36. I love when I get called into work to help out a co-worker who's being slammed.


37. I love being organized and prioritizing.


38. I love the paycheck.


39. I love the benefits


40. I love all the PTO I get.


41. I love the flexible schedule.


42. I love 12 hour shifts.


43. I love working 3 days a week


44. I love having 6 days off in a row every other week.


45. I love it when I actually look forward to going to work because I know it's been slow there. Sometimes this is like a mini vacation.


46. I love it when it's hot and muggy outside and I get to go to work in the cool air conditioning.


47. I love it that people can't smoke at work
48. I love it that people rely on me.

The anonymous RT over at Respiratory Therapy 101 wrote Q&A post from his perspective of the job of respiratory therapy (Click here to view this Q&A) .

I agree with what he says, for the most part, except that he works for a larger hospital with much more critical patients than we get here in the small town of Shoreline.

I work here because this is my hometown, and this is what my town offers. Some RTs love the milieu of the small town setting like I do, and some love the rush of a large hospital critical care or emergency room -- not that we don't get rushes here.

Personally, I love the challenge offered me here. Yet, if I lived in a city like Grand Rapids or Ann Arbor, I would probably try my luck working with pediatrics or neonates. I think that might actually be more rewarding than working with adults.

One thing you have to understand about the medical field is that it is a flawed profession. While it's rewarding, you are still going to have to deal with the politics, pushy bosses who think in terms of money, the occasional arrogant co-worker, and doctors who order therapies for reasons that are non-scientific.

However, at the same time, these same administrators, arrogant co-workers and doctors that I make fun of on this blog do many great things that I certainly wouldn't be willing to do. Like the scheduler who has no choice but call people at 2 a.m. and risk every person in the department hating her. Or the doctor who makes fluent decisions to save a life, and has to carry a beeper 24-7.

I do not write enough on this blog of all the good things about being an RT; about working in a hospital. I will continue to write about the challenges, the rewards, the interesting cases and interesting people. I will continue to write about the diseases and RT educational materials.

But, so long as this remains a flawed profession, I will have no choice but to report on that part of the field too.

This profession has continued to grow since the days of the infamous Iron Lung, and the only way we will continue to grow as a profession is if someone is available to make doctors and administrators aware of their flaws, so we can work together to find a solution.

Plus it's fun to write satire about stupid doctor orders and inexplicable administrative decisions.

So, while it is flawed as probably all medical jobs are, or any other job for that matter, it is a challenging and rewarding profession at the same time, worth my time and effort. And if I had a chance to go back and do it all over, I'd probably go the same route.

It's also a good job for you too, if you can handle the challenge.

There will always be physicians who hate RTs

While I don't know how it could be possible, but there are a few physicians who do not like respiratory therapists.  One day, while the respiratory therapist was doing my job, or so he thought, by reviewing the chart of a patient he was taking care of in the emergency room, an angry doctor approached him.

The angry doctor said, "why are you looking at that chart?"

The RT said, "It's my job."

The angry doctor said, "No it's not."

"Well, yes it is."

"No, looking at the chart is my job."

"I have to know what's going on with the patient."

"No you don't. That's confidential."

"I was ordered to do a treatment, and I need to know about the patient."

"No you do not."

Hmmm.  By this point the blood running through the RT's veins was starting to boil, and so so he marched out of the emergency room.

He reported the physician, but nothing was ever done.  Over time he learned there were many therapists who had been cornered in such away by this doctor, and in all cases the incidence was reported, and in none of them was anything ever done.
That's just the way it is in the real world.  To reprimand this one physician based on the word of said therapists would only rock the boat, and Lord knows it's easier to listen and do nothing.

Doctors like this, far and few between I must add, do come around from time to time, and we RTs simply have to grin and bear it.  They think we RTs are mere ancillary staff, not trained with any medical skills that might benefit them and the patient.  They do not, as a matter of chance, ever ask for advice from a lowly RT.

One day I was helping a coworker take care of a COPD patient in respiratory distress.  My coworker knew the guy and was chumming with him.  The doctor pulled him aside and said, "Please don't talk to the patient, he needs to concentrate on his breathing!"

However, the doctor's order was not complied with, because my coworker's bantering with this patient was well received by the patient.  The doctor was wrong.

Justice was when the patient called for the supervisor to complain, not about the bantering therapist, but the physician.

One of my RT friends emailed me once and said she heard one doctor say: "Stupid RTs think they know everything."

It's true!  It's rare.  But it happens.  There are pathways to solving such problems, but professionals learn how to cope with these kind of things.

Dry drowning: Drowning on dry land

"Did you ever hear about dry drowning before?" my wife asked.

"No." I said.

She told me that according to a woman on one of her nursing websites, one lady was writing about how she took her eight-year-old boy to the beach, and on the way home he lost control of his bowels. It was unusual, but she chocked it up as him just being exhausted from swimming.

When she got home she noticed he seemed very tired, so she had him go to his room and take a nap. He never woke up.

On autopsy, he was diagnosed as being a victim to dry drowning. This occurs to about 100 kids per year about the same age as this ladies son. However other estimates show that it's about 10-20% of all drownings annually.

Usually what happens is kids who think they know how to swim but really don't end up inhaling a bunch of water, and this water sits in their alveoli making it difficult to exchange oxygen.

Actually, the patient may be rescued from a near drowning incident, be considered to be completely fine, and then die 1-24 hours later of dry drowning.

Thus, instead of drowning under water, the child drowns on land. Squidkid wrote an excellent article on this. Injuryboard.com also has a good write up.

According to WebMD, "This can result in laryngospasms, which minimize the amount of water aspirated into the lungs. Respiratory arrest may follow, leading to an inadequate supply of oxygen in the blood, cardiac arrest, and eventually brain death."

The laryngospasm is your bodies natural response to inhaling a foreign object into the lungs.

According to Wikipedia, "The laryngospasm reflex essentially causes asphyxiation and neurogenic pulmonary edema."

To add to the problem, during this process an increased amount of blood is circulated to the pulmonary system. This overwhelms the heart with blood, and causes it to pump harder. In the lungs, the pulmonary vasculature is narrowed, "narrow enough that red blood cells have to pass through in single file."

The walls of the arteries also become very thin to enhance the lungs ability to exchange oxygen and carbon dioxide, however there is no oxygen to exchange. "This partial vacuum draws some of the fluid from the vasculature and into the air spaces of the lungs, creating pulmonary edema, and the patient is now drowning in their own fluids."

To add to the problem, the sympathetic nervous system causes constriction of arteries and veins, which results in increased blood pressure which further exacerbates the pulmonary edema.

This is not unlike another process we RTs are familiar with: ARDS. ARDS "is an acute, severe injury to most or all of both lungs or electrolyte abnormalities resulting from a dilution of the blood after aspirated water is absorbed into the blood, leading to heart rhythm abnormalities."

Slowly, they die of hypoximic hypoxia. According to one doctor there is nothing that doctors can do to prevent death in these dry drowning kids even if they make it to the hospital. However, I don't necessarily believe that. I think we'd treat it just as we would treat ARDS, and the survival rates of ARDS are going up.

Another time dry drowning can occur is with a torture technique called water boarding. This is where one person will pour water over the head of a prisoner to make it feel like he is drowning. This is done to get people to talk.

So, who is at risk? Definitely first time swimmers, or, as I mentioned above, children who think they are good swimmers but really aren't. Children and adults with pulmonary illnesses such as ASTHMA "may also be at increased risk for drowning."

How do you prevent dry drowning? According to WebMD, "use common sense and never let inexperienced swimmers in the pool without a lot of supervision."

What are signs of dry drowning?

1. coughing


2. shortness of breath


3. chest pain


4. change in mental status


5. strange behavior


6. lethargy

If you witness these symptoms in your child after he or she spent time in the water, you need to get them to the hospital immediately.

And, when your children are in the water, they need to be very closely supervised.

My turn to do stupid

I'm quick to criticize doctor's and nurses when they do stupid things, so tonight I have to do the fair thing and criticize myself.

