I just called work, and I'm going in late, which means I get to go trick-or-treating with my kids tonight. This is another great advantage of working for a small town hospital, and of it being very slow.
Last year my kids only had a little bit of candy in their bags, and they were content. I wasn't. I wanted to have more candy so I could steal it from them. I ended up putting my 3 YO on my shoulders and knocking on doors myself.
My son is nine this year, so hopefully he is self driven. We'll see. My daughter is already whining about wearing her Winni-the-Poo costume. She says it makes her look too fat. So I told her to wear her chicken costume. "That makes me look too fat too, da da."
Hmmm, I wonder where she got that idea from.
No dieting tonight.
---------------------
Well, KK finally decided on the chicken costume, but it took her mom to persuade her that she didn't look fat. My son was actually into moving fast house to house, which is the way I like to do it, but the wife and daughter were content to lallygag along. I looked back once and observed my wife and daughter doing the chicken dance.
"Come on, mom!" my son yelled. It was of no use. There was no sense of urgency back there.
That's how it went for the first hour, until my son wanted to go to his school. Here the kids had to wait in line to play various games in order to get candy. How boring for dad. But, being the good dad I am, I waited patiently the 10 minutes it took for my kids to get to the front of the line. They bot got their prizes and we were out of there.
When we were back outside my wife said, "How about if we go home now."
"Yeah, I'm ready to go home," my son agreed.
I looked at the clock as I hop into the car. It was only 7:15. "You guys have another 45 minutes, don't you--"
"Sush!" the wife looked at me bug-eyed. "They already said no."
"Fine by me," I said. "You might as well drop me off at work."
"Besides," she said, "I'm tired and want to go to bed."
I suppose by the time my kids are really into Trick-or-Treating I'll be too old too care. I'll turn into my dad and just drop them off wherever they want and follow them around inside the toasty car with a beer between my legs.
The funny thing is, my kids ended up with a huge hoard of candy in that hour, enough to last us until Easter when I'll end up throwing half of it away.
Speaking of Easter Candy, it's time to toss it.
Wednesday, October 31, 2007
Monday, October 29, 2007
Ways RNs can irritate RTs
We have some of the best nurses in the world here at Shoreline hospital, and for the most part we work together well as a team. However, there are times when we don't see eye to eye.
Here I have composed an extemperaneous list of ways an RN can annoy an RT. If you're an RN go ahead and try one of these. We might grumble initially, but that's only if we're tired. Don't worry, we RTs don't hold grudges.
Here's the list:
1. Ask the same question 10 different ways and have RT paged for each question.
2. Wait for RT to leave and page them right back.
3. Call for stat Incentive Spirometers when you know they are busy.
4. If Sats drop, call for STAT breathing treatments. If patient doesn’t have treatments ordered call Dr. and get treatment ordered.
5 . Let the RT think she is smarter than you. This is cool, because you snicker while listening to her grumble about how a breathing treatment is not indicated, and then you turn around and call the doctor and recommend treatments anyway.
6. As a rule of thumb, if the therapist asked you to check the I&Os, be sure to get treatments ordered.
7. Any irritating lung sounds merit a breathing treatment.
8. If possible, do not ever call RT prior to calling the doctor, for doing this will merely build up their ego.
9. Complain about the RT being too slow getting to the ER, even though you know they were busy.
10. After a patient's been on treatments for two weeks, put the pt in MRSA isolation.
11. Better yet, let us assume all nursing home patients have MRSA, especially if they have bronchodilator.
12. Tell RTs that all treatments are needed because the DR. said so.
That's all I can think of for now. If you can think of any more let me know.
Later in the week I'll tackle ways Drs can irritate RTs.
Here I have composed an extemperaneous list of ways an RN can annoy an RT. If you're an RN go ahead and try one of these. We might grumble initially, but that's only if we're tired. Don't worry, we RTs don't hold grudges.
Here's the list:
1. Ask the same question 10 different ways and have RT paged for each question.
2. Wait for RT to leave and page them right back.
3. Call for stat Incentive Spirometers when you know they are busy.
4. If Sats drop, call for STAT breathing treatments. If patient doesn’t have treatments ordered call Dr. and get treatment ordered.
5 . Let the RT think she is smarter than you. This is cool, because you snicker while listening to her grumble about how a breathing treatment is not indicated, and then you turn around and call the doctor and recommend treatments anyway.
6. As a rule of thumb, if the therapist asked you to check the I&Os, be sure to get treatments ordered.
7. Any irritating lung sounds merit a breathing treatment.
8. If possible, do not ever call RT prior to calling the doctor, for doing this will merely build up their ego.
9. Complain about the RT being too slow getting to the ER, even though you know they were busy.
10. After a patient's been on treatments for two weeks, put the pt in MRSA isolation.
11. Better yet, let us assume all nursing home patients have MRSA, especially if they have bronchodilator.
12. Tell RTs that all treatments are needed because the DR. said so.
That's all I can think of for now. If you can think of any more let me know.
Later in the week I'll tackle ways Drs can irritate RTs.
Sunday, October 28, 2007
The reality of small town hospitals
Shoreline Hospital is a relatively small hospital on the shore of a Great Lake in Michigan. I noticed the first time I walked into this place I was going to like it here. As one of the senior RTs described it to me at the time, "this place has a nice down homey feel to it."
There are the obvious goods and bads of working for a small place as this.
The good: We RTs have time to sit and get to know some of our patients. That's one of my favorite things about this job is learning about an elderly persons entire life in just a few short hours. Sometimes it reminds me of the movie Fried Green Tomatoes. If you haven't seen that movie you should.
