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Sunday, December 1, 2013

Medical specialties are gift to healthcare

I just want to touch gently, ever so gently, on a subject today.  It's something that's near and dear to every medical professional.  It's called specializations in medicine. It's something that I think was a brilliant idea when it was first created in medicine over 5,000  years ago by the ancient Egyptians.

Yes it is true: specialization in medicine was started by the community of physicians in ancient Greece.  Even way back then they must have realized there is so much to know about each specific part of the human body that specialties were essential for adequate medical care. 

Of course the medical profession was a bit different back then.  Instead of neuro surgeons, and neurologists, and cardiologists, and nephrologists, and pulmonologists and Internists, there were heart doctors, anal doctors, surgeons, astrologists, and internists.  The surgeon, for instance, would suture a wound, but if the patient had internal disease, he'd refer to an internist. 

And there was a little overlap.  Back then, as is the case today, all physicians, no matter what you specialize in, learn the basics.  So just about everyone of them could perform as family practitioners.  But certainly you wouldn't want the family practitioner performing a major operation on you.  That, my friends, would be crossing the line. 

Today, other than physicians, we have many other medical specialties.  You have x-ray technicians, laboratory technicians, nuclear medicine technicians, MRI specialists, monitor techs, nurses, and respiratory therapists.  Each of these professions has a specialty.  While they all have basic medical knowledge, and all can perform certain duties, there are certain things that only the particular specialist is trained to do. 

For example, and this is what I'm getting at.  Nurses give all the medicine that a patient receives except respiratory medicine and oxygen.  The respiratory therapist specializes in respiratory medicine and oxygen.  Now, nurses surely know the basics of oxygen therapy, and some even know more than some respiratory therapists. BUT, when it comes down to it, the respiratory therapist is responsible for oxygen. 

Personally, I want and encourage nurses that work with me to put on a nasal cannula and tweak it up or down by 1 or 2 lpm.  I'm fine with that.  Whatever is needed to maintain that SpO2 of 90%.  But any major changes I need to know about right away. 

You know what I love most  about nurses.  I'll give an example here.  A nurse nurse set up a ventimask, and it's a nurse I trust really well, and that nurse pages me to call her.  So I call her, and she says, "Rick, I set up a venti mask in room 208, and I just want you to check it to make sure I did it right." 

"Awesome," I said, "I will be right there." 

To me, that's a major ego booster.  It's a nurse taking charge to help the patient when she knows I'm not around to do it (we RTs work solo where I come from), yet is wise enough to doubt herself in an area she is not an expert it.  I just admire that so much. 

On the contrary, recently I came across a situation where I entered the room of a patient on a nonrebreather, and the liter flow was at 2lpm.  I immediately turned it up to 15 lpm, and went to the nurses station to discuss this situation with the nurse.  The nurse was on break, so I turn to the chart.  Upon reviewing the doctor's notes, I realized that the doctor did it.  She even wrote about it in her notes: "oxygen mask turned down to 2lpm.  Wrote order to keep it there."

So, I'm sitting at the desk, and the nurse comes back from break.  I watch as she enters the patient's room, and then I hear her saying to the patient's family, "Oh, it looks like someone turned her oxygen up.  I better turn it back down." 

That's when I trudged intot the room, and just as she was about to put her fingers on the flowmeter, I said, quite bluntly, and in front of all seven visitors in the room and the patient: "Don't you touch that flowmeter!"

The nurse froze!  All the family members froze!  The patient didn't do anything because she was being oblivious due to her dementia.  The nurse was so stunned she started shaking.  "But," she said, "the patient's daughter wants it at 2lpm." 

I said, calmly, "I'm all for turning the oxygen down, but we need to do it the right way." 

Of course then I had to back track so I didn't look like a jerk to the family.  I made a teaching moment out of it actually; a quick five minute oxygen therapy made easy class.  I explained why the liter flow had to be at least 10lpm in order to blow off CO2 if the patine is on a nonrebreather. 

I later pulled that nurse aside and said something like "I have total respect for you.  I think you are an awesome nurse.  But please, please, please, don't be afraid to call me before making a major oxygen change."  So we hug, and no harm is done (or so I think).

Together we placed the patient on a nasal cannula at 2lpm because that's all she needed anyway.   

On the nursing specialist side, respiratory therapists don't touch IVs.  Well, again, I do sometimes.  Every time we get new IVs I make a point to discuss with the nurses what I'm allowed to do.  Most nurses encourage me to silence alarms and to inform the nurse that it went off.  I usually love to provide this service, because it saves the nurse from a lot of extra running around. 

It's also nice, because most of the time the IV alarms because of a distal occlusion caused by the patient bending her arm to hold the mouthpiece in her mouth.  So, once again, there is some overlap.  But, as a rule of thumb, RTs don't mess with IVs other that the basics, and vise versal for oxygen therapy.  Of course I place the exception for RTs specially trained in IVs, and nurses specially trained in oxygen. 

Again, I think the fact medicine is specialized is awesome.  I love working as a team.  I love when each specialist performs his or her duty to the benefit of the patient, and all goes well -- as it does most of the time.


1 comment:

Beth said...

My only critique is your saying that every specialist is also a GP. I think GP's do have a specialty: keeping the big picture in mind and being aware of how all the specialist treatments and bodily systems interact.

With asthma that's especially important because the lungs stand in at the center of so many systems and some treatments, i.e. systemic steroids, can affect multiple systems.