The door to the elevator swung open, and lying on the floor of the lobby was a man -- not moving.

"What's going on here," I said, rushing to the man's side.

"He came to the desk, said he took too much Xanax, and collapsed," the front desk clerk said.

I shook the guy, yelled at him, and he made no response. I checked for respiratory rate, and he didn't appear to be breathing. I checked for a pulse, and found nothing.

"Call a signal!" I said to the desk clerk.

The nurse showed up seconds later, and showed me off. "I have a good pulse right here, radial."

So we live and learn.

This RT thinks IPPB therapy is useless

So, I'm watching this old show called Emergency for no better reason than the fact I loved this show when I was a kid. I remember watching it in, say, 1976 or so on Saturdays. In fact, every Saturday I looked forward to this show.

Anyway, it's 30 years later and I find a re-run of this show at 3:00 in the morning while I'm working one night here at Shoreline, and just as I'm about ready to get up and go check on my patients, the scene switches to a patient in critical care on a ventilator.

The room looked nothing like the rooms of today, and the acting was of questionable quality, but I can tell you that my eyes lit up when I saw the ventilator: a bird mark 7 respirator.

Heck, we have these sitting at the back side of our respiratory storage room collecting dust, and most hospitals have probably thrown theirs out or given them to some foreign nation as a charitable donation.

What a sight it was not just to see this old IPPB machine, but to see it used as a ventilator.

Believe it or not, I have seen this machine used as a ventilator short term during a catscan of an intubated patient, but that was before we had super fast catscan technology, and before the advent of the transport ventilator.

And to believe that on occasion we still use this piece of junk, the same piece of junk that was used to ventilate patients 30 years ago, is scary medicine.

Last weekend I could have choked one of my co-workers because she asked a doctor to write an order for this machine. I wanted to choke her because it was a doctor who never would have thought of ordering this on his own.

However, I diplomatically smiled at my favorite co-worker and said, "Cool."

Why was I disgruntled at this IPPB request, when my co-worker was only trying to do what she thought was best for the patient? Because I'd hate for this doctor to learn to like the IPPB and want to order it again.

Yes, the patient did get better that day, but it was his fourth day post-op, and during the night before I had decreased his oxygen from a NRB to a 50% VM. He was making great progress with cough and deep breathing excercises and Preventolin breathing treatments alternated with cracklin nebs to re-inflate the collapsed alveoli (see olins bottom of blog for more detail here).

Needless to say, the IPPB (Bird mark 7) was a good machine in its day, but now its used to force air into a patient and force them to take a deep breath -- if it is used or taught properly, and it rarely is.

The theory is that it is good for post-op patients, in that it works as a glorified incentive spirometer to expand collapsed (atelectic) alveoli, and exercise the good alveoli. It's about a 5-10 minute therapy session.

However, most studies show that all the IPPB really does is over-expand the good alveoli, and does nothing for the collapsed alveoli. In other words, it's an over-hyped piece of junk.

(Click here for a video of how the IPPB works that might soon be seen only in RT museums.)

Now, some of the RTs who have worked here a lot longer than me, however, truly believe this IPPB can do some good for some patients. They say that it has kept some patients off the ventilator.

However, I think what really kept those patients off the ventilator was the special attention they received from the RT, the incentive spirometry enforcements, the encouraging of the patient to cough and deep breathe with good breath hold. All of that coupled with moving the patient as often as possible.

I don't think it was the IPPB that made my patient better. I hate that thing. I think it's an ineffective waste of my time and the patient's time. I think the only thing it's good for is good old TV, like I saw the other day when I watched that old re-run of Emergency.

I loved that show.

Further reading:

• Up with IPPB (coming soon to RT cave)
• Down with IPPB

You absolutely do not want to be suctioned

As I was reviewing my patients chart at around 10 p.m. last night, a saw an order that I as not informed about in report. The order was this: "RT to NT suction patient Q4-6 hours with breathing treatments."

I just about flipped. You can bet that I cursed. I couldn't help it, this may simply be one of the stupidest (is that a word?), doctor orders in the history of my life.

It was about as stupid as when i was a patient last October, and this very same doctor ordered a foley catheter for me -- of which I so duly refused. I certainly didn't need a tube stuck into my privates when I was fully capable of going to the bathroom on my own.

Thank you, but no thanks.

I looked further, and the doctor wanted the NT suctioning to be done in order to get a sputum sample. I have to tell you something dear readers, and this brings me back to my very first RT Cave Rule:

RT Cave Rule #1: NT suctioning is a very traumatic procedure to be done only when excessive secretions are disrupting a patient's breathing and all other options have been exhausted.

Now, allow me to tell you about this patient. He was a 29-year-old man who came to the hospital seven days ago because he had been suffering with very bad side pain for about three days. The general surgeon ended up having to do a laparastoc surgery on him to remove his appendix.

On his second day after the surgery an RRT was called on him because his SpO2 dropped into the 70s. He had developed some atelectasis and maybe even pneumonia due to his not taking deep enough breaths for all this time he has been hurting.

But, in the past two days we had weaned his Oxygen down from 100% to 4LPm. He was obviously getting better. So, now, why the hell would a doctor want a sputum sooooooo bad that he has to order this invasive procedure? I'm telling you, this procedure is really terrible.

"We need to suction this patient after the next treatment, Rick," the patient's nurse said. She was a relatively new nurse, and was quite laconic.

I was blunt: "Absolutely not. There is no damn reason this patient needs to be suctioned."

"Well, it was ordered, and if you're not going to do it than I'm going to."

"How would you like it if I poked a tube into your nose and sucked the air out of you while you were completely awake, and do this very traumatic procedure for no flipping reason at all."

"The doctor needs a sputum sample. And the patient isn't spitting anything up."

"The patient has been here for four days, and has been on antibiotics all that time. What good is a sputum going to do now. It's an absolutely stupid procedure." Besides, the doctor doesn't NEED this sputum, he WANTS it. "Would you want someone sticking a tube up your nose?"

I looked at the other nurses: help anyone???

"Absolutely not," one of the other nurses put a finger in her throat and feigned a gag. "No way would someone stick that down me. That's absolutely inhumane." Ah, right on cue.

"It is inhumane," I said. I looked at the melodramatic nurse, a nurse I knew had excellent common sense and I knew she would agree with me on finding a way not to suction just because an order was written, and then at the attending nurse.

"Well, we really need to do it," the attending nurse said.

"Awwww, I would never..,." the melodramatic nurse made a noise like a disgusted cow, "No way. I.... whooooo.... I would never want THAT done to me. NOOOOOO Wayyyyyyy."

I was hoping this melodramatic display would convince her coworker here that this was one doctor order that should be skipped, but in a professional way of course.

"Well, we still need to do it."

I said no more. I knew a losing battle when I saw it. Besides, I had a great working relationship with all these nurses, and I didn't want to insight flames. There's more than one way to skin a cat, and I'll figure something out here.

Now I had to do some damage control.

"Sorry, I didn't mean to get you mad at me," I said to the attending nurse, " I just think this is an asinine order." Plus I'm extremely tired, and have lost my ability to be diplomatic.

"That's okay. You don't have me upset. I understand your point-of-view. I'll just do it myself."

Now she had me feeling guilty.

I did a review of the chart, and learned that my co-worker on day shift yesterday, the same one who had, I thought, conveniently forgotten to tell me about this order, had attempted the NT
suctioning of this patient immediately after the initial order was written.

Joy rushed up my veins as I read her charting.

"I see here that my co-worker had already attempted to do this yesterday," I said, "And all she got was a little blood." Figures, thought, because the blood was probably from scraping the back of his nose with the catheter.

"Well, still, I'm just going to have to try for it after your next treatment. That's okay, just let me know when you do your next treatment."

Ahhh, you're about as obstinate as myself. Okay, you win. I will find a way to get a sputum out of this man one way or another.

I woke the guy up from a sound sleep. "Oh, please, do you have to do this now," he grumbled.

"No," I said.

He went back to sleep.

"He refused," I said to the nurse.

