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Wednesday, October 13, 2010

An interview with myself

To commemorate the third anniversary of the Respiratory Therapy Cave, I recently sat down with myself in the comfy confines of my own mind and interviewed myself.
(begin transcript)

Me: I'm honored to have this opportunity to interview you. I just want to start out by saying thanks for my allowing this time, and to congratulate you on three wonderful year at the RT Cave, as it was three years ago today you posted your first blog entry, The Beeper."

Myself: Wow! I completely forgot about that post.

Me: What were you thinking as you were writing it?

Myself: I was thinking, 'What am I going to write about? How am I going to come up with an idea every day.'

Me: How has your blog changed since that day?

Myself: Great question. I think back then I thought I was going to be writing about what I did every day on the job as a respiratory therapist. Since then it's evolved into a lot more than that.

Me: Like...

Myself: There's not enough excitement at a small town hospital to keep a blog afloat. And then there is this HIPPA thing. I can't write about certain cases I'd like to write about because being a small town it would be easy to trace back to who I was writing about. So out of respect for others I have to restrain myself. Plus I want to keep my job.

Me: Have you ever written anything you decided you can't publish but wish you could?

Myself: Yes. Real exciting cases only happen in a blue moon here at Shoreline Medical. Once I wrote about my experience taking care of a man who was shot in the chest... The premise of the post was not so much that we were doing CPR and such, but about the conversations that took place while this was going on, and how we discovered on our own what had probably happened. It was a great post idea, I thought. Yet after I wrote it I decided better of it.

Me: If you worked in Detroit where there's a murder every day you could probably get away with it.

Myself: Exactly. I have written many posts I simply cannot publish. Common sense aside, HIPPA had this unintended consequence of making people afraid to share information about patients, which is bad in that it stifles learning.

Me: I see.

Myself: Yet it also comes down to respect for people. I refuse to write what might come back to hurt someone, even if it would be a big hit on my blog. A part of being an RT is prioritizing, and part of being an RT blogger is also prioritizing. People come first. Plus I love my job and would like to keep it. So due respect is justified.

Me: Working for a small hospital, though, don't you have to be more well rounded as an RT. Didn't you say something about that once?

Myself: Yeah. I would say that's true. While 90% of our patients might be adults, we still have to be proficient at taking care of pediatrics and neonates. It's not like you can just become proficient in one population or one type of patient. RTs at small town hospitals have to KNOW IT ALL.

Me: So isn't that why you started this blog?

Myself: In a way I started this blog before I started this blog. I was simplifying complicated material for myself and my coworkers for several years before I started writing here. I started by working with my coworker Jane Sage on creating a cheat sheet for how to set up a vent on neonates. We don't set vents up on newborns very often, so when it does happen we need to know what to do, and we need to be cool and calm. That cheat sheet comes in handy.

Me: So you created a bunch of cheatsheats to make life less stressful for RTs in your department.

Myself: Yes. I created a bunch of RT cheatsheets. My coworkers and I also created some cool RT humor
. I have since published both on the RT Cave. So the purpose of this blog is to have a little fun while sharing RT wisdom.

Me: What's the greatest challenge of writing at the RT Cave?

Myself: The greatest challenge is making sure I don't repeat what everyone else is doing. I want to make sure I write about facts, yet I have a personal, unique touch to all my posts -- or at least most of them. Or at least I try. I want people to know they are getting facts, and they are getting my honest opinions too. Wit and Wisdom.

Me: And what about...

Myself: Also I think I like to do on this blog is simplify complicated things. I mean, for new RTs, you can have a heart attack just trying to make sense of ABGs to the point just the thought of ABGs can give you the ABGBs.

Me: (laughter) Yeah. And that's the other unique touch you have, is the ability to find humor in something as dry as respiratory therapy.

Myself: Someone asked my coworker once what is the best part about doctors, and he said, 'Doctor's orders.' Then my coworker was asked what he liked least about doctors, and he said, 'Doctors orders.'

Me: (laughter)

Myself: Now he wasn't intending to be rude by any means, just stating the fact that doctor's orders save lives -- doctors save lives. Yet most of the time doctors write orders simply based on habit, or just to cover their bases, or just to make the patient think they are doing something, or just to make sure the patient meets intensity of service. Then since doctors are so well respected, few question them.

Myself: That's something you touch on a lot on your blog, is wasted medical care. You say that's what drives up the cost of healthcare.