When it's slow we talk, play cards or simply hang out. Sometimes, when a good ballgame is on, we turn on a TV and enjoy it, only to leave every ten minutes or so to check on our patients, or, in my case, to run down to ER occasionally. And, on nights like tonight, we have pot-lucks.
When it's really, really, really slow I sit here and do this. Earlier in the summer we wrote protocols for everything imaginable, we did research, we looked for new innovations to improve our hospital. That's what we do here. Or, that's what I do here when it's slow. I can't just sit around twiddling my thumbs or gossiping. I hate gossipping.
If I were busy I highly doubt I'd be making entries here every day. How many jobs can someone get paid to blog all night long? When it's like this, coming to work is like going on a vacation. I tell my kids this is what you get to do at work when you go to college.
The bad: When I first started working here Dave came up to me and said, "Rick, you should go to work in Grand Rapids. If you go there you will be able to use your skills all the time, instead of once in a while. If you stay here, you might lose your skills."
He told me he's been working here so long doing frivolous breathing treatments that he didn't have any real respiratory skills left, and that there was no hope for him ever getting them back.
Needless to say Dave is our complainer. He's a great therapist, but a complainer. You know what they say about complainers, that they say more about themselves than the people they are complaining about. Every hospital has them. I hate complainers. I avoid them to the best of my ability.
I also hate doing breathing treatments on people who don't need them. I hate going into a room at 5:00 in the morning to wake up a patient just because the doctor said. If the patient is not having bronchospasms, if he's sleeping, he doesn't need it. I hate waking these patients up. I feel stupid. I feel like any person out of college could do this part of my job. This is why I'm such an ardent supporter of protocols, to get rid of this junk.
We will get busy again soon, and more than likely it will happen all of a sudden, and involve 20 Q-forever breathing treatments for no reason, and ER will be swamped.
My ideal workload: I want to be busy doing real RT work. I want to be busy with critical patients, COPD patients, asthma patients, real chest pain patients, and the only breathing treatments I do are for bronchospasm.
Reality: We will have a mixture of all the above. I will not move to Grand Rapids or Ann Arbor and definitely not Detroit where I'd actually get to use my skills on a daily basis. I can't because I'm not switching my kids to a new school, and I hate moving as much as I hate complainers and gossipers.
So we make the best of it here at Shoreline Hospital. The complainers will continue complaining, the button pushers will continue pushing buttons, and us hard workers will continue researching, writing protocols, and thinking of new ways to make this the best small hospital respiratory therapy cave, even if it's just to appease ourselves.
But there's only so much of this we can do. So when we're slow as long as we've been it's easy to drift off into la la land. When you don't do work for a long time you get lazy.
And I guess that goes full circle to what Dale said. And, ironically, that was one of my biggest fears when I graduated with my RRT: do I go to the small Shoreline in my hometown and risk getting lazy, or challenging my skills in GR?
Anyway, my point is: Despite the bad, despite my newly formed laziness, despite the high school work, we still have a pretty good team here when it comes to solving real patient problems. I think this is a well respected, well experienced, well educated group of RRTs; and this is a pretty nice place to work. I suppose what it comes down to is: it is what you make of it.
There are the obvious goods and bads of working for a small place as this.
The good: We RTs have time to sit and get to know some of our patients. That's one of my favorite things about this job is learning about an elderly persons entire life in just a few short hours. Sometimes it reminds me of the movie Fried Green Tomatoes. If you haven't seen that movie you should.
When it's slow we talk, play cards or simply hang out. Sometimes, when a good ballgame is on, we turn on a TV and enjoy it, only to leave every ten minutes or so to check on our patients, or, in my case, to run down to ER occasionally. And, on nights like tonight, we have pot-lucks.
When it's really, really, really slow I sit here and do this. Earlier in the summer we wrote protocols for everything imaginable, we did research, we looked for new innovations to improve our hospital. That's what we do here. Or, that's what I do here when it's slow. I can't just sit around twiddling my thumbs or gossiping. I hate gossipping.
If I were busy I highly doubt I'd be making entries here every day. How many jobs can someone get paid to blog all night long? When it's like this, coming to work is like going on a vacation. I tell my kids this is what you get to do at work when you go to college.
The bad: When I first started working here Dave came up to me and said, "Rick, you should go to work in Grand Rapids. If you go there you will be able to use your skills all the time, instead of once in a while. If you stay here, you might lose your skills."
He told me he's been working here so long doing frivolous breathing treatments that he didn't have any real respiratory skills left, and that there was no hope for him ever getting them back.
Needless to say Dave is our complainer. He's a great therapist, but a complainer. You know what they say about complainers, that they say more about themselves than the people they are complaining about. Every hospital has them. I hate complainers. I avoid them to the best of my ability.
I also hate doing breathing treatments on people who don't need them. I hate going into a room at 5:00 in the morning to wake up a patient just because the doctor said. If the patient is not having bronchospasms, if he's sleeping, he doesn't need it. I hate waking these patients up. I feel stupid. I feel like any person out of college could do this part of my job. This is why I'm such an ardent supporter of protocols, to get rid of this junk.
We will get busy again soon, and more than likely it will happen all of a sudden, and involve 20 Q-forever breathing treatments for no reason, and ER will be swamped.
My ideal workload: I want to be busy doing real RT work. I want to be busy with critical patients, COPD patients, asthma patients, real chest pain patients, and the only breathing treatments I do are for bronchospasm.
Reality: We will have a mixture of all the above. I will not move to Grand Rapids or Ann Arbor and definitely not Detroit where I'd actually get to use my skills on a daily basis. I can't because I'm not switching my kids to a new school, and I hate moving as much as I hate complainers and gossipers.