"Okay," she said. Wow, that was easy.

But, the responsible thing to do was to try again.

Two hours later.

"It's time for your treatment. We have to do it this time." Whether you need it for those crackles or not.

"Oh, okay," he grumbled.

"After this treatment," of which you do not need either, "I'm going to to have to suction you like that lady did yesterday."

"What's that?" His eyes became big.

"That tube in your nose."

"How often?" He was looking me square in the eyes. Looking in those things, I could read his thoughts.

"Every four hours. That's what the doctor wants."

Why don't you simply refuse? Please just refuse. I don't want to do this to you, and you don't want me to do it to you. Please just refuse.

I watched him as he did his treatment. I could see he was deep in thought.

"Okay, we're finished, why don't you roll over so I can listen to you," I said, after I snatched the nebulizer from his, rolled up the O2 tubing and stuffed it into the plastic bag.

He painfully rolled. He took in a deep breath. He produced a mouthful.

"Don't spit."

"Oh, I most certainly will not," he mumbled through closed lips, making sure not to swallow.

I placed the cup by his mouth, and he let the thick yellow and blood tinged sputum slide into the cup. I closed the lid.

"I got your sputum," I said to the attending nurse as I left the room. " I scared the S#$# out of him, and he responded. Works every time."

She gave a faint smile, "Awesome."

RT Cave #29: If the doctor orders for a patient to be NT suctioned because the patient cannot obtain a sputum sample on his or her own, explain the procedure, make it sound as miserable as it really is, and wait for that sputum to find its way into the cup.

An RN kills her RT husband

When I woke up today my wife told me she watched an interesting news program on TV last night. She said it was particularly interesting because the program was about a nurse who was married to a respiratory therapist, just like she is an RN and I'm an RT.

Only, this couple was newsworthy because the RN wife was accused of killing her RT husband.

She may even have gotten away with it, my wife said, if the wife hadn't lied. He was dead, his bed was burned, and all they had against her was circumstantial evidence.

Well, obviously she was going to lie about the murder. Of course "I didn't' do it" applied to her as much as it did to OJ. The problem with her story was that she said she did not leave the hospital during her shift, and the video surveillance camera clearly showed her leaving and returning 17 minutes later.

If she had told the truth, her lawyer probably could have argued that she couldn't possibly have left the hospital, poisoned her husband with whatever drug is used to put people under during surgery, set the bed on fire, and returned to work in 17 minutes.

But she lied. So, anything she said would be thought of as a lie. And, therefore, the jury decided that she did it. She was found guilty of murder.

They decided that she had intended to set the entire house on fire, but she set the bed on fire and that's all that burned. So, they had a body and were able to do testing on it and end of story.

Anyway, I told my wife I'm hoping she didn't watch that show to learn what not to do when she kills her RT husband.

"Yep," she said, "I won't lie."

More money wasted in the ER

Well, you get what you deserve. After I jinxed myself yesterday morning when I gloated about not getting paged once on my shift Thursday night, I ended up spending last night in ER until about 1:00.

No, I didn't save any lives. In fact, I really didn't do much good at all. But, the doctor wanted those Q1 hour treatments on all her SOB patients. Who did the infamous Dr. Krane order Q1 hour treatments on last night?

1. A lady with a history of pneumonia.


2. A lady who was diagnosed with a pneumo


3. An elderly gentleman with lung cancer (Left lower lobe removed) and Lymphoma. He never smoked a day in his life, so I would rule out COPD here.


4. An elderly man who was scheduled to have a pleural effusion drained. He was diagnosed with sepsis and probable pneumonia.


5. PE.

Sure, these all presented with symptoms similar to asthma, and the initial treatment did help on a few of these, but treatment # 3, #4 and #5 certainly weren't indicated.

Let's see. According to my new research, that is $88 * 5 = $440 worth of treatments when one and a good assessment would have been suffice.

ER treatments at our hospital are $88 a piece. Pharmacy probably charges even more for the medications used.

If Obama and McCain want to address something that would benefit the health care crisis, this is it. What a waste of resources.

Check out my 'olins at the bottom of the blog. I've finally updated them.

Be silent and you will not jinx yourself

I knew I shouldn't have said it when I did say it, but the need to gloat was sitting their in the back of my throat. I should have resisted, but I just couldn't.

"Do I need to tell you what happened to me last night?"

"What? she said.

"You know, I'd hate to jinx you by telling you how this beeper treated me last night," I said, as I grabbed the thing from my pocket and proffered it to my relief.

"Maybe you better not. I don't want you to jinx me." She grabbed the cold object and stuffed it into her pocket.

I don't want to jinx myself either. "Oh, but I feel like I need to gloat."

"I don't even want to know." She was smiling.

You know. I know you know. "Not only did ER not page, this thing never even went off at all last night."

"You bum."
------------------------

Twelve hours later, the tide had turned

"You bum," she said as I sauntered into the department sleepy eyed.

"What?" I said.

"You jinxed me. It was nice for a while, but then all shit hit the fan. I've been in and out of ER all day."

"Then I jinxed myself too."

I've been in ER all night.

And this brings us to RT Cave Rule # 28:

RT Cave Rule #28: If you are having an exceptionally good night at work, do not gloat about it. Not only will you jinx the incoming RT, you will jinx yourself. If you are having a good night, do not mention it lest the good night will end.

This is just one of many RT superstitions (for more, click here.)

That, my fellow RTs, is the RT thought of the day.

Ventolin does not prevent asthma -- my opinion

When I was 15 and a patient at National Jewish in Denver, all of us asthmatic kids were forced to take 2 hits off a Ventolin inhaler prior to working out.

"Why do this now, when I'm going to need it as soon as I finish working out," I said once. My gym instructor made me run an extra lap for my mouth. So I learned not to speak up, regardless of my opinion.

Still, as soon as I was done with an aerobic session, I found that I needed a little hit of Ventolin regardless of the pre-workout dose. Not always, but there was still that bit of tightness after working out.

In retrospect, I think that even 18 years ago, long before I would even think of entering RT school, I was questioning doctor orders. Still to this day I do not think that Ventolin is a preventative medicine, but it's still ordered that way.

Why else do you think doctors order it QID on COPD patients who show no signs of being short-of-breath, or TID or even Q4 for that matter. At least in the hospital, I see no need to order Preventolin. A steady dose of Allbetterol might work better for some of the sick patients we have, but not Preventolin.

The other morning I had to give a treatment of Ventolin 30 minutes prior to a stress test. This was on a lady who had a history of asthma, but has not had a problem this visit. If she's SOB I see no problem with this, but not just because.

"Well, she has exercise induced asthma," my RT co-worker said.

"So, that's not a preventative medicine."

Is it? I have heard this talk all my life, but on me personally, taking a hit of Ventolin has never prevented asthma. There are other more appropriate medicines that can work preventatively, like Flovent, Atrovent, Singulair, Advair, Azmacort, Spiriva. These are medicines made to help prevent asthma. Ventolin does not prevent.

I have talked to an Internist of whom I really respect, and I asked her if we could DC the treatments that were ordered QID on a COPD patient who had been on treatments for two weeks, but never indicated any signs of SOB.

She said, "NO. We need to keep the Ventolin in his system to prevent an attack. You know that!" She looked at me like I was a dufass.

Oh well. That's all I can do is state my opinion. I have that right. I have a right to my opinion, I have a right to be wrong. I have a right to be stupid. We all have a right to form opinions, as have all the doctors and nurses.

It's one of the better parts of living in America.

Again, I have had asthma almost my entire life. I have been using Bronchodilators off and on since I was about five, have had my own inhaler to abuse since I was 10 (Alupent), have had a prescription to Ventolin since 1991, and have never noticed Preventolin (that's what I call Ventolin when it's used to prevent asthma) ever having an effect on me.

If I was going to have an exercise induced asthma attack, it's going to happen regardless of whether I take a hit of Preventolin. In fact, that's why I take Advair and Singulair, to prevent me from having problems while running. And I do run (okay, since you want to be technical, I jog) 2.5 miles every other day without having asthma, and without using Preventolin. I also do not use Ventolin after I work out.