Me: Yep. If more patients asked questions, doctors would be held up to accountability. What makes matters worse is government intensity of service and...

Me: Can you remind us what intensity of service is?

Myself: That's where the patient is sick enough to be admitted. Usually, Medicare will automatically view someone as sick enough if an IV is ordered, and that's why IVs are put in every patient who even goes to the Emergency room. I mean think about it, when do you ever get an IV put in you if you go to the doctor's office?

Me: Never.

Myself: When have you ever gotten an x-ray because you went to your doctor's office because you have nasal congestion and a cold and just wanted an antibiotic?

Me: Never.

Myself: That's because you don't need an IV most of the time. Yet if you have insurance, and you go to the emergency room because you have a simple cold, you're going to get labs drawn and you're going to get an IV, and you're going to get an x-ray. All those things aren't needed, yet the government or your HMO is going to have to pay for all those things. And then if you get admitted, you're going to have neuro checks every four hours, because neuro checks are one of the biggest indications -- according to the government anyway -- that a person needs to be in the hospital. Now you may not need neuro checks, but if you get them Uncle Sam says you probably needed to be admitted. So it's neuro checks on anyone.

Me: Do you think that's the biggest rip off in the health care industry?

Myself: It could be. Yet if people are admitted to the hospital and they have insurance, then the insurance company, or the government if they have Medicare or Medicaid, gets to pay a discounted price, which may be a 50% discount. They pay a flat fee regardless of how many services are rendered. Yet if you don't have insurance, you have to pay the full price, and pay the full price for every procedure. You don't get to pay a discounted flat fee. To me that's the biggest rip off.

Me: You make a good point.

Myself: Basically intensity of service is an excuse for hospitals to justify wasteful medicine, and offer unfair costs to people without insurance. I have a posts coming up about all these issues, so you'll hear more about this soon.

Me: You mentioned earlier that healthcare costs would be lower if the patient questioned doctor's orders more often instead of letting the doctor do whatever he or she wanted. How would questioning doctor's orders lower the cost of medicine? How can this be achieved?

Myself: It can be achieved by getting rid of the third payer. Since people don't see the bill, they never question a doctor. Say you had to pay your own bill, and your doctor ordered a breathing treatment on you. That treatment costs $100 a pop. You came into the ER for a cut on your foot. Would you not question whether that treatment was needed?

Me: I would.

Myself: Since most people don't pay for their own medicine, they just let the doctor do whatever. This increases demand. When demand for a product goes up, and the supply stays the same, the price goes up. So, demand for breathing treatments is high, and there's only so many RTs and so much Ventolin to go around. That means the price of a treatment will be high.

Me: So you mean if people paid for their own medicine the price would be low.

Myself: Right. Welfare had this same effect on the price of medicine. While it provides free or discounted medicine to the elderly and poor, it makes medicine cost more for everyone else. If you have to pay a co-pay, even $1, for medicine, you will be more likely to question, "Do I really need to go to the doctor for this cold?" Or, "Do I really need this, or do I really need that." Yet if medical care is free, then you'll be more likely to say, "It's free. I might as well just go see the doctor." So if you give away something for free, people flock to get it.

Me: And since many doctor's offices don't accept welfare, these people flock to emergency rooms with things that are not emergent. And since laws prohibit emergency rooms from turning patients away, this results in overcrowded ERs with long waiting lines.

Myself: Exactly. So then you have people waiting in the ER for three or four hours, and they are irate that they had to wait so long, yet they are the exact reason the wait is so long. If they really needed an ER, they wouldn't need to wait for four hours. People who really need an ER, real emergencies, get seen right away. If you have a heart attack, you aren't going to have to wait for four hours. Think about it. The next time you have to wait in an ER for four hours, chances are you could have gone to your doctor. If you have a wart
on your penis you've had for four years, you're going to have to wait, because in the ER we have to prioritize. We have to take care of real emergencies first.

Me: So lack of questioning on the part of patients, third party
payers, and even welfare, Medicaid and Medicare, have made it so medicine costs more, and results in overcrowded emergency rooms.

Myself: The price of medicine was low enough people could afford their own medicine until the 1960s when government got involved in medicine, and HMOs were started. It's my opinion anyway. Sure it's more complicated than that, and sure I could be wrong. I'm always open to any opinions here.

Me: No opinion is wrong, a wise man once said.

