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Thursday, May 26, 2022

My Question About Bias Training?

I have a question for you. So, we in healthcare have to go through Bias Training. This is a mandate set forth here in Michigan by our great governor. And the whole idea of bias training is we all have unconscious thoughts that give us biases. And that we consciously act out on our unconscious biases. 

So, my question is this: If I am having unconscious thoughts, that means that I don't know I am having them. So, if I don't know I am having these thoughts, how do THEY know I am having them and that I will or might act out on them? How do they know this? Can they read minds. 

And this is health related, of course. Its health related because our great governor mandated bias training on all health care people. So, the next time we get our licenses renewed, or if we get new licenses, we have to go through this training. 

And it's for a noble cause. The goal is to prevent bias in healthcare. There is evidence that some black people are treated poorly due to their race. And this should never happen. And the governor wants to make efforts to make it better. I do think this is a noble concept. My question is: Is bias training really the way to go about it? 

Thoughts? 

Further reading: 

Wednesday, May 25, 2022

Thank God For Acapella

No! I'm Not Talking About Music!
There's an old saying: If there is a healthcare tool, it will be abused once doctors catch on to it. This was true for IPPB back in the day. It was true for alupent and now albuterol. It was true for BiPAP. It was true for CPT. And now it's also true for Acapellas. 

Such is how it is in healthcare. And there's the old saying to justify such orders, "Well, it can't hurt!" 

Well, it can. It can hurt me, as getting all this nonsensical stuff done, plus all the sensical stuff done, creates a lot of work for us. And we get burned out, and when we do eventually get to doing CPT all we have energy for is a weak thud... thud... thud.   We teach our patients and we give the pithy version because we don't have energy or time to go into any great detail. It burns us out. But, at least it won't hurt the patient. Or will it? Hmmmm. Could be a debate here in the RT Cave. 

Now, CPT does work for some people. Don't get me wrong there. You have people with cystic fibrosis or bronchiectasis who may greatly benefit from it. You do have some patients who benefit from it. But, just like anything in healthcare, any thing that is available is going to be abused. And that is what lead to CPT on post op patients. Yes, we had a doctor years ago who ordered CPT four times a day on all of his patients who had abdominal surgeries. 

Really, all this accomplished was giving us RTs exercise. It really did not benefit the patient in any way shape or form. Yet we did this for years. And no one but me questioned it. Or, no one but me and some of my fellow RTs who got burned out from this type of stuff. 

And here I will segue to acapellas. Similar to CPT, they do benefit some patients. But, as with all things in healthcare, it is another tool that is abused. Now we have doctors ordering acapellas for every patient admitted with COPD and pneumonia and anyone with annoying lung sounds. This is interesting because only some of these patients would benefit from them. 

The nice thing about acapellas is it is something you can teach a patient and they can do on their own. It doesn't require us beating on a patient every four hours. And, for that, I think acapellas are one of the best inventions ever in healthcare. Thank God for acapellas. 

Monday, May 23, 2022

My Humble Take On Bias Training

There was a day when we were in the heart of a covid surge. And my coworker and I happened to both be sitting in the department. And we so happened to have the TV on watching the Price Is Right. And our broadcast was interrupted by a news bulletin. Governor Whitmer was having a press conference about the pandemic. 

She gave statistics and informed us she was expanding the mask mandate. And she talked about statistics about how the black population was being hit the hardest. So, her solution was to mandate bias training for all healthcare people.

My coworker and I were like, "What the F#$#!" And we usually don't swear. We are both Catholics. We were irate about this. We had to shut the TV off.  And we were busy, so moments later I was back on the floor taking care of COVID patients. And my coworkers who also watched the Whitmer press conference were also ticked off by this news. 

Here we are law obeying citizens. We treat every person who enters this hospital with respect and dignity. We don't even think, nor care, what color or sex a person is. We treat them all very well. And here our governor is telling us it's our fault that black people have a higher incidence of COVID than the non-black population. 

Do black people in some locations get treated poorly. I know for a fact that some of them do. I have had black patients tell me that they were treated unfairly at other hospitals (no ours of course). So, if this is the case, then punish the people who treat black people poorly. Do not punish the nice people like me and my coworkers. Do not punish the law obeying citizens. 

So now all my healthcare coworkers and I have to sit through five hours of bias training. You want to talk about boring. We already have to sit through hours and hours of annual compliance training where we just repeat the same boring stuff year after year. And now they tack this on. 