I've never noticed it to prevent anything. I do notice it treats bronchospasm, but that's old school now I guess. Now that Ventolin comes packaged and marketed as the next coming of holy water, it seems to have unlimited uses.

For more uses for Ventolin, check out my list of 'olins at the bottom of this blog. Of course this is all in good fun, and it's all at the expense of stupid doctor orders -- my humble opinion of course.

Please feel free to agree or disagree with a comment.

A night shift RT gets to work days

Well, I just thought I'd report here that work called and asked me if I would sacrifice part of my day off and work from 9-12 on DAYS. Being the nice guy I am, I said, "Definitely."

I'm telling you, that after working nights for 10 years, days is like a whole different world. You have doctors, suit coats (administrators), family members, and meals to work around. And that's not even the worse part.

The worst part, is when I got all my treatments done, and still had three hours to kill, I didn't know what to do with myself. I'm certainly not going to stock considering I'm doing a good thing just by my showing up.

So, I did the next best thing: I hoped it would get busy.

I would never do that on nights, considering if it gets slow on nights, I can hide out in the RT Cave, or I can sit in one of the waiting rooms and watch TV, or I can play on the Internet. Those really aren't options during the day.

Then, a neat thing happened. Within moments of my thinking this, I was called STAT to ER, where I spent the rest of my brief shift taking care of an 84-year-old lady.

The initial report was that she was coming in by ambulance, was a full arrest, but after epi she had a good heart rate. She had a history of brain aneurysms that she decided to not have anything done about, and she definitely did not want life support. According to her daughter, "She just wanted to bide her time."

Well, here time is up. CT showed massive intracranial bleeding.

It turned out to be good for her, though (in an ironic way), because she was doing something she loved to do when she died: shopping. She was at Lowes buying stuff for her beloved garden. And, her daughter reassured us, she lived a wonderful life.

After the doctor pulled the family aside, they made the right decision to extubate the patient and let her go with her maker. So I got to do another thing that I rarely get to do on nights: extubate.

And, the greatest irony of all, right after I shut off the Ventilator and was pulling out the ETT, a familiar song was playing on the overhead speakers: "Rock-a-bye-baby on the tree top, when the wind blows, the cradle will drop."

That's a song we hear every time a new baby is born at Shoreline. So the dry irony here, is while one was going out, another was coming in.

Not much, but that is the thought of the day.

My Dr. now prescribing Singulair for allergies

My Internist and I had a neat little conversation about medical fallacies yesterday. He assured me that it isn't just RTs who get irritated with people getting all excited over "one" study.

I wrote here last December how I was hospitalized with a bleeding ulcer. My Internist wasn't the one who took care of me then, and he asked me if the surgeon who managed my care ever determined the etiology of my ulcer.

"Well," I said, "At first he said there was a 90% chance it was caused by H. Pylori, then he said the test came back negative. But I think I had H. Pylori, because I could have sworn when I looked at my chart the test was positive."

"I guess it really doesn't matter," he said.

"Why do you say that?"

"I think the H. Pylori thing causing ulcers is over hyped." Then he rattled of some facts so fast they rolled right over my head.

"How do you think I got the ulcer then?"

"Nobody really knows for sure. It's just since many people have H. Pylori, some people say that is what causes ulcers. The truth is, they really don't know. So the pharmacy company has us doctors treating the H. Pylori, and all it does is run up the medical bill."

I wanted to say, "Kind of like Ventolin." But I held my tongue.

Later I told him how miserable I was last spring with allergies. "I decided I can't suffer like that again," I said. "This year, since you started me on Singulair, it's almost amazing the difference. It's almost like I don't have asthma."

You must note here that when I mentioned to him last Jan. that I should try Singulari, he told me he thought that drug was over hyped. In May I told him how wonderful the medicine was working for me.

He said, "I just started a new person on Singulair today based on your testimony last time you were here."

"Cool," I said, "I have heard some bad things about it, though."

"Really, like what."

"Well, one kid was having suicidal thoughts, so now they blame it on Sinulair. Like you say though, I think it's all overblown."

"Yeah, I've heard that too now that you mention it."

"So now you have a lot of moms taking their kids off Singulair based on the this, and it's very unfortunate. My childhood sucked because I had allergies so bad, and my doctor wouldn't even let me have anithystamines because on the box it said not to take it if you have asthma. Now they have this new drug that will allow these kids to live normal lives, and parents and doctors won't let their kids take it based on a fallacy. It's a shame."

"I agree."

"So, anyway, my allergies are basically non-existent right now, and I give Singulair credit. Of course it could be a coincidence, so I'm still open minded. But it seems to be working great."

"Cool."

"I kind of joke about it though. I tell everybody that since I started on Singulair I don't have allergy problems anymore, but I have suicide thought."

"Yeah," he laughed, "If your allergies come back you'll kill yourself."

There's some truth to that, too. I can understand how allergies can get so bad sometimes, that you might rather be dead. There were times when I was a kid, and even as recently as last summer, where the allergies were just unbearable. (Not that I would ever kill myself, I'm just saying that allergies can cause severe misery).

Singulair is a great medicine. It has worked a miracle for this RT. I think all asthmatics should at least try it if nothing else works, it beats the alternative of being miserable all the time.

Another bad thing about Singulari is it is expensive because it is still under patent.

Related articles: Some drugs get a bad rap, and Singulair: Another asthma miracle drug.

Treatment Jockeys and Button Pushers

These are two more types of RTs to add to our list of "The different types of RTs." We'll add this to our RT lexicon.

Treatment Jockey: An RT who goes about his job of passing out breathing treatments without questioning whether they are needed or not; an RT who just does what he or she is told, no questions asked. Quite often, these types of RTs are well liked by RT Bosses and Administration Officers, and doctors seem to like them too because they usually don't provide the lip. However, treatment jockeys tend to not do so well under stressful circumstances.

These types of RTs are related to button pushers who work in the critical care unit.

Button pushers: An RT who works with ventilators in the critical care unit and all he or she does is push buttons without questioning orders. Initial ventilator settings and all succinct ventilator changes are made by the RT pushing a button, but what to change is decided by the doctor. This type of RT is more prevalent in smaller hospitals that don't have ventilator protocols. However, even with a protocol, this type of RT finds it easier just to call the doctor than risk making a mistake.

These types of RTs are related to the treatment jockeys who work throughout the hospital.

Button Pushers and Treatment Jockeys are more prevalent of the contents and the quitters, and only about 20% of the complainers. The learners and the leaders tend lead the charge away from the button pusher/treatment jockey era.

As the latest statistics show, the number of Pushers and Jockeys has actually diminished over the years. In 1965, when most RTs were OJTs (on the job training), 71.2% of all RTs were were among these types, and by 2005 their numbers had dwindled down to about 30%.

The reason the numbers have not dropped further, experts figure, is that some RTs in certain hospitals develop poor attitudes because a few doctors don't want to give up autonomy to RTs.

However, this attitude is quickly changing with the advent of protocols and improved RT morale.

One of the reasons for the steady decline is the improved educational requirements imposed by the NBRC, coupled with all the great RT programs across the country. It is a simple fact that RTs are slowly generating improved respect within the medical community.

The number of Jockeys and Pushers is inversely related with respect within any respective RT department. You will see that as the percent of the previous declines, the later increases.

Humility is the key to success as an RT

I would like to ad something to what I wrote yesterday. That along with all the great things about being an RT, the politics gets pulled right along. And the best way of dealing with politics is good old fashioned humility.

Sometime in life we have to do things we don't want to do. One of the biggest reasons for this is pure-D-politics. As much as we hate politics, we all get caught into it on a daily basis whether we want to or not.

Yesterday I wrote that I have learned that it is best to keep my mouth shut than to have the nurse telling me I'm a lazy RT who is just trying to get out of work. I'm not trying to get out of work, just being honest. That, my friends, is politics.

One of the things I have realized about the drug Albuterol, is that it basically has no side effects. It might make a person shaky, but that's a mild problem. It may make the occasional heart palpate, but that incidence is far and few between now that the "bronchodilator" has been so chemically refined.