Myself: Yeah, but some say the opinions of common folks don't matter, that experts in Washington know what's best for us. You believe people are smart, and each individual should and is capable of deciding what's best for him or her self.

Me: We'll...

Myself: Well, let the readers decide what they think. That's what it's all about here at the RT Cave. Let the people decide. It's about thinking. It's about critical thinking.

Me: So do you...

Myself: I'm not saying we need to make all Americans fend for themselves either. I'm just saying that I think all the tinkering we've done with the Healthcare system has contributed to the unfordability of healthcare. I think we have gone in the wrong direction. I think we have the best healthcare system in the world, and according to polls so do most people. Yet when we open up a newspaper we read that we have one of the worse healthcare systems in the world. In this sense, the powers that be want to scare us into believing we need more government control of it all. Yet most of us don't want that. And that's why I think the recent healthcare reform package is so unpopular.

Me: Ah, I actually have a question about that healthcare reform bill -- Obamacare. But first, I want to talk about bronchodilator reform. You mentioned earlier about stupid doctor orders, and you often write about bronchodilator reform. What got you started on that tear?

Myself: Actually, that got started because I do have asthma, and I know when a person should have a breathing treatment because I know when I need one. And I know that nobody needs a Ventolin breathing treatment when they aren't short-of-breath, and I know nobody needs a Ventolin treatment when they are sound asleep in the middle of the night, and I know nobody needs a Ventolin treatment when they never have and still don't have respiratory distress. Yet due to ignorance we give any patient with a lung disease or annoying lung sounds on bronchodilators every 4 hours round the clock for the entire month they are admitted. It's poppycock. It's wasteful spending. It's a waste of resources, of your respiratory therapist's time. It's a perfect example of what's wrong with the medical field.

Me: Ah, so I got you going on that one. I don't want to spend any more time on bronchodilator reform.

Myself: Yeah. I've written about it ad nauseum.

Me: Yet since you mention wasteful spending, and to get back to what we were talking about a moment ago, what do you think of the healthcare reform package?

Myself: All I want to say about that is that too many people believe it's better to do something than to do nothing at all. One of my co-workers said that once at a meeting I attended, and I said, "It's better to do nothing than to do something stupid."

Me: What did you mean by that?

Myself: Well, once you make a law, or a new policy, it's nearly impossible to get rid of it if it's stupid and doesn't work. Yet if you try to make due with what you have, and try to make what works work better and to get rid of what doesn't work, that to me is the best strategy. A perfect example here is when Warren G. Harding died and Calvin Coolidge became President during a recession. Coolidge said he believed in holding back and shutting out. He conducted his official life according to his own version of the doctor's Hippocratic Oath -- first do no harm. It sounded easy, and many mocked Coolidge as being lazy in office -- the same people who made fun of him by calling him Silent Cal. And Coolidge's 'no harm' rule came out of strength of character. By holding back, Coolidge believed he sustained stability, so that citizens knew what to expect from their government. And, by holding back he allowed the country the opportunity to solve it's own problems.

Me: I see what you're saying.

Myself: If health care reform works, great. Yet if it doesn't, we're stuck with it forever. The same can be said of any time you add a new policy or order sheet or whatever in the hospital. If you're going to add something, you better be damn sure you know what you're doing. You better make sure you've tested it all the way through. And sometimes the best way to solve a problem is simply by keeping what you have right now and seeing if you can fix that first.

Me: So are you saying you aren't for breathing treatment protocols?

Myself: Treatment protocols, or RT Consults, or whatever you want to call them have been proven again and again to work. They improve the moral of RTs because RTs get to do what they are trained to do. And it makes a doctor's work easier because they don't have to be paged 20 times during the night. It makes the patient's life better because they can get what they need right when they need it. It makes the people paying the bills happy because it gets rid of frivolous procedures being done.

Me: So basically protocols allow for the medical professional at the bedside to decide what's best for the patient based on the patient's needs at that moment, rather than some doctor sitting in an office three miles away. It localizes health care.

Myself: Exactly. All problems are better solved locally. If you have pot hole in the road in front of your house. You can fix it by filling it in with dirt and be done with it. The cost will be very little. Yet if you have to wait for Washington to fix that hole, they will have to prioritize it, study it to make sure it needs to be fixed, and then what to do to fix it will have to be filtered through the bureaucratic system. When -- if -- it is ever fixed it will be a long time, and it will cost a ton more than if you fixed it yourself -- locally.