So, it's understandable the frustration about this bias training. And, for the record, this has nothing to do with my place of employment. They do have to enforce this upon us. But, it's not their fault. It's the fault of politicians who are using this as an excuse to push their political agenda on the innocent. 

Further reading: 

Friday, May 20, 2022

How To Cope With Bias Training

The whole idea of bias (diversity) training is that we all have unconscious bias. This is bias that we are unaware of. It's thoughts that we have that we don't know that we have. Or at least that's what they say. Because we have these thoughts, we need to become aware of it so that we do not act out because of it. We need to be trained as to how to resist the urge to act on our implicit bias. The assumption here is we are prone to acting out on our unconscious thoughts. 

It's also called diversity training. It's an effort to create equity and fairness in the hospital setting. 

Allow me to take a time out a second here. Whenever you see the term equity replace it with socialism. This is because the term "equity" is a new term for the old unpopular term "socialism." So, bias training is basically an effort to create more socialism in the hospital setting. That's all it is. 

Now, that said, let's get back on topic. So, this whole idea of bias training has created quite the uproar among my coworkers and me. And in our discussions we have dissected the idea of bias training. And we have come up with some conclusions. 

For starters, it makes many of us feel uncomfortable. But we are reluctant to speak out due to fear of personal and professional retaliation. We find it great that efforts are being made to make blacks and gays feel comfortable when in our hospital. And no one will argue that the goal is to make everyone in the hospital feel comfortable. But we feel this is done at the expense of making people like me  – white, conservative Christians – uncomfortable.

And to our perspective, this is unfair. 

The whole idea of bias training is based on the theory of white supremacy. And this is based on the idea that we are not in control of our conscious behavior. And this is because we have implicit or unconscious bias towards people of certain races or sexual orientation. 

The problem I have with this is that it is not based on science. And this comes at a time where people are telling us we need to listen to the science. Well, I have never seen a study showing that there is a connection between implicit bias and conscious bias. Implicit bias meaning that we have unconscious thoughts. And conscious bias in that we act on our conscious thoughts without realizing we are doing it. And only white people do this. 

As noted above, there is no science proving the link between unconscious bias and conscious bias. This is so much so that this information cannot be used in a court of law. Yet here we have our governor of Michigan saying that there is a link. And that all healthcare people have to go training to undo this bias. And it is based on what? We do not know. No one knows what this is based on, not even Whitmer. And I am saying this is true because no one knows what is in someone else's head. And to assume we all have implicit bias when you have no idea how to read someone's mind is poppycock. 

Look at it this way. Let's accept the premise for a moment that I am having unconscious thoughts against black people. I don't, but let's just say I do. How can I change it if I don't even know I have it. You can force me to undergo training. But If I don't know I have it, I will never admit it, so I won't change. So, on its face, bias training is a waste of time and billions of dollars. 

Bias training is based on the idea you can stop unconscious thought, or stop yourself from having conscious thoughts based on it. It's also based on the assumption that all people have bias towards others, and also will act on this bias. But, this in itself is untrue also. It cannot be proven by science. 

And I will give you one example. I am a single male. I like women. So, if I have unconscious thoughts about women. And I am prone to acting out and cannot control it. Then I would chase every cute woman that I see. And this would cause a ton of trouble for me. And I do not do this. So, even if I have such an unconscious thought, I do not act on it.  Again, assuming we have unconscious thoughts, we are not prone to act on them. We have limits. We have control. And we do not need bias training. 

So, these are just some of my thoughts on bias training. I am not happy with it. I will do it if that is what I need to do to keep my job. But, Lord knows I will challenge the teacher in any way I can. And I will tell them what they want to hear (fingers crossed behind my back) so I can keep my job. And I know many of my friends who will do the same. 

Disclaimer: This article is not a criticism of my place of employment. If my place of employment has us do bias training, it is only because it is mandated by state regulation due to governor Whitmer's executive order

Friday, May 13, 2022

Oxygen Levels Can Go Way Lower Than We Once Thought

During COVID, we had patients walk into the ER on their own two feet. And they talked to us. And when we asked, "Are you feeling short of breath?" You would get the answer, "No. My breathing is fine." 

And we knew this not to be true. We saw that their saturation was in the 70s. And yet you saw a patient sitting on the edge of their bed talking away. And this sort of changed our perception of a low oxygen saturation. 