And doctors know that. So, they decided long ago that it is better to give a bronchodilator than risk being seen as doing nothing. It is easier to just give the bronchodilator, than to assess the patient and waste your time thinking.

There are RTs that do this. There are RNs and doctors who are victims as well. When an RT does this, they are called treatment jockeys (more on this tomorrow). When doctors and RNs do this, they are just doing their jobs.

None of this would be possible, however, if not for the fact that this drug has been so refined. This refining has made the perfect medicine for bronchospasm.

But, with all good things must come the bad. The bad is that the refining has taken away our need to second guess whether a treatment is needed. "Oh, there are no side effects, so let's just give this treatment and see what happens."

And, if the RT complains, it's because he or she is lazy. So we RTs have learned to do our own PR and do not complain where others can hear us (well, most of us don't, or most of the time we don't). Then we just shut up and give the treatment.

You want to know why I really give the treatments even though I don't think they are
indicated?

Because in life nothing is certain, and nobody is perfect, and I could be wrong.

And, even though sometimes I am quite certain I am right, humility, keeping the peace, is often more important that being right.

Allow me to quote something Biblically. This is not from the Bible, but it comes from a religious pamphlet, so it's pretty close to the Bible: "Lowliness of mind, or humility, can help you suppress the urge to insist on being right in a disagreement."

So, I suppose, what it comes down to is humility. And, to put it simply, humility is the key to success as an RT, especially when it comes to maintaining a good rapport with the rest of the people we work with.

This brings us to RT Cave Rule #25:

RT Cave Rule #25: The key to maintaining a good rapport with the other people we work with is good old fashioned humility. It's okay to not let people know that you are right.

And now for RT Cave Rule #26:

RT Cave Rule #26: A good RT will admit when he is wrong.

Allow me to add to this post one quote I read in a good book that fits in well here. In fact, I'll just make this another RT Cave Rule:

RT Cave Rule #27: "When a person complains, he is saying more about himself than about the person he is complaining about." Therefore, the most respected people in life are those who do not complain.

Thus, it is just better to bite your lip and get yourself burned out doing frivolous therapies than to complain.

There are exceptions to this rule, however. If there weren't exceptions, there would never be change brought about, and we would not have protocols. There are those among us who have the ability to get their way. They are the smooth talkers.

So, if you are not a smooth talker, like I'm not, you're better off using your humility and just keeping the peace.

An RT co-worker of mine likes to refer to us RTs as keepers of the piece. He says that one of the main jobs of us RTs is public relations. We are the PR department.

Which isn't so bad I suppose.

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

An honest RT has "A bad attitude"

I didn't mean to be rude to the nurse, I was just being honest when I said, "This patient is wet, he doesn't need a breathing treatment."

"That's a bad attitude," My RN friend said.

"I'm just being honest."

That's exactly why we RTs go about our work, keep our mouths shut, and grumble and gripe to ourselves when we get tired of being called every five minutes for another treatment for some stupid reason.

This time, the patient had swollen ankles, diminished lung sounds coupled with a throat squeak indicative of CHF. Oh, and he also had a cardiac history.

I thought for a second about educating her on why I thought a treatment wasn't indicated, but decided better. It's easier just to keep my mouth shut, and let her think I'm just being grumpy.

One of my co-workers told me he told a nurse the other day a patient didn't need a breathing treatment, and the nuse said, "You're just trying to get out of work."

In other words, we RTs are lazy. We just want to sit in our RT Cave without being bothered.

So, basically, when we are called because a patient is SOB, or has some annoying lung sound, we have no choice but to give a treatment, whether it's indicated or not.

Mind you, it's no big deal sticking a pipe in some one's mouth, it's just the principle of the matter that counts.

It should speak highly of us RTs that more often than not we simply give the breathing treatment just to keep the nurse happy; to keep the peace. At least that's how I usually work.

For me, secondary to taking care of the patient, there's nothing more important than maintaining a good rapport with the nurses.

This brings us to RT Cave Rule #24:

RT Cave Rule #24: It's better to just keep your mouth shut and give the breathing treatment, than to risk being told that you are lazy and just trying to get out of work.

That, my friends, is the thought of the day

No medicine works the same for every patient

Every once in a while I get involved in an intelligent discussion with one of my patients that I have a difficult time plucking myself away from. Like I have a choice, when my beeper tends to take care of certain things for me.

While my patient was puffing away on her pipe, her husband was talking to me about medicine. He started by asking some intelligent questions like, "How do you know that medicine in that pipe is working?"

I told him how I would determine that, which basically involves asking the patient, assessment and the infamous peek flow meter.

He seemed impressed by my answer, or the excitement in my answer when I did so. I could tell almost immediately that these were intelligent people who were directly involved in their care, as opposed to most patients I work with on a nightly basis.

Then this guy went further, telling me there are some doctors who treat every person the same way with the same drug, when, in reality, no medicine works for all people. That is, despite pharmacy companies marketing that their product is the cure all for this illness.

"Some doctors buy into it," he said, "but others fail to realize that there is no medicine that is the cure all for any illness. The most you can expect out of any such medicine is that it will work for about 6 out of 10 people it's used for. And, if it doesn't work, some other therapy should be tried."

"Yet it's still used for everybody with a certain illness or symptoms regardless," I said.

"Exactly.

"You know what," I said, "This medicine I'm giving your wife right now would be a perfect example. I talk all the time how it is used for every annoying lung sound, for all people that are SOB. But it only works on a those patients that are having bronchospasm."

"Yep. That's exactly what I'm talking about." He looked gleeful, like he was really entertained by this intelligent discussion. "The company probably marketed it as the ideal medicine for any pulmonary problems."

"And when we try to tell a doctor that it isn't working for a patient, they don't listen to us. They say the patient has bad lungs sounds, or the patient is short-of-breath, and therefore a bronchodilator is indicated. In fact, most of the time, they order this medicine simply out of habit, rather than by actually assessing the patient. I don't just think that, I have watched it with my own eyes."

"Exactly. As you are in here every four hours to assess my wife, you know more than anyone whether this treatment is really indicated."

"Wow," I said, "You could have my job. You know exactly how the medical field works. I wish more of my patients were as intelligent as you guys. I spend hours discussing how frivoluos some of the therapies we do are, most of the time I feel as though I'm just blowing against the wind."

"That's why you have to be careful who you choose as a doctor," I said, thinking of my own quest to find a doctor I clicked with. "You have to find a doctor who fits your style, and your personality."

This guy has to have some connection with the medical community, I thought at this point.

"Exactly," he said, "I had the same doctor for 50 years," he said right on cue. "I don't like change much. But when he died, it was a stuggle to find a new doctor."

Turned out he was best friends with a doctor who worked in this area for over 50 years and has since expired. Turned out he and his wife had been through the rigmarole of various illnesses with themselves and their children. So it only made sense that this couple has formed the same opinion of medicine as myself; as many of my medical co-workers.

I wish that more people had the common sense to see that doctors are not gods, that they do not have all the answers, and that there is no such thing as a cure all medicine for any particular disease or symptom, as the pharmacy companies will have us believe.


There are patients who rush to the hospital begging to try some miracle drug, and too many doctors willing to prescribe based on what they heard on TV. It goes both ways.


Yet, still, too many doctors order based on habit. Every person with any adventitious lung sound gets a bronchodilator treatment, every person with this disease gets this drug or this therapy.


It simply doesn't work in the real world. Yet, in the real world, however, this is what we have to deal with.

Is it too much to ask for a little more common sense when it comes to medicine? Perhaps then we could cut back on a good portion of wasteful medical expenses.

No human is worthy of god status

One of the things about this job, is it is absolutely not predictable. When I left work Sunday we were finally down to to seven patients, and things were starting to look really good.

Sometimes I wish I had the power to predict a good night, but only God has that power.

I take two days off, and come back to work with 16 patients on breathing treatments. I'm not sure how many of these patients actually need these treatments, but that's beside the point.

