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Wednesday, January 10, 2007

RT Cave Rules

  1. NT suctioning is a very traumatic procedure to be done only when excessive secretions are disrupting a patients breathing and all other options have been exhausted.
  2. Modest men feel stupid about coming to the ER, especially when they are perfectly fine, so make them feel like they did the right thing, even if you have to tell a white lie.
  3. If you are trying to get a protocol passed, you have to keep your mouth shut about treatments not being indicated. You must be diplomatic.
  4. Hospital workers, especially one's that work nights, do not hold grudges.You can't hold coworkers accountable for what they say under stress, pressure or lack of sleep -- especially lack of sleep.
  5. There is only one purpose for bronchodilators, and that is to treat shortness-of-breath due to bronchospasm
  6. STAT means that you need to get to the patient's side right now. We are talking about a life and death situation.
  7. if you are having a true emergency, you will not have to wait to be seen by the ER physician. If you are suffering from anything critical, you will find yourself in an ER bed faster than you can say ER.
  8. A true RT professional never carries a mood into the patient room. It's best to keep it in the RT cave.
  9. Not all procedures doctor's order are really needed. Some are needed. But others are ordered just as a precaution, and thus are wanted. Thus, some are wanted. In order to prioritize, we RTs need to know the difference between a need and a want.
  10. Nasal cannulas do not belong in mouths. Not only is this not necessary, it is unsanitary. The nasal passages and sinuses act as a reservoir for oxygen entering via the nasal cannula. Even if the patient is a mouth breather, or has a stuffy nose, the patient will still entrain oxygen via a properly inserted nasal cannula.
  11. NOT everything pulmonary should be treated as bronchospasm. Ventolin does not work like Scrubbing Bubbles bathroom cleaner and scrub the lungs clean of all that ails them. It is for bronchospasm only.
  12. Just because a patient has pneumonia is NOT an indication for a breathing treatment.
  13. In order to know that a breathing treatment is needed, you have to actually assess the patient.
  14. If you have a chronic lunger, expect that the room will be cool, a fan will be on, and/or the window will be open. You may find yourself looking around in all the dark ends of the hospital for a fan.
  15. A guideline is just a guideline. It is not a substitute for experience and common sense. For the most part, that guideline is just a tool.
  16. If you have asthma and you do not miss work, and you do not miss school when you are a kid, and you are able to lead a relatively normal life, then your asthma is controlled. That's how we define asthma control. It's not based on how often you use your rescue inhaler.
  17. Whether someone has controlled COPD is not based on how many times a rescue inhaler is used, or how much oxygen the patient is on, but whether or not that patient can continue to be a productive member of society.
  18. While guidelines should always be considered, each patient and each patient situation should be assessed and treated individually. We cannot treat all patients the same, as most guidelines portray.
  19. Humidity or cool mists may work wonders for croup, but can make the air difficult to breath for asthmatics. In the hospital, cool mist therapy can be used for croup patients, but not for asthma.
  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.
  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.
  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.
  23. All adventitious lung sounds are not an indication for a bronchodilator.
  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.
  25. A wise medical care worker will know the indications for ordering a breathing treatment and not request a treatment (or order one, or give one) unless a patient meets this criteria
  26. Cardiac Asthma should not be treated as asthma. Throat wheezes, upper airway wheezes, and dyspnea on exertion are signs of cardiac asthma, and a wise medical specialist will not confuse this with asthma.
  27. Know the 27 non-indications for bronchodilators and do whatever is in your power to make sure breathing treatments are not ordered for these reasons.
  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.
  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.
  30. The breathing pattern is another consideration in using a nebulizer or inhaler with a child. Quiet tidal breathing is the best pattern for drug delivery. Crying is a problem during a nebulizer treatment due to high inspiratory flow during the short, rapid inspirations and prolonged expiration that result in a significant decrease in medication deposition in the lung.
  31. The technique of directing the nebulizer output toward the patient's nose and mouth (referred to as "blow-by") is considered to be inappropriate and should not be used. The AARC CPG on aerosol delivery devices recommends that a nebulizer with a mouthpiece and an extension reservoir be used in children >3 years of age if they are cooperative, are spontaneously breathing, and do not have an artificial airway in place.
  32. You can talk about anything with the patient so long as the patient approves of it. In a sense, you will want to baby your patients. A stressed patient heals slower.
  33. Never talk politics within earshot of your patients unless you know the patient will not be offended by opposing views. Or, if you don't know the patient, keep your mouth shut. This is especially true of naive and stubborn patients.
  34. Sometimes it's okay to lie to your patients. You may try to get around it, but you will many times decide there is no way to get around it no matter what your morals tell you.