So we make the best of it here at Shoreline Hospital. The complainers will continue complaining, the button pushers will continue pushing buttons, and us hard workers will continue researching, writing protocols, and thinking of new ways to make this the best small hospital respiratory therapy cave, even if it's just to appease ourselves.
But there's only so much of this we can do. So when we're slow as long as we've been it's easy to drift off into la la land. When you don't do work for a long time you get lazy.
And I guess that goes full circle to what Dale said. And, ironically, that was one of my biggest fears when I graduated with my RRT: do I go to the small Shoreline in my hometown and risk getting lazy, or challenging my skills in GR?
Anyway, my point is: Despite the bad, despite my newly formed laziness, despite the high school work, we still have a pretty good team here when it comes to solving real patient problems. I think this is a well respected, well experienced, well educated group of RRTs; and this is a pretty nice place to work. I suppose what it comes down to is: it is what you make of it.
Saturday, October 27, 2007
What RTs can do that RNs can't
Djanvk made a great post on his blog about the differences between RTs and RNs RTs vs RNs
I have to say this is a great list. I will make a facetious version of the list here:
1. RTs get to leave when the patient poops.
2. An RT can tell a coworker to beep him in 5 minutes so he has an excuse to leave the room of a loquacious patient.
3. RTs can silently fart in an obtunded patient's room and snicker as the RN takes a peek at the patient's bottom.
4. An RT can sit in his cave all night while the RNs think he's working hard. This is a good excuse when you're late for a treatment or feeling lazy and know the RNs are busy with a patient.
5. If there's an annoying nurse the RT can get his work done and leave.
6. An RT can take a break when he gets a minute, and for me right now that's been the past 90 minutes.
I have to say this is a great list. I will make a facetious version of the list here:
1. RTs get to leave when the patient poops.
2. An RT can tell a coworker to beep him in 5 minutes so he has an excuse to leave the room of a loquacious patient.
3. RTs can silently fart in an obtunded patient's room and snicker as the RN takes a peek at the patient's bottom.
4. An RT can sit in his cave all night while the RNs think he's working hard. This is a good excuse when you're late for a treatment or feeling lazy and know the RNs are busy with a patient.
5. If there's an annoying nurse the RT can get his work done and leave.
6. An RT can take a break when he gets a minute, and for me right now that's been the past 90 minutes.
Considerations for readiness to wean
Here are some things to consider when determining if an intubated patient is ready for a weaning trial.
1. Awake and alert
2. Able to follow commands
3. Spontaneously breathing
4. Adequate cough
5. Pain controlled
6. No obvious signs of respiratory distress
7. Little to no anxiety
8. FiO2 equal or less than 40
9. PEEP 5 or less
10. Temperature equal to or less than 100.4
11. Hemodynamically stable
13. A-a gradient less than 300
14. a-A ratio greater than 50%
15. PaO2/FiO2 greater than 150-200
16. Underlying condition resolved
17. Chest X-Ray improving
18. Adequately nourished (Albumin >2.5)
19. Electrolytes stable (CA, Mg, K)
20. Secretions thin and minimal
21. Adequate Hemoglobin (>8-10)
22. Adequate Hematocrit (>25% or baseline)
23. Absence of bowel problems (diarrhea, constipation, ileus)?
24. Weaning parameters within normal limits:
25. PS must be at patients weaning level:
1. Awake and alert
2. Able to follow commands
3. Spontaneously breathing
4. Adequate cough
5. Pain controlled
6. No obvious signs of respiratory distress
7. Little to no anxiety
8. FiO2 equal or less than 40
9. PEEP 5 or less
10. Temperature equal to or less than 100.4
11. Hemodynamically stable
- No Dopamine infusion greater than 5 mc/kg
- Systolic BP
- Pulse >50
12. ABGs normal for patient
13. A-a gradient less than 300
14. a-A ratio greater than 50%
15. PaO2/FiO2 greater than 150-200
16. Underlying condition resolved
17. Chest X-Ray improving
18. Adequately nourished (Albumin >2.5)
19. Electrolytes stable (CA, Mg, K)
20. Secretions thin and minimal
21. Adequate Hemoglobin (>8-10)
22. Adequate Hematocrit (>25% or baseline)
23. Absence of bowel problems (diarrhea, constipation, ileus)?
24. Weaning parameters within normal limits:
- NIF greater than 20
- VC >10ml/kg IBW (2*VT)
- VE less than 10- 5ml/kg IBW
- VC double VT
- RR less than thirty 30
- RSBI (VT/RR) less than 100
25. PS must be at patients weaning level:
- PS = Static minus PEEP
- Normal PS usually at least<=10
26. P0.1 = or less than 4.2.
27. P0.1 > 4.2 is "associated with failure to become liberated from the ventilator... If under 4.2, weaning was successful 78% of the time." (reference is Vent world)
Friday, October 26, 2007
A Canadian's opinion on Federalized Medicine
It is estimated that 40 million people in the U.S. do not have healthcare insurance. Therefore some politicians have proposed we go to a nationalized healthcare system, where the government makes healthcare available for free to everyone.
I've done a ton of research on this, and have decided this type of system sounds great on the surface, until you consider somebody has to pay for it. Well, we all know that will be you and me via more taxes. So, in essence, it will not be free (more on this tomorrow).
“But the fact that taxes will go up is the least of your worries,” wrote a friend of mine who lives in Canada.
She explained it this way to me: Lets say such a program passes through the legislature and is signed into law by the president. Within a week, since healthcare is now free, people start to rush into hospitals to get that knee replacement they couldn’t afford a week ago. Or, maybe it’s to finally see a doctor about that ailing back, bum shoulder or mole on your ear that you’ve been living with fine the past 10 years.