The doctor thinks the treatments are needed, and that's really all that matters. Our RT bosses are more than happy to absorb the extra money they will generate. RT bosses aside, I want to take a moment to talk about doctors.

I know on this blog I spend a great deal of time writing about humor I find in stupid doctor orders. I know that there are people out there who think everything a doctor says or does is gold, but the truth is doctors are humans just like you and me. They are not gods.

On a similar note, I am not a god either. I read somewhere that kids think of their parents as gods. We are everything to them. They worship us. My kids worship me. It's true. My nine year old thinks I can't do wrong. He learned to love baseball because he wanted to impress his god -- me.

Truth be told, however, I am no god. I am not worthy. Just as a doctor is not worthy of god status. No disrespect here, it's just the truth.

However, like a god, I am feared by my kids. When you fear someone, it's because you respect that person. When you know there are consequences to disrespect, you have a tendency to spend a lot of time trying to be good, especially around the people you respect.

And, like the One God, if I do a good job of raising my kids, they will continue to make decisions not so much out of respect for me, but out of respect for themselves once I am not there for them, or once I am but a voice in the back of my child's mind acting as a conscious.

This voice saying: "Don't do that," or "I wouldn't do that if I were you."

So, while I am not a god, I am like a god to my kids. And, while doctors are not gods, they are like gods in the medical community. They are revered and honored in ways others are not.

When a doctor comes to the nurses station, I usually get up and offer him or her my seat. This used to be standard practice back when nurses used to have to wear those cool white caps, but it's a practice reserved for respectable people like myself.

Doctors are gods in a way that they are able to save lives. They are gods in that they have the ability to overrule any medical thought I have. I can have this idea that this treatment is completely useless, but if the doctor ordered it, I must do it (within certain limits).

In that sense, doctors are like gods.

Occasionally my fellow RTs or I approach the RT Bosses to see if we can do something to get doctors to stop writing orders we think are stupid. The RT Bosses treat doctors as gods, and therefore they don't want to do anything to over rule them.

I think it's funny how the medical staff has to stay awake for an entire 12 hour shift no matter how busy it is, but if it's slow a doctor has a bed that he can sleep in. If it gets busy, we just wake him up. This, in essense, is on par with god status.

We RTs can ask for something 100 times, but if a doctor asks for something once, it's as good as done. As least that's the take I have on most hospital administrations.

Despite my RT humor, I want my readers to know that I truly do respect doctors. I couldn't do HALF of what they do. I certainly wouldn't want to take the responsibility they have, and have to purchase the liability insurance that goes with that responsibility either.

Still, as with us dads, as with all people, doctors make mistakes. Doctors are prone to be stubborn. Doctors hold on to old fallacies that have been disproven since they left college. Doctors do order things based on habit, rather than based on science. Doctors order things that are not indicated. Doctors misdiagnose. Doctors screw up sometimes. Doctors have bad handwriting.

Sometimes they even have bad attitudes. And, of course, these fallacies go along with all the good that they do, which is why they EARN respect. It is true that any HUMAN -- not a god -- has to EARN R-E-S-P-E-C-T.

Therefore, doctors are flawed just as all of us are flawed. They are not gods. Which is probably a good thing, because there is a lot of responsibility, I surmise, for a god. I'm sure a doctor wouldn't want THAT responsibility.

Which is why I have to cringe when I hear a nurse say: "The doctor ordered it, so it is needed." And I cringe when I listen to a patient telling me he knows nothing about his illness, and "I just rely on the doctor to tell me what to do."

Ummm, that would be just fine if doctors were, in fact, gods. But, the truth is, doctors are not gods. And, as we've decided by deduction, that is a good thing.

From an RT perspective, we go to school for 2.5 gruelling years learning the body as it pertains to the respiratory system and respiratory therapies inside and out. Not only that, but we have, in my case, ten years of respiratory experience, and even more experience for those of us of whom have respiratory illnesses.

My point is, we are the respiratory experts. While the doctor spends less than 10 minutes with each of his in-house patients per day, we RTs are there to give EVERY breathing treatment. We are right there to assess the patient before and after EVERY treatment -- and many times in between.

It doesn't take long to know when a treatment is needed or not. Therefore, it is a flaw for doctors (of whom we truly respect) to not utilize the respiratory knowledge and assessment skills of RTs to determine what RT therapies are indicated.

It's called using the resources available to you for the best interest of the patient, the RT, the nurses, and the doctor himself. It also benefits the economy, as frivolous therapies that are not indicated are not given.

So, while we can't call up a doctor and tell him how flawed we think he is -- we usually do the opposite out of respect, we here at the RT Cave like to find humor in this. Thus the humor link to the right.

In review: We RTs really do respect doctors, but we know they are not gods.

So, what got me on this tangent was the following quote from a member of COPD International regarding my blog:

"I loved this guy's blogs on 'Cave Rules'...especially about asthmatics and COPDers using fans and Albuterol not being a treatment for pneumonia. He and his fellow RTs certainly don't think of doctors as Gods!"

She is right, we don't think of doctors as gods, as well as we shouldn't. And no patient should either, lest he or she wants to gamble on one man's opinion.

I am inspired by my readers

I didn't really have a lot of patient on the floors last night when I worked, but ER was absolutely swamped. I was paged down there at one point to do "Several EKGs." When I arrived, I found there were seven EKGs for me to do.

"We're running a Blue Light Special on EKGs tonight. Anybody else want one?"

Finally around 3:00 in the morning ER gave me a break, and I needed to find something to entertain myself. I was way to tired to write anything intelligent, so I did an IceRocket Blog Search to see who was talking about the RT Cave, if anyone.

This is not something I do on a regular basis, but I was pooped out after working the entire 4th of July weekend. With all the vacationers we have in this town, I'd say about half of them were right here in our ER. Oh, and of course they all needed an EKG and a treatment.

So, I found that a story I wrote a few months back called, "The five different types of COPD patients," was posted and being talked about in a couple COPD community websites. I thought this was so cool.

One such website was COPD International. It was really cool reading all the nice comments about this post, and my blog in general. I will be honest here: I expected when I started this blog that I might get some fellow RT readers. But I never would have guessed in a million years that I would acquire a following of patients.

To me, the fact that patients find entertainment in my RT humor, or useful information from my insights and informative posts, brings me great joy.

Here is my favorite comment: "Thanks Annie most interesting I went to the source and what a wonderful site. Kind of like being behind the door. If you know what I mean."

Kind of like being behind the door. If you know what I mean.

What a cool comment. I might have to steal that and use it in my header, if I ever figure out how to make one that's cooler than what I currently have.

Here's another cool comment: "I'm glad you went to his blog, Madblue. It IS interesting to see this disease from a care giver's point of view...especially from one who has been trained to help COPD patients."

I guess I never really think of it this way. You know what I mean? I write because I love writing. I write about things I am passionate about. I write because there are things in this career field that are great, and then there are things that could be better.

And, if I wasn't optimistic that change were possible in the RT business, I probably would still continue to write on this blog, because there is a certain amount of knowledge base in my head, in all our heads, that others can benefit from.

The fact that I discover that people are reading my blogs and then posting my writings on other websites because they are entertained by what I write, is an absolute honor for me. It inspires me to keep writing.

So, I suppose, by me writing this post, I am saying Thanks.

And that, my fellow readers, is the thought of the day.

SOB is not always caused by bronchospasm

So long as there are doctors who think that a bronchodilator treatment will cure everything that causes shortness-of-breath, there will always be frustrated RTs.

As long as their are doctors who believe that all adventitious lung sounds are an indication for a bronchodilator, there will be frustrated RTs.

Let's make this simple, and get right to our next RT Cave Rule:

RT Cave Rule #22: Everything that cause shortness-of-breath does not get fixed with a bronchodilator. Bronchodilators relax the smooth muscles of the bronchioles, and thus treat bronchospasm only.

RT Cave Rule #23: All adventitious lung sounds are not an indication for a bronchodilator.