  35. A wise doctor admits when he is to the limits of his medical wisdom and seeks the education, experience and wisdom of RTs. A wise RT will be ready with a veritable option for the doctor, and stay humble if he is right.
  36. It is not necessary for doctors to get irritated with RNs and RTs for doing the jobs they are prepared and fully qualified to do during a code. Getting irritated only makes those around you more stressed in a situation that is already stressful."
  37. If you want to succeed in life you have to supply the effort, which may involve going out of your way or doing things you don't necessarily want to do. Thus, success is not determined by IQ, but through effort
  38. When we are relaying private information about the patient, we must remember to keep our voices down.
  39. RT Cave Rule #39: Make sure your patients on oxygen do not get close to a flame, and that includes gas stoves with the burners on and cigarette lighters.
  40. Whatever it takes to keep a patient over 80 happy, do it. Whatever it takes to keep an end stage COPD, CHF, CF or cancer patient happy, do it. Use your common sense.
  41. RT Cave Rule #41: Poor planning on the part of administrators, bosses and supervisors does not constitute an emergency on the part of the staff.
  42. RT Cave Rule #42: It's best to do what's right now, do good charting, and worry about a lawsuit some other day.
  43. However annoying it may be, you should assess treatments ordered prn, and chart treatment not given and why. At the very least you get that all important procedure count, and make your boss happy.
  44. If a patient needs a treatment, and the doctor approves the frequency, give the patient the treatment when she needs it or wants it. It's that simple. Don't let a patient a sit there short of breath because you think you need to "spread the treatments out." Ventolin is a safe and effective medicine, so don't make the patient suffer due to some fallacy.
  45. Even when you are right, and someone accuses you of doing wrong, keep your mouth shut and take the hit. So long as you're a good worker, your good character will be visible to all in the end
  46. Its important to keep up on your RT Wisdom and practice scenerios occasionally, especially regarding procedures you rarely do. Thus, a well prepared RT is the calmest person in the room.
  47. RT equanimity is the most important RT trait. It allows the nurse and doctor to concentrate on their jobs instead of yours.
  48. If you want someone to page you they won't.  If you're in a room and the patient won't shut up, and you can't think of a way to escape, your pager won't go off.  It's just the way it is
  49. One mistake does not constitute a crisis.  One mistake is a normal human error, and several mistakes may be considered a crisis that needs to be dealt with.
  50. Hotheads never win.  Getting hot says more about your incompetence in dealing with stressful situations and resolves nothing.  It merely results in you looking like the bumbling moron you are.
  51. When dealing with a hothead, it's best to shut your mouth and walk away.
  52. So long as you have a good airway and ventilations are effective, intubation can wait until the patient is stabilized.
  53. Keep your respiratory therpast happy by calling him/ her by name.  Do not refer to your respiratory therapist as respiratory.  Do not say, "Hey, respiratory!" (1/26/13)
  54. If you want you RT to help you out in the future, don't tick him off today
  55. If you're grumpy, turn it off at the door of the patient's room  
  56. Smile when you're talking on the phone, it will make it easier to be pleasant.  
  57. The best caregivers are people orientated first, task orientated second. 
  58. The kindness rule entails that you get all your work done so you don't create work for your coworkers. (7-27-12)
  59. Don't be a space hog:  Follow the Social Space Rule.  During a social conversation you should stay 4-5 feet from the person you're talking with. (9-19-12)
  60. Hospital scrubs are only for people that are financially secure, such as doctors and admins.  RTs and RTs must buy your own scrubs.  We do not have enough money to pay for scrubs for everyone
  61. Do not carry something of someone else's in your lab coat, because chances are you'll be in a rush to go home at the end of your shift and you won't be thinking about what's in your pockets. You'll then be responsible for something that's not yours, and you'll end up a slave to the lender.
  62. Sats low? Check the tubing first


Anonymous said...

What happens when an off the clock paramedic gives an unprescribed breathing treatment to a child-one that hasn't been seen by a Professional? Is this illegal?

nick said...

yes. since they are not on the clock then they are not technically working under the medical control of their medical director. paramedics and emts are only approved to perform procedures under standing orders while they are actually working, not off the clock. it could, in the worst case, be considered practicing medicine without a license. also they could possibly be guilty of theft if they are using supplies that are not theirs. i remember a paramedic that recently got fired for taking albuterol home for his son because he could not afford an mdi. same thing as your question. its theft.

nick said...

paramedics are only allowed to perform procedures under standing orders when they are not working. when they are not on the clock they are not allowed to do anything. at the worst it could be considered practicing medicine without a license. also it could be theft if he took the neb from the service he works at. i remember recently a paramedic that got fired and charged with theft because he was taking home albuterol for his son because he could not afford and mdi.