Me: Yet you wrote recently that the keystone project and core values make it so there might be a little overkill, but they work. You wrote that the pneumonia order sheet calls for Ventolin to be ordered every six hours, and while the treatment may not be needed, at least the RT is in the room every six hours assessing that patient. Did you not say that?

Myself: Well, yes I did. The keystone project injects what has been proven to work into the system. The Keystone Project and core values (an upcoming post) are based on things that have been scientifically proven to benefit a patient given a certain illness. Now I'm never a fan of doing something that is not needed, and that's where protocols come into play.

Me: So you still like protocols?

Myself: Man, I'm a protocol fan all the way. A doctor orders whatever he wants, yet it's up to the RT to decide if it's needed. It's not that RTs are smarter than doctors. I'm not saying that at all, because doctors know a whole lot more about fixing patients than we RTs. What I am saying is that we RTs, and RNs, are trained and skilled in taking care of patients at the bedside. Let us use our skills. Let us do what we are trained to do. And then, if the doctor so wants, he always has the right to overrule the RT at any time. That, to me, is the best policy. It's kind of a checks and balance system.

Me: I see.

Myself: Either that or you order scrubbin bubble therapy on everyone.

Me: (laughter) For... For (laughter) For those readers who aren't familiar... What is scrubbin bubble therapy.

Myself: Well, you know, many doctors think the ventolin particles act like that bathroom cleaner scubbing bubbles, and the ventolin particles get down into the lungs and sud up, and then they act like sponges and scrubbers and scrub out lung cancer, pneumonia, pulmonary embolisms and whatever happens to be in the lungs that doctors don't want.

Me: (laughter)

Myself: It also prevents bronchospasm. It makes a patient cough. It makes a patient stop coughing. It hydrates the lungs. It dehydrates the lungs. Basically, some doctors believe they can push whatever button they want and the Ventolin will do whatever they want. Or, to put it simply, all that wheezes is treated as asthma. It's that simple. That replaces thinking and common sense.

Mt: Interesting. Let me change the subject

Myself: Good.

Me: What to you think of overly critical doctors?

Myself: I think the more critical you are the less likely someone will want to talk to you.

Me: And that's bad how?

Myself: Well, say I know you're going to be rude to me if I call you at 2 in the morning because I have a concern about the patient. Say the patient has a very low blood pressure. Do you think it's better if I call the doctor, or that I don't call because I'm afraid the doctor will say something like, "So why are you calling me at 2 in the morning with this?"

Me: I see your point.

Myself: Doctors that are overly critical, as well as anyone who is overly critical, are basically telling other people they are useless dummies and don't want you thinking. Yet you have to think, because human beings think. And critical thinking is essential for good patient care. As nurses and RTs, we are at the patient's bedside, and we are taught to be proactive. Since we are at the bedside and the doctor is not, it's our jobs to do what's best for the patient. If we're concerned about a patient, we should call the doctor. And a good doctor doesn't have to be happy about getting a call at 2 in the morning, but if he's going to be grumpy and rude and cynical and overly critical, then he should get another job.

Me: True

Myself: It must be noted that most doctors aren't that way, thankfully.

Me: So are there any other types of doctors that aren't good in the hospital setting.

Myself: Any doctor is good for the hospital setting. Doctors are great. We could never function without doctors. Yet I also think the best doctors are those who appreciate the experts at the bedside -- the nurses and the RTs. I don't like any arrogant, all knowing doctors. Yet, if you are nice -- a downright pleasant doctor, chances are I'll like you even if I don't think you're the best doctor. Pleasantness goes a long way toward likability. I can get along with any doctor, or any co-worker who is nice.

Me: That makes sense.

Myself: I think it's easier to be rude when you're not working side by side with someone all night long. I think ER doctors who are right there with the nurses and RTs are more likely to be pleasant
than a doctor who gets a call at 2 in the morning. The ER doctor has to work with that person, and wants to maintain a good rapport. The further you get from the person, the further removed from the situation, the greater the likelihood your rudeness will stick out.

Me: Good point.

Myself: Thanks. Yet, allow me to add, even a doctor with poor bedside manners, and even a rude, irritable, intractable, ruthless, and arrogant doctor with the worse bedside manners can be a great doctor and good for your institution. In real life, you get all personalities. So sometimes we RTs and RNs and patients to some degree simply have to put up with a personality flaw because the doctor is so dog gone good at what he does.