These surgeons will become inundated with new patients, and will be reaping in the profits. Right out of high school young kids will be filing in droves to attend medical school so they can participate in this profitable business. New surgical doctor’s offices will spring up all over the United States, and they will all be filled with new patients -- it’s all free, the government pays.
Dishonest and honest surgeons are having a field day while they are all making tons more money than they ever would have dreamed of making under the old system, but the government starts to get all stressed out. “How are we going to pay for this? We are running out of money.”
New government offices spring up filled with bureaucrats and red tape, and they start to require permits as to who is going to be allowed to perform surgery in an attempt to cut down on the number of surgeons, and as to what types of equipment surgeons will be allowed to buy.
Then there will be new laws limiting the types of surgeries surgeons will be allowed to perform, and potential patients will have to file for permits to get operated on. Officials will be asking, “Is this mole really bothering you? You’ve been getting along fine with that heart your whole life, why do we need to replace it now?”
There is so much red tape now that long lines develop. People that just want to be routinely checked will have to wait in line with the person with a clogged artery in his heart. Of course, this heart patient won’t be able to escape his country to go see an American doctor, because that’s the medical system that is now broken.
Thursday, October 25, 2007
Beware! There's a full moon tonight.
I've been off work the past 6 days, so as I was driving to work this afternoon I was kind of hoping to have a good night: then I noticed the full moon.
I never believed in superstitions until I got this job. I've had good nights and I've had bad nights, but I have rarely had a good night with a full moon lighting up the night sky.
One night during a full moon we had a patient in for detox and he escaped through the window and onto the roof. An hour later he was found by the ER staff; he had walked in as a new patient. Have you ever had a patient escape like that? We've had it happen more than once, and our windows are but little slits.
If there's a crazy person out there, tonight's the night he'll make a public appearance. Will it be the cops, the social workers, or us hospital staffers who will have to deal with the brunt of it? I'm hoping it's not me tonight.
Who's going to be busy tonight, and what kind of busy is it going to be? Is this going to be one of those nights where we have three codes on the floors, or one of those nights where I have to do 20 EKGs in ER? Or will it be something totally unexpected, like another escapee.
I'm prepared for the worst but hoping for the best tonight.
You guys have any good full moon stories?
I never believed in superstitions until I got this job. I've had good nights and I've had bad nights, but I have rarely had a good night with a full moon lighting up the night sky.
One night during a full moon we had a patient in for detox and he escaped through the window and onto the roof. An hour later he was found by the ER staff; he had walked in as a new patient. Have you ever had a patient escape like that? We've had it happen more than once, and our windows are but little slits.
If there's a crazy person out there, tonight's the night he'll make a public appearance. Will it be the cops, the social workers, or us hospital staffers who will have to deal with the brunt of it? I'm hoping it's not me tonight.
Who's going to be busy tonight, and what kind of busy is it going to be? Is this going to be one of those nights where we have three codes on the floors, or one of those nights where I have to do 20 EKGs in ER? Or will it be something totally unexpected, like another escapee.
I'm prepared for the worst but hoping for the best tonight.
You guys have any good full moon stories?
Wednesday, October 24, 2007
The RT Cave in the year 2020
An elderly nurse with short, dark hair and a scowl implanted on her red face glared at the small crowd of students as they passed the nurses station on 2 East at Shoreline hospital. The year was 2020.
"Stay away from the nurses station, kids," Mr. Yankshire ordered. "They have lots of work to do." He directed the kids down the hall and stopped in front of a large picture window with "In case of emergency break glass" written in large white letters on it.
"Okay, now this is an interesting display." The teacher pointed at the young man with dark hair and white lab coat behind the glass. He was visibly sleeping in a recliner amid an array of equipment. Mr. Yankshire rapped on the glass, cleared his throat, and rapped on the glass again. The man behind the glass stirred, but did not wake.
"Who's that, Mr. Yankshire?" A young poc-faced boy asked.
"That, my students, is the respiratory therapist." To the left of the window is a small sign that read "Respiratory Therapy Cave: Rick Frea on duty." Under the green sign is an intercom box with a red light under it. Beneath that is a hammer hanging from a chain. To the right of the window is a large white metal door with no knob, and Mr. Yankshire pounds on it.
The man behind the glass finally opens his eyes. "Oh, hey, Roger. How's things going today?"
"Great," Mr. Yankshire said. "We were wondering if we could have a tour."
"What you see is what you get," said the respiratory therapist. He waved a hand to indicate all his equipment. "To my left are my ventilators, and to my right is my breathing treatment machine." He jerked a hand through the air over his head. Mr. Yankshire heard an audible click. He looks to his right and noticed the light on the intercom had changed to green.
"Hello. Hello." A tinny voice shoots from the intercom.
Questions pop from the mouths of the six high schoolers: "What is a ventilator?", " I don't see no breathing treatment machine?", "You get to sleep on the job?"
"Um," the teacher scratches his head, "well, let's be nice. We'll let the RT explain himself. Rick, would you be willing to tell us about your job."
The RT winced, then reached a hand into the air and appeared to pull a cord Roger knew was there but was certain the kids didn't see until just now by the expressions on their faces. There is a click behind him and then a misting sound. "Okay," the RT said, "Now look in the patient room behind you."
Mr. Yankshire turned and saw a mist coming from the room. He lead the students through the mist and into the room.
"Holy cow!" one female student exclaimed.
"Well, good morning to you all," the patient said. He was an elderly man with a hunched over back. He was sitting on the edge of the bed leaning on the bedside stand, and he was breathing in deeply the mist that filled the room.
"What is this?" a student asked.
"That, my students, is a a mist from the breathing treatment machine." Mr Yankshire pointed to a vent above the patent's head. "It's coming from that vent there."