In the past, we saw sats in the mid 80s as horribly bad. When COVID hit, we decided that it was okay to maintain sats in the mid to low 80s, so long as the patient was doing okay. If they showed signs of failing, only then did we think of using BiPAP and intubation. And this was how we learned to manage hypoxia due to COVID. 

We learned to be patient. We learned not to panic about sats in the 70s. 

Now, does that mean we did not treat the hypoxia? No! If I had a patient with sats that low, I'd be setting up a high flow nasal cannula. I'd set the flow as high as I could (like 60 or 70 if needed). And I'd set the FiO2 at 100%, or as close to it as I could get given the device I was using. 

And if this maintained a sat in the mid 80s, and the patient was seemingly fine otherwise, I'd be patient. If the sats dropped, I'd have the patient try proning. And in many instances this worked just fine. 

There were times I had a patient do just fine (well, given the situation) on 100% FiO2 high flow nasal cannula, mixing in proning, for weeks. And they would get better at times and we'd reduce the flow and FiO2, and they would get worse again. This cycle would continue until they either eventually got better or required more invasive treatment. 

What we learned is that humans can tolerate low oxygen levels way better than we once thought. We had one patient on 100% Fio2 for an entire week with sats in the 70s. This was during the heartof the first surge when we didn't know much about COVID. 

And eventually this patient started to fail. His respiratory rate increased to 40 or higher. His body was starting to shut down. And he eventually decided to let us intubate him. And even just before he was being intubated, he was mentally fine. I had a discussion with hem. 

And, I think, in retrospect, we should have intubated this man much earlier. And if he didn't make himself a DNR we may have. Still, experiences such as this has us rethinking low oxygen levels. It has us rethinking hypoxia and its effects on the human body. 

Personally, I do not think our current definitions of hypoxia should be changed. I think 88-90% is a good bottom line to maintain. With COPD, we have learned to tolerate sats in the 88-92% range. And for COVID we have learned to tolerate sats in the mid 80s. We certainly do not want it to stay that low too long.

But, given that intubated COVID patients have a 50% chance of dying. I think that being patient bodes well for them. 

How long can a human being tolerate a sat in the 70s? We do not know for certain. Eventually their body will shut down. But, we do know that the body has fighting power to maintain oxygenation to vital organs way longer than we once thought. And a person has the ability to maintain normal functions for way longer than we thought. They can talk. They can think. 

Tuesday, May 10, 2022

The Art Of Drawing Blood

I had a kid with cerebral palsy a while back. And he was a good boy. Although, he hated his breathing treatments. He was constantly writhing his arms and his head as though I were torchuring him. Although I was not. I was trying to help him. 

Were the treatments really needed? That is sometimes difficult to determine. But the boy did need frequent suctioning, as his secretions were white and thick and sticky. Although, in my humble opinion, he did have a good cough. When I'd suction out via his nares, he would cough hard and then I'd have to suction out his mouth, which in itself was difficult, as, when he is angry at me, he also clenches his teeth. So getting him to open his mouth, and not bite down on the yanker, is quite the challenge. 

So then the doctor ordered an ABG. And I'm like, "How the hell am I going to be able to draw an ABG on this kid?"" There's that moment of anger where you are like, "What the hell? Did the doctor not LOOK at this patient?"

And, of course, then I gain a grasp on my inner psyche and calmed myself down. This is a skill I learned a long time ago when I realized that so many doctor's orders are stupid. And, as a disclaimer, that is no knock on doctors as it is on the powers that are likely to sue them. So we do a lot more than is necessary. And, when you are already burned out from previous orders, the stupid ones sometimes set us on a rampage. And, so, long ago I learned to temper my anger at these. I throw my fit when no one is around. And as soon as I am by another person, be it a nurse, doctor or patient, or patient family member, I am my usual kind and nice self.

And so, I set off on gathering my ABG equipment. And, of course, I approach the doctor, who says, "Yeah. I understand it might be a challenge to get it. And if you don't I can always to a VBG. But, I just figured, since he has been here for 8 days and isn't getting any better, that I'd order some more tests and check some things out." 

Okay. I respect that. I can't argue with that. And, so I enter the room to do the ABG. And I recruit the nicest nurse ever to help me hold the patient while I poked. And I did not feel a pulse. Calmly I check for pulses at various spots: right radial artery, left radial artery, right brachial. And then I realize I'm just going to have to poke blindly. 