That in mind, I have a few case studies here. I would like you to answer three questions for each case study: 1) What is your initial impression of the patient, or what do you think is wrong? 2) Would you recommend a bronchodilator and why? If yes, what frequency? 3) What do you think the doctor actually ordered?

I'll put the answers below, don't peek.

#1: You are doing an EKG on a patient who says he is mild SOB, but feels much better once he is on 2lpm nasal cannula. You notice he has the cardiac scar. After you finish the treatment, you learn by auscultation he has crackles 1/2 way up.

#2: You are doing an EKG, and you ask the patient if he is having any shortness-of-breath or chest pain. He says, "No. I'm having bad back pain." Upon auscultation you learn the patient has crackles in the left lower lobe. He then reveals that he does have pain with deep inspiration.

#3: You are called STAT to ER for a patient in severe respiratory distress. He has been a 3 pack a day smoker since he was 7, and he's 77. His ABGs are cruddy, and reveal severe acidosis. You look up on the monitor and see the prototypical fireman's helmet on the rhythm strip. This is verified by an EKG.

#4: You have a patient who has asthma and he smokes. He states that he is mild sob.

Here is how the above cases turned out:

#1: The patient has obvious signs of CHF. No breathing treatment indicated. If the patient is wet, you don't want to put more fluid into his lungs. The patient should be treated for suspected CHF, with some Lasix perhaps. Along with diagnosing and treating the CHF, the doctor ordered Q1 hour bronchodilator.

#2: I surmised the patient had pneumonia of the left lower lobe. I would recommend no breathing treatment because the patient is not SOB and shows no signs of bronchospasm. The doctor diagnosed the patient with pleurisy. She diagnosed this way because "the x-ray showed no pneumonia, and his labs are normal." Still, I think this guy has pneumonia, but that's just my humble guess. Either way, a bronchodilator doesn't treat inflammation. Still, a Q1 hour bronchodilator was ordered. The patient noted no difference with any of them.

#3: The pt is labored secondary to having an MI. The patient needs to be intubated. The doctor eventually intubated the patient, but only after an hour long continuous bronchodilator treatment was finished with no results.

#4: This patient has a good chance of bronchospasm. A bronchodilator is indicated because bronchodilators treat bronchospasm. The patient was diagnosed with asthma attack. The treatment really opened the patient up, and a second one was probably warranted. The doctor ordered a one time breathing treatment. A second treatment was never ordered on this patient who actually could have benefited from a second one.

So, how did you do. I bet you did pretty well.

Personally, I think it is fine to try a bronchodilator on all these patients, because there's always a possibility there might be a bronchospasm component. The ordering of further treatments should be based on assessment.

But that's just me.

Oxygen therapy: Stripping the threads

I always tell my patients that the hardest part of the job is screwing stuff into the oxygen flowmeters. It's something I never really think of except for when I'm in the process of doing it, so it's my patients I usually mention it to.

And I've had patients, or nurses, laugh at me as I struggle to screw on that nipple adaptor (often referred to as Christmas Trees), or that bubbler, onto the flowmeter. And I grumble and gripe as I try again and again to get it to screw on just right without stripping the plastic threads.

That has got to be the hardest part of this job. It's not so bad when a patient doesn't require a bubbler, but when a patient has a bubbler, and a treatment is indicated, you have to unscrew the bubbler and screw on the nipple adaptor. Those cheap nipple adaptors never seem to go on just right.

Yet, if you aren't patient, and you strip the threads, you have to walk all the way to the supply room to get a new one, that is unless you just so happen to have a spare in your pocket, of which I usually do except for when I need one.

And then, once the treatment is done, you have to thread the bubbler back into place.

Sometimes, as I struggle to do this, I find myself thinking maybe I should just say "screw it," and leave the nipple adaptor in place so I don't have to go through this process again in four hours. But, being the good RTs we are, we have to do the right thing and hook the bubbler back up.

Today, though, as I was doing my last treatment, I thought that when you have a code, you never seem to have a problem hooking up the AMBU bag to the flowmeter. That's because these things are designed to be fool proof, so you can just plug it onto the flowmeter.

My thought was, why can't nipple adaptors and bubblers be that easy? Why do we have to screw the darn things on? Why can't some entrepreneur invent an easy way to hook stuff up to flowmeters.

Thankfully, I never have a problem screwing in the ventilator tubing, but those things aren't made out of plastic either. I think it's the cheap plastic that causes this frustration. I suppose that's the cost we pay for cheaper, disposable equipment.

I searched the Internet to see if maybe some company had made a screwless nipple adaptor, but I have yet to find one. However, I suppose it really doesn't matter, because hospitals usually sign contracts, and get whatever supplies are provided by the one company.

So, I suppose we'll continue to be stuck with these cheap plastic nipple adaptors, and cheap plastic bubblers that never seem to want to thread on easy, or at least not when we are in a hurry.

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

The greatest document ever signed

Happy 4th of July Folks. Even though I'm stuck working the holiday, doesn't mean I can't still celebrate. I started with a free midnight meal our bosses provided, and now I'm here looking up neat 4th of July facts.

I found this really cool website with all the original documents, transcripts, and some cool information. I kind of enjoy perusing this kind of stuff.

Here are some pretty cool facts:

1. Not all members of the 2nd Continental Congress supported a formal Declaration of Independence, but those who did were passionate about it. One representative rode 80 miles by horseback to reach Philadelphia and break a tie in support of independence.
2. Independence Day commemorates the formal adoption of the Declaration of Independence on July 4, 1776, when it was unanimously approved by the 2nd Continental Congress.
3. However, it was not observed as a holiday until after the War of 1812
4. And, it was not declared a legal federal holiday until 1941.

This site was pretty cool too. When I first learned the song Yankee Doodle when I was in kindergarten I wondered what a Yankee noodle was. Well, Yankee is believed to be a misinterpretation of the word English, and Doodle is supposed to refer to a dumb person.

So, while it was used in the past as a "derogative" song, it was sang by the British to make fun of the American Colonists. The colonists in turn adapted this song as their own and made it their own "rallying anthem."

Anyway, I love the picture I pulled out for this post. It shows how hard the founders worked at creating the worlds most perfect document. I wonder what the world would be like today if these guys were still alive.

I sometimes wonder what the world would be like today had that document not been signed. City life would be like living in the 1800s, and we would still be riding around in horse and buggies, living amid dust and horse poop and the bugs and rats that come with it. And a world far more polluted than it is now because we wouldn't have the technology to clean it up as much as we do now.

Sure we have pollutants in the air today, but without modern technology, we may not have the scrubbers in coal factory chimneys to filter out most of the crud. Human feces would still be a problem, as toilets may never have been invented, let alone the ability to purify this crud and keeping it safe for our water supply.

Instead of having clean drinking water, we'd be drinking water which is a breeding ground for diseases, and we would not have the know how nor the technology to fight these diseases.

As the worlds population grew, and industrial factories, coal burning would have accelerated with no fear of global warming as the current activists wouldn't have the time to be active, as they'd be working to survive as people did in the 1800s. People had far less luxury time in the primitive world as we do today.

Smoke would be billowing from the growing number of homes, and this would far exceed the pollutants we have in the air today, because there would no contraceptive devices to allow families to control the number of children they have, and there would be no population control.

There would be less sanitation, and the ability to fight diseases may never have been discovered. Polio would have ripped through the world, and would be scientists would still be working on their primitive farms instead of having the time to invent and discover.

Sure there probably wouldn't be the prevalence of COPD and asthma as there is today, because the sky rocketing rates of these diseases are often theorized to be the bi products of the modern, clean world we live in. And life expectancy would be primitive as well, decreasing the need for long term nursing homes and longevity.

Diseases like Alzheimers and Parkinsons never would have become an issue, as these diseases are the result of longevity for the most part, a longevity that may never have arrived

There probably would still be hospitals, but the use of oxygen may not have been as huge as in the post WWI big boom in cigarette sales era and rise in lung cancer and COPD. People would still get pneumonia and other lung diseases, but the era of discovery may never have arrived. Many of these disease infested people would simply suffer and die in their homes.