"What's a breathing treatment?"
"Well, we'll let Mr. RT explain that to you." And, with that, he lead the students out of the room and back to the window with "In case of emergency break glass" written on it.
"Pretty interesting, hey?" The Rt said. He was smiling. "This is the best job in the world. You see, when a patient is short of breath I pull a cord from a respective room and give that patient a breathing treatment."
A chorus from the students rang out. "Cool."
"Or, better yet, I give a treatment at any doctors whim. It's easy as pulling a cord." He laughed at his pun.
"How does it work?"
"It's kind of like a giant mist tent from..." the RT stopped as he laughed at himself again, then stopped abruptly as he seemed to realize nobody was laughing with him.
"What's a mist tent?" The poc-faced student asked.
"It's an ancient device RTs used to use to, um," he scratched his head, "Oh, I guess that's ancient history. This is how we give breathing treatments today." He waved his hand again through the air and Mr. Yankshire could see the strings waving through the air over the RTs head.
"I didn't see those before. What are those?" It was a female student this tiime.
"These are breathing treatment cords. If a patient in room 207 is needs a breathing treatment, I pull cord number 206. It's easy as..."
"Okay, step back students." Mr. Yankshire interrupted, and motioned his students to the side as a man in a suit rushed to the window. He pushed the button by the intercom, and an audible click is heard. Mr. Yankshire observed the light by the intercom had turned red.
"We need a breathing treatment in 210," the man said, and rushed past the students as though they didn't exist. Mr. Yankshire noticed his name tag said Dr. Brown. Mr. Yankshire turned and peered into the window. He noticed the RT was still be talking, but could not be heard.
"Yeah, he is a prick," an elderly lady in scrubs grumbled as she walked up to the RT window. "That Rick Frea is a prick. All respiratory therapists are pricks." She pressed the button by the intercom; it clicks. The light turns from red to green.
The respiratory therapist could be heard again: "...and the old IPPB machine was used on that old show "Emergency" back in the 1960s as a vent. Funny thing is, we used that machine as a vent up until, oh, I'd say about 2000."
"Will you shut your lazy crank!" The nurse grumbled.
"Well, hey, nurse Ratchet." The Rt gave a friendly smile and waved at the nurse.
"Dr. Brown wants a treatment in 210," said the nurse.
"Does he wasn't Scrubblin-Bubblin Ventolin or Preventolin Ventolin."
"How the hell am I supposed to know."
"Scrubblin-Bubblin it is." The RT reached up and pulled a cord. A click and a mist was heard down the hall. Mr. Yankshire looked down the hall and could see a mist coming from one of the rooms.
"That must be 206," Mr. Yankshire said. "You can see the mist from here, students."
"Ah, what a great career this is," said Rick Frea. His smiled radiated cheek to cheek. "You guys definitely should invest two years to become this." He leaned his head back and pulled a lever on the side of the chair so his feet are now up. "This is the life."
Roger figured Nurse Ratchet wasn't her real name, but the old nurse turned to look at the students. Her large lips were turned down; she was tapping her foot. The students stepped back until they were against the wall. "RTs are useless dummies. They aren't needed here unless there is an emergency, hence the writing on the window."
Mr. Yankshire watched as the kids eye's rotated from the cranky nurse's eyes to the window, which read "In case of emergency break glass."
"Damn RTs!" A young lady in scrubs rampaged from what seemed like mid-air, shoved Mr. Yankshire aside, grabbed the hammer, and threw it into the glass, which shattered into a million pieces inside the RT cave.
"Oh come on! What NOW!" he grumbled as he stumbled out of the chair, shards of glass falling onto the floor as he did so.
The young lady said, "We need you STAT in 210. You're treatment didn't do any good. The wet rhales persist."
The RT crunched his way across the pieces of glass and clambered through the window. "Some things never change." He sighed, and calmly sauntered to his emergency. "Some things never change."
Tuesday, October 23, 2007
Have another donut Mr. Respiratory Therapist
"Have a donut." My coworker Dee slouches back in her chair, apparently exhausted after a long, busy day.
"No, I'm trying to stay fit." I grab the worksheet and sit down.
"Oh, come on, one donut won't hurt."
"Well, I suppose just one." There goes my diet. "You have a pen."
Dee reaches into her pocket, yanks out a pen, and hands it to me. "You'd think people who work in a hospital would be among the healthiest, most fit people in the world."
"I don't want your favorite pen," I said with a mouth stuffed with donut,
"I don't care. I just want to get out of here."
"Oh, well I can tell you from personal experience working in a hospital makes it impossible to stay healthy."
"Why do you say impossible?"
"Well, I get to work and you offer me a donut. Last night In ER they insist I eat the chili and apple pie in the break room. Then I go up to North and they insist I have some sloppy joes and chips, and then I go to CCU and I'm offered more food.
"Oh, I see what you mean."
"And that's not even mentioning the candy jar Jerry keeps filled in her office. And then I go into Mrs. Roger's room and she insists I take a handful of candy bars. In fact, not only does she insist I take some, but she insists I eat one in front of her. And how the hell do you say no to one of your sweetest patients?"
"And this isn't even a Holiday."
"There's no hope of dieting within a month of a Holiday around here. I try every year. In fact, I'm trying right now. The Halloween candy is already out and about. And then comes Halloween and New Years."
"True. And look around at all the overweight people working here. Well, you're not, but I certainly am."
"What do you mean I'm not fat. Look at me. I've been working out the past 5 weeks and I'm still 20 pounds overweight. In fact, I've lost 30 pounds or more 4 times since I got hired here, and every time I gained it all back.
"Really?"
"Yeah. I'm telling you, it's impossible to lose weight in a hospital."