"Just poke. You can do it!" The nurse says with, with a graceful half smile. 

I will do it once, I decide. And then I will tell the doctor I can't get it. 

Now, for all sakes and purposes, I am pretty good at drawing blood gases. I have been doing this for 25 years now. So the nurse grasps the inside of the patient's elbow, and holds his arm stiff. And I say, "Can I get you to hold the elbow straight by another method?" And she says, "Sure." And I say, "Can you place your palm under the patient's elbow. That way he won't be able to bend it and you won't be obstructing the artery." 

"Oh, yeah, that makes sense," she says, eager to help. 

And so I pull out my syringe. The cap is already on it with needle. I prep the skin. I get a band aide and peel the sticker off the backside. And I stick one side of it to the edge of a table. This will make it easy to grab with one hand after I succeed at getting the ABG. And I feel for a pulse with the pointer finger of my left hand. I take my time. I do not find a pulse, as expected this time. 

And so I let go and step back. And I say to the nurse. "See if you can find a pulse." So she ckecks for a pulse on the patients right side while I jump over to check for one on the other side. This is my last ditch effort to do the ABG the proper way, which is by palpating a pulse and putting the needle over the pulse. This greatly increases your odds of success. And she says, "I feel one. It's right here." And she holds her spot with the tip of her finger as I walk around the bed. And she removes her finger and I set my finger over the same spot. I patiently wait for the pulse to be felt.

I will be honest. I wasn't sure I could even feel the pulse. It was hard to tell if the pulse I might be feeling was the patients, if it existed at all, or me. And, there's also the fact that I am loaded with beta agonists from my morning dose of Symbicort. And I am also loaded with caffeine from my morning cup of tea. So, it was difficult to know if I was feeling a pulse or if it was just me tremoring.

"I do feel it, I think," I say. Was it a lie what I just says. Not really, because I did add in the "I think" part. "But it is so week. How do I isolate that weak pulse?"

And she says, "As best you can." 

And so I decide to poke. And basically this is a blind poke, as that very, extremely, soft pulse is not enough to isolate his little artery in his little wrist. If you draw blood gasses on a regular basis you know what I mean. 

So, rather than using the pulse to guide my poke, I use landmarks. Although, because I can feel maybe even the slightest faint of a pulse, I use this to guide my direction. And so I try to find the location where the artery usually rests under. And I poke. I readjust the needle three times and am about to give up when the patient jerks his arm. The nurse readjusts to grab a hold of the arm, and she does this while still holding the patients elboy. And this is no knock on the nurse as this is expected, and that's why she is there to help. 

And she says, "Sorry." And I say, "No need to apologize. When the patient moved he moved his artery right into the tip of the needle." She and I both laughed at that. And I allow the blood to flow smoothly into the syringe. And I pull the needle out. 

i have had times in the past where I go into droughts. I know that anyone who works in medicine and draws blood or puts in IVs does this from time to time. But, I have been doing this so long now that my success rate is very high. Usually, if I do miss, it's because the patient has no pulse. So it does feel nice when you succeed when expect to not succeed. It boosts the ego up from zero to one. 

And, truly, there is a sense of satisfaction. Although you humbly suck it up because you know the next one might not come so easily. Someone once said that baseball is a humbling sport. In the same way, drawing blood is a humbling act in healthcare. 

Monday, May 9, 2022

"Breathe!"

We had a two-year-old come into our ER. He was seizing. And no matter what the doctor ordered he continued to seize. So, it was decided to intubate the child. 

And I work for a small hospital. We are a small hospital in a large chain of hospitals.So the corporate bosses -- the powers that be -- did not stock us up with a ventilator to use on a child like this. So, I was forced to resort to the antediluvian technique of bagging the child. I think I ended up bagging for about an hour before the EMTs arrived to take the child to the big city hospital. And, lo and behold, the EMTs didn't have a ventilator for this situation either, so they also had to bag the child for the duration. 

The reason I bring this us, is as I'm bagging, the dad of the child is standing on the other side of the bed. We are engrossed in a nice discussion. And my Apple Watch dings. And on the watch it says, "Breathe!" 

I think nothing of this. However, the dad says, "I think that's neat that you are a respiratory therapist and you have to have your phone tell you to breathe!"

And we both laughed. It's neat how we humans can find humor even in the most mundane of situations. And I think that is a good way of reducing stress.