Food would be less safe, as we may never have invented quality assurances to guarantee safe foods. Likewise, we may never have invented pesticides and chemical fertilizers that provide us with an abundance of safe foods.

Even the poorest in America today can afford to buy fresh produce from a local market. And those who can't usually can get fair government assistance to do so. Would it be this way had Ben Franklin persuaded other members of the 2nd Continental Congress against signing that document.

The ABG machine and other lab technologies so important to our medical field may never have been discovered, let alone the ability to know what pH, CO2, PO2 or hemoglobin is. The hypoxic drive theory that drove this profession for its first 50 years would never have been concocted, let alone disproven. That type of deep research would be left to a far fetched country with a booming economy to afford such luxuries.

The iron lung would have remained the work of fiction writers, and the technology we have today to allow people with life threatening diseases to get over the hump and live another 20 years would be a pipe dream. So to would be the ability to give babies born with abnormalities, or born too early, a chance to survive past birth.

People complain today about how bad we have it. I hear it every day. I hear people wining because they have to wait too long for the Internet, or wait too long in the emergency waiting room, or wait to long for their pain medicines. I can't help to think when I hear these people that they are taking what they have, what we have, for complete granted.

They do not think that millions have died to allow us the luxury time to complain. They died to give us the freedom to cry out that our president isn't doing enough to fight global warming. They complain that technology is destroying the planet, while at the same time scientists are working hard to improve technologies to make a cleaner and safer world.

These people never thank God for Ben Franklin and Thomas Jefferson. They never thank God that new technologies have actually made the world cleaner and safer. They never thank God when progress is made. And lots of progress has been made.

Sure there is a ton more progress to be made, and concern for the environment, concern for slow emergency rooms, is needed. Without concern there never would be progress. My dad always said, without complaining lazy people nothing ever would be invented.

He may have been right about that. But without that founding document, the know how and the technology may never have come about for these lazy complainers to invent and discover with. Let alone, since the economy never would have boomed, there would be little time to be lazy nor to complain.

Why? Because it is the wealth that has been derived as a result of American freedom, American capitalism, that has made us lazy, and gives us the ability to complain, the ability to be concerned for the sick, for the poor, for the lazy complainers.

So, what we have in this world is pretty darn good compared to what life was like even 100 years ago, let alone on those hot, musty, bug infested days when the founding fathers had to lock themselves in a burning hot room with the windows shut so no onlookers would hear what they were talking about...

...while they wrote their document free hand instead of on a word processor.

Furthermore, most people born with diseases like myself never would have made it out of childhood. So perhaps disease would be the one population control we'd have. Yet, population would not be a concern to environmentalists, as they would not exist in this alter world.

So we should all take the time not just to celebrate the 4th of July, but to really think for a moment how great we have it compared to our forefathers, and compared to other nations where freedoms do not exist.

Happy 4th of July.

The frivolouis holiday rush is imminent

Here we have the 3rd of July, and the beginning of a long four day weekend here at Shoreline. With all the vacationers in this neck of the woods, there's bound to be a fair share of chest pains and short-of-breathers.

Likewise, there will be a fair share of people who are bored with nothing else to do on a holiday who will stumble into the ER.

As soon as I arrived here I was called to do an EKG in ER, and as I walked past triage, I was hit with my first sample of this.

I heard the nurse ask:

"So how long have you had this rash?"

The patient said, "Two weeks."

Ah, the stuff we see on a holiday weekend. Fortunately for us RTs, we only have to deal with a certain small percentage of these patients.

I have a feeling my readers will have better things to do over the 4th of July holiday, like celebrate our Independence, and spending time with families. So I'm not going to publish anything to deep this weekend.

I think what I will do here is keep tabs on all the ridiculous and frivolous reasons people mosey into our ER this weekend. I highly doubt I'll be surprised, for once a few years back this 18-year-old came in on the 4th because he had a mole on his penis.

Behind the curtain I heard:

"You have nothing better to do on the 4th?" the doctor asked.

"Well, ahh, I...uh...," the patient said.

"Well, pull down your pants."

Seeking RT Consult or tx protocol information

One thing about our hospital is we tend to do some treatments for really stupid reasons, as you probably know by now by reading my blog. I'm not complaining, merely stating my observation.

We have one surgeon who orders "treatments QID." That's exactly how he writes the order. What he wants is Albuterol neb, cpt and IS * 3 days.

We have a urologist who likes to order Albuterol Q4 on all of his patients who develop crackles or a fever. I have no idea what he expects to gain by doing these treatments, but it provides some neat material for my 'olin list.

Believe it or not, I feel stupid doing txs on most of these peeps, because there's no reason for it.

We RTs joke here at Shoreline that once a treatment is ordered, even if the patient is no longer having trouble breathing, the treatment must never be dc'd.

The other day when I worked a patient asked me, "Hey, Rick, when are you going to stop giving me these treatments I don't need?"

I said, "When you are discharged. Our docs like to give treatments here."

Keep in mind I have no problem giving a neb, it's not hard to do. It's just the principle here. It seems like it's a waste of money for both the hospital and the insurance company. But, I have to do what I'm told. And I don't complain (too much).

So, yeah, it would be cool to have a protocol to get rid of these txs, but then again I suppose it is work, and work guarantees we get all our hours.

That's the big fear of RT Bosses is that we'd protocol ourselves out of a job and have to lay one of us off. I'm wondering here if this fear is true. Hey, if one of my readers works at a hospital new to the protocol idea, let me know if it increased or decreased your patient load.

I've read studies that showed that the workload after the initiation of an RT treatment protocol actually stayed the same, considering the RTs were doing more assessments and doing treatments on people they thought needed them, and when they were needed instead of when they were scheduled by the doctor.

Still, I'd be curious to know what you guys thought on this matter. We are hoping to go this

route soon (fingers crossed). Perhaps we'd be stabbing ourselves in the foot. Perhaps not.

Jane Sage and I wrote an RT Consult that we are hoping to get implemented after our vent protocol is redone, and it would be nice to have more ideas. So if you guys have any, your advice would be greatly appreciated.

Basically, I'm thinking that there are enough RT protocols, or RT Consults, in hospitals now for us to learn from. If there's something that works well, we'd like to incorporate that into ours. If your protocols have something you hate, we'd like to avoid those problems.

One of the big fears of at least one of my fellow RTs is that an RT Consult would lead to more unnecessary work. Does the protocol create extra paperwork?

I certainly want our RT Consult to work. I want it to be ideal for the patient, the doctor and us RTs.

You cannot schedule SOB time

It is a firm belief of mine that if a patient isn't having constant problems with bronchospasm, like an asthmatic or COPD patient, then Albuterol b10reathing treatments should never be ordered QID.

The reason I say this, is that bronchodilators should, technically speaking, only be given when a patient is having trouble breathing secondary to bronchospasm, and the only way you can tell if this is occurring is to be in the room assessing the patient.

In other words, it is not possible to know in advance when a patient will be short of breath. You cannot schedule SOB time. Therefore, Dr. should use all the recourse's that are available to them, which are their respiratory therapists. RTs can go into the room at scheduled times to assess the patient to determine if the treatment is needed.

This is why I am such a proponent of protocols. Or, at the least, I think all treatments should be ordered every four hours as needed (Q4prn) . We go into the room, assess the patient, and give the treatment only if there are signs of bronchospasm.

Thus, here is RT Cave Rule #20:

RT Cave Rule #20: You cannot schedule SOB time. You cannot know in advance that a patient will be short of breath every four hours. Therefore, unless the patient is chronically SOB due to asthma or COPD, treatments should not be ordered Q4, they should be ordered Q4 prn.

Why force your RT to wake a patient up in the middle of the night to give a treatment that is not indicated. Use your RT, have him assess the patient every four hours if you think that is necessary, and determine if a breathing treatment is really indicated.

And this brings us to RT Cave Rule #21:

RT Cave Rule #21: You cannot know in advance when a patient is going to be SOB, and SOB due to bronchospasm is the only indication for a bronchodilator.

That concludes today's class.