"Want a piece of chocolate?" She slides the box across the table.
I grab one " Okay, now give me some times so you can get out of this unhealthy place."
"Sure, and then you can eat that last donut."
"Oh, you know I will, right after I visit Mrs. Rogers."
"No, I'm trying to stay fit." I grab the worksheet and sit down.
"Oh, come on, one donut won't hurt."
"Well, I suppose just one." There goes my diet. "You have a pen."
Dee reaches into her pocket, yanks out a pen, and hands it to me. "You'd think people who work in a hospital would be among the healthiest, most fit people in the world."
"I don't want your favorite pen," I said with a mouth stuffed with donut,
"I don't care. I just want to get out of here."
"Oh, well I can tell you from personal experience working in a hospital makes it impossible to stay healthy."
"Why do you say impossible?"
"Well, I get to work and you offer me a donut. Last night In ER they insist I eat the chili and apple pie in the break room. Then I go up to North and they insist I have some sloppy joes and chips, and then I go to CCU and I'm offered more food.
"Oh, I see what you mean."
"And that's not even mentioning the candy jar Jerry keeps filled in her office. And then I go into Mrs. Roger's room and she insists I take a handful of candy bars. In fact, not only does she insist I take some, but she insists I eat one in front of her. And how the hell do you say no to one of your sweetest patients?"
"And this isn't even a Holiday."
"There's no hope of dieting within a month of a Holiday around here. I try every year. In fact, I'm trying right now. The Halloween candy is already out and about. And then comes Halloween and New Years."
"True. And look around at all the overweight people working here. Well, you're not, but I certainly am."
"What do you mean I'm not fat. Look at me. I've been working out the past 5 weeks and I'm still 20 pounds overweight. In fact, I've lost 30 pounds or more 4 times since I got hired here, and every time I gained it all back.
"Really?"
"Yeah. I'm telling you, it's impossible to lose weight in a hospital."
"Want a piece of chocolate?" She slides the box across the table.
I grab one " Okay, now give me some times so you can get out of this unhealthy place."
"Sure, and then you can eat that last donut."
"Oh, you know I will, right after I visit Mrs. Rogers."
Monday, October 22, 2007
The demographics of RTs will not change
Djanvk, in his blog Respiratory Therapy Driven, wrote on Friday his thoughts on why someone would choose respiratory. I thought recently about writing about this topic, but now I don't think I could word it better than he did. You can check it out here: http://respiratorytherapydriven.blogspot.com/
I have asthma, and my parents encouraged me to go into respiratory, but didn't think I could pass chemistry since I failed it in high school. A friend of mine told me she liked Ferris, and she provided me with an application. When I was filling it out I just happened to be sitting in my journalism class, so I selected "journalism."
The only thing I accomplished in those first 2 years of college was, as I tell my Friends now, joining the fraternity Tappa Kegga Brew. No that's not a real fraternity, but that pretty much sums it up.
While I did learn how to write, as you can see, I failed to make a career out of it. After I graduated I got a found a job, but after three months of stress I decided I couldn't do this the rest of my life. So I went on to get a BA in Advertising. After I graduated in 1993 I ended up spending the next year as front desk clerk for the Shoreline Days Inn while living with my parents. I decided I better go back to school to learn a trade.
As I think of the RT and Rt students I've met, I think Djanvk's list is accurate. I know several who tired of waiting to get into RN school, former construction workers, a former nurses, various moms, and a good share of asthmatics.
A friend of mine was invited to give a presentation about her career at her daughters school, and she asked me, "How am I going to explain what we do?"
"I don't know," I said. "How do you explain about suctioning, about ventilators, about being short of breath to 8 YO kids. I don't even think most adults, unless they have had use for an RT, would even know we exist."
She ended up showing the kids about BLS.
Unlike nursing, I think most quality hospitals are saturated with RTs. At least that's the case where I work. I've been next in line for a day job nearly 8 years now.
I suppose until the demand for RTs increases, the demographics of RTs will not change.
I have asthma, and my parents encouraged me to go into respiratory, but didn't think I could pass chemistry since I failed it in high school. A friend of mine told me she liked Ferris, and she provided me with an application. When I was filling it out I just happened to be sitting in my journalism class, so I selected "journalism."
The only thing I accomplished in those first 2 years of college was, as I tell my Friends now, joining the fraternity Tappa Kegga Brew. No that's not a real fraternity, but that pretty much sums it up.
While I did learn how to write, as you can see, I failed to make a career out of it. After I graduated I got a found a job, but after three months of stress I decided I couldn't do this the rest of my life. So I went on to get a BA in Advertising. After I graduated in 1993 I ended up spending the next year as front desk clerk for the Shoreline Days Inn while living with my parents. I decided I better go back to school to learn a trade.
As I think of the RT and Rt students I've met, I think Djanvk's list is accurate. I know several who tired of waiting to get into RN school, former construction workers, a former nurses, various moms, and a good share of asthmatics.
A friend of mine was invited to give a presentation about her career at her daughters school, and she asked me, "How am I going to explain what we do?"
"I don't know," I said. "How do you explain about suctioning, about ventilators, about being short of breath to 8 YO kids. I don't even think most adults, unless they have had use for an RT, would even know we exist."
She ended up showing the kids about BLS.
Unlike nursing, I think most quality hospitals are saturated with RTs. At least that's the case where I work. I've been next in line for a day job nearly 8 years now.
I suppose until the demand for RTs increases, the demographics of RTs will not change.
Saturday, October 20, 2007
Finally I get to be a dad
A day off. Actually, I get the next 6 days off. Ah, this feels nice. It really picked up at work the last two days, which makes having taking time off all the more appreciated.