Me: I know you're a busy person. With that son of yours striking out 17 of the 18 batters that got out the other night, and with those two girl's pretty eyes and vibrant personalities, it shows you spend more time with those kids than you do writing. You have your priorities straight. So I know you're busy, and I'd hate to take up any more of your valuable time. So just a few more questions.

Myself: Shoot.

Me: What's the most common diagnosis you see?

Myself: Pneumonia. I think it's the most common diagnosis because it provides to best reimbursement. The funny thing is that many times it's ordered, and I look at the chart, and I see no evidence of pneumonia. The x-ray is normal, labs are normal, yet here's a patient taking up space in a bed with no pneumonia. How's that for good medical service. Yet that's what the government has forced on us. They encourage doctors to lie.

Me: Do you ever lie?

Myself: I think sometimes you have to. I mean, if a patient asks me why he's getting a breathing treatment I don't think he even needs, it's sometimes easier to simply say: because it will help you breathe better. Yet I know I'm lying. Yet I also know that's why the doctor ordered it. It's idiocy, yet to keep my job I have to lie.

Me: Did you ever lie to benefit a patient? I mean, did you ever give Ventolin to a patient that wasn't ordered?

Myself: Consider the doctor who believes that every asthma patient should get three treatments 1 hour apart. Yet as an asthmatic yourself, you know the patient could better benefit from a back to back treatment. Would you slip in the extra ventolin and not tell the doctor?

Me: Are you pleading the fifth here?

Myself: If you had a CF patient ordered on Q4 breathing treatments and, when that first treatment was finished he said, "Can I have another treatment?" Would you not throw in another amp into the nebulizer?

Me: Have you?

Myself: I'm not saying I have, I'm just posing the question. It would be a great topic for an ethics class, hey?

Me: It would. You ever get caught in a lie?

Myself: Not really. Yet I did tell the truth once to a patient, that he didn't need the treatment, and then it came back to my boss what I said, and that when that patient told the next RT that I said the treatment wasn't needed, that this information put that RT on the spot. My boss told me then that I had to tell the patient the reason the doctor ordered the treatment, which, ahem, is based on either a lie or idiocy. So, in a way, I got caught telling the truth and was punished for it. Ironic, isn't it?

Me: That is pretty funny.

Myself: It's not funny. It's a perfect example of how bass ackwards the medical industry is sometimes, or too often. We are encouraged to lie. We are encouraged to do what we know is wasteful, and then to lie to the patient that it's needed.

Me: What's your favorite part about blogging.

Myself: Sharing facts. Creating humor.

Me: Why did you start blogging?

Myself: To share facts. To tell what it's really like being an RT.

Me: When will you have enough blogging?

Myself: When every bronchodilator loving doctor has conformed to the idea that all that causes annoying lung sounds does not benefit from a bronchodilator.

Me: Do you ever get hate email?

Myself: It's funny you say that. I get lots of emails from people telling me they love what I do. That motivates me to keep doing this. Yet from time to time I get someone who emails me and says something like, "I hate your opinion. Because you wrote that I'm never reading your blog again."

Me: Wow! That's harsh. Does it bother you? Does it slow you down?

Myself: No. It has no effect on me, because whether people like or don't like what I write is not why I write. I write to entertain myself first. I write because I love to write. I love doing this. I don't do it for money because there's no money in this. D don't do it for praise. I do it because I love it.

Me: So you think it's good to put your opinion in a blog, even if that will mean you will get fewer people reading your blog?

Myself: I think if I didn't put my opinion in my blog posts there would be no point to this blog. I think all blogs should be opinion orientated. In fact, I read the blog advice of a person once who said he made $1,000 a month on his blog. He said you can put your opinion in your blog all you want, and people will still read it. That's true, he said, so long as your blog has a useful purpose, and in his case he gave advice to bloggers on how to better their blogs. In my case, it's RT wit and wisdom.

Me: Where do you see the RT Cave in five years?

Myself: I see the RT cave making me a million dollars a day. (laughter)

Me: (laughter) If that happened, then we could quit our day job. (laughter)

Myself: (laughter) Sure thing. Then we wouldn't be able to continue blogging, would we?

Me: Probably not. But we still would. Writing is in my blood and I'm not very good at writing novels and short stories. So for now it's asthma and RT.

Myself: That's about it. Have a good day. Here's to another three years of RT Cave Success.

{end transcript}

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