Even though I work nights, I had to get up at 7:00 this morning because my wife worked last night. She's an OB nurse and she works on my day off. We do this so our kids are always with one of their parents. Nothing like a full swing-like shift. Had to get my kids ready for a soccer game at 8:30. Now, who in there right mind would schedule a soccer game for that time? Probably someone who wants to annoy a night shift RT.
But, like a good dad, I got up bright and early and got my 4 YO to the game on time. They usually play 2 games at the same time as they split the field in half for this age group. Only this day, only my daughters team showed up, with one kid from each of the other teams. We did play, but it was my daughters team against a hodge podge of other kids from various teams.
It's actually funny watching 4 YO's play soccer. Most of the kids, my daughter included, don't care about the game. All they care about is being out there with the other kids and having fun.
After the first game of the year I joked to my friends, "My daughter scored two goals -- for the other team." But she didn't care. She was happy.
Today, however, she scored her first real goal. Her response was no response. The ball went into the goal and it was no big deal. It's neat the 4 YO perspective on things. While parents are on the sidelines screaming for their kids to "kick the ball", or, "don't look at me, pay attention to the game," kids are just playing.
My daughter has a chance to kick the ball into the net. She looks up at me and waves, "Hi daddy." That's the 4 YO perspective on life. While adults are out there making a big deal over nothing, these kids are just out there having fun.
There was one dad whose kid was on the other team. His kid was the little boy who kept scoring a goal every two minutes. "Okay, Troy, that's 2 goals, you only need 4 more." Four minutes later and four goals later by Troy, his dad yells, "Okay, Troy, that's six goals. Now you can let the other kids score."
That's good sportsmanship by Troy's dad (the prick).
There's always one in every crowd.
I just sit there and watch, proud that my daughter is out there giving her all.
We went to McDonalds after the game. Both my kids played on the play area while I sat there and watched. I didn't eat because I'm supposed to be dieting. What a good day I am, hey.
My boy's game was at 11:00. We had to do something to eat this time away (no pun intended), and entertain the kids. They had fun. I had fun watching them.
My boy is 9 YO, and he's getting really good. He even scored a goal today.
It's just nice to be away from work to enjoy life, and I certainly did today.
Even though I work nights, I had to get up at 7:00 this morning because my wife worked last night. She's an OB nurse and she works on my day off. We do this so our kids are always with one of their parents. Nothing like a full swing-like shift. Had to get my kids ready for a soccer game at 8:30. Now, who in there right mind would schedule a soccer game for that time? Probably someone who wants to annoy a night shift RT.
But, like a good dad, I got up bright and early and got my 4 YO to the game on time. They usually play 2 games at the same time as they split the field in half for this age group. Only this day, only my daughters team showed up, with one kid from each of the other teams. We did play, but it was my daughters team against a hodge podge of other kids from various teams.
It's actually funny watching 4 YO's play soccer. Most of the kids, my daughter included, don't care about the game. All they care about is being out there with the other kids and having fun.
After the first game of the year I joked to my friends, "My daughter scored two goals -- for the other team." But she didn't care. She was happy.
Today, however, she scored her first real goal. Her response was no response. The ball went into the goal and it was no big deal. It's neat the 4 YO perspective on things. While parents are on the sidelines screaming for their kids to "kick the ball", or, "don't look at me, pay attention to the game," kids are just playing.
My daughter has a chance to kick the ball into the net. She looks up at me and waves, "Hi daddy." That's the 4 YO perspective on life. While adults are out there making a big deal over nothing, these kids are just out there having fun.
There was one dad whose kid was on the other team. His kid was the little boy who kept scoring a goal every two minutes. "Okay, Troy, that's 2 goals, you only need 4 more." Four minutes later and four goals later by Troy, his dad yells, "Okay, Troy, that's six goals. Now you can let the other kids score."
That's good sportsmanship by Troy's dad (the prick).
There's always one in every crowd.
I just sit there and watch, proud that my daughter is out there giving her all.
We went to McDonalds after the game. Both my kids played on the play area while I sat there and watched. I didn't eat because I'm supposed to be dieting. What a good day I am, hey.
My boy's game was at 11:00. We had to do something to eat this time away (no pun intended), and entertain the kids. They had fun. I had fun watching them.
My boy is 9 YO, and he's getting really good. He even scored a goal today.
It's just nice to be away from work to enjoy life, and I certainly did today.
Friday, October 19, 2007
When it's asthma it's personal for me
(Two weeks ago)
"I can't breathe! I can't breathe!"
I did not recognize her as Leanne because she looked so miserable. She sat on the edge of the bed, all 300 pounds of her, with her arms to her side holding her shoulders up. She was extremely labored. She was literally gasping for air like a fish out of water.
My first instinct was to get her in bed because I could just see her coding and falling to the ground. Nurse Boo helped me set the bed up and put her feet in bed. Then I started a treatment.
"Go get your biPap," the doctor said. BiPap on an asthma patient? I had heard of it before, but never tried it. I know some asthmatic RTs who contend they would never let someone put a BiPap on them when they were SOB.
It was a rental doctor I had never seen before. "Let's try BiPap!" he ordered again.
He was impressed because I just happened to have my LTV 1200 plugged into the wall right next to the bed. Within a minute I was holding the mask on the patients face. I figured if I attached it to her head she'd feel even more trapped and claustrophobic. In other words, I had a good feeling this BiPap wasn't going to work.
"Put that thing on her!" the doctor ordered, and he grabbed it from me and put the straps around her head. She isn't going to tolerate this, I thought. To my amazement she made no attempt to yank it off.
That was when I realized this was Leanne, and she's only a couple years older than me. She had a history of asthma and did wear a BiPap at home. So that would explain why she tolerated it so well. She also had a history of fluid retention, so I was thinking CHF. And, considering she had audible upper airway congestion, that's kind of what I was thinking.
The doctor disagreed with me. "This is status asthmaticus, he said, "I want you to keep the treatments coming; just give continuous." I did. I set the treatment inline. Nothing we were doing seemed to be doing any good.
"She's really bad," nurse Lee said. "We're going to have to intubate."
I knew from past experiences with nurse Lee that she has a tendency to get over excited in intense situations, and I see too many doctors jumping the intubation gun. I also knew from past experiences that I did not want this patient to be intubated. It was personal. This patient had asthma. I have asthma.
"Let's just be patient," I said, knowing no one was listening. The doctor was already leaning on the airway box. Stay away from that, I thought.
-------------------------
(Nine years ago)
It was in my first year at Shoreline Hospital. Her name was Erin. She came in with status asthmaticus. I knew her personally as a nurse and because she took care of me when I had my asthma attack and had to stay the night. Her Internist happened to be here that day, gave her all the essential medicines like Epi, Steroids, bronchodilator, etc., and sent her to CCU despite the fact she was still quite labored.
Thirty minutes later she was doing much better, "Looks like she escaped the tube this time," Dr. Peterson said that day.
Two weeks later Erin came back in. She was equally as labored as her last visit. This time, however, Dr. Peterson was unable to come in. Dr. Samson ordered the essential medicines like Epi, Steroids, continuous bronchodilator, etc, and decided to intubate.
Wait!, I thought. Don't intubate this patient. Let's be patient and give her time to recover. Let's give the medicine some time to work. It worked 2 weeks ago when Dr. Peterson was here. I was a new RT at this time. I did not say what I was thinking, what my gut instinct told me to say. I regretted this for years to come.
Erin got intubated. It was a horrible intubation. She fought vigorously and turned blue when we sat her back. As soon as I placed the mask on her I could see vomit building up under it. We set her on her side. She vomited all over the side of the bed. Since she was overweight, she was an awful intubation.
In CCU she fought the vent like no patient I have ever seen since. Dr. Peterson ordered a tidal volume of 700, but the vent breath stopped at 300. The high pressure alarm blared with every breath. I turned the tidal volume to 250, and the high pressure was still barely under 60.
Dr. Peterson was not happy. More than likely I was new and hadn't earned his trust. "I ordered 700."
"I can't give 700."
"Is something wrong with your vent."
"No." I had intensely been studying my machine and nothing was wrong, I was sure of it. The vent was doing its job, I was certain. She was in severe bronchospasm. She had asthma. She was tight. She was airtrapping. She needed low tidal volumes. Why the hell is this doctor insisting I give her 700 tidal volume?
He paralyzed the patient. Still, a low tidal volume was needed. Dr. Peterson was insisting something was wrong with my vent. I was sweating.
I went to the nurses station and called sagacious Jane. I explained the situation. "What do I do," I said. She assured me what I was doing was correct, and then came in to help me.
She ended up doing a 1 on 1 with Erin the rest of the night, that's how bad she was. I felt bad because I wished I had told the ER doctor my recommendation that we not intubate. At least if I had said something and he still intubated, I wouldn't have this on my chest.
She ended up spending a month on the vent. At one point we were told she might have brain damage because we had taken all her sedatives away and she wasn't waking up. It was very sad. We were told she might not make it.
Then one day I walked into her room and her eyes were open. The next day I was explaining to her the weaning process.
------------------------
The doctor decides to intubate Leanne against my wishes. It was actually an easy intubation despite what I had expected. I set the LTV 1200 up to give ventilator breaths and did a blood gas. The ABGs read: pH 7.24, CO2 56, PO2 90 (on 100% FiO2), HcO3 25.
According to this ABG she was starting to fail. That's when I realized the nurse and the doctor were probably right about intubating this patient. I was basing my decision on not to intubate on emotion rather than experience and knowledge. And she was so panicked she might not have turned around had we not intubated. As it was, we had no choice but to intubate.
I suppose we can't be perfect all the time. Two days later she was off the vent and back to her usual cheery self.
While the ER doctor assured me she was "a classic case of status asthmaticus," and I agreed with him, I still suspected a CHF component too, although she wasn't treated as such until she was up in CCU and I was at home sleeping.
--------------------------
(last night)
In report I was told she had been crying. She was scared about going to pulmonary rehab. By the time I enter Leanne's room to give her a treatment she's her usual cheery self, however I see the pulmonary rehab packet on the bedside table.
Leanne had been a regular patient since she spent time on the vent two weeks back. I always tell people working at a hospital is no different from working at a grocery store, you have your regular customers.
She asked me if I read any good books lately, and so we discussed our favorite books. Then somehow we ended up discussing a show she was watching on the history channel and, before we realized it the treatment was no longer misting.
"Oh, I guess that's done," I said. "When I have fun patients I try to make this thing last longer." She smiled. I proceeded to put the neb away while she talked.
I grabbed my clipboard and was standing by the door. "You know," she said, "I'm really leery about going there. I have a 17-year-old at home. I don't want to leave him."
"You know," I said, "I can relate to you here. When I was a kid I was a regular patient, kind of like you right now. I'd spend at least 2 weeks a year in the hospital. When I was 14 I got so bad my doctors didn't know what to do, so they shipped me to an asthma hospital in Denver."
"Really."
"Yep. Only I didn't get to go for just 18 to 24 days. I was initially scheduled to be there 6-8 weeks. It ended up taking them nearly 6 months to straighten me out. And it really wasn't that bad really. I learned a lot about my disease. You see they did all the best asthma research in the world there, and they put me on all the most up to date asthma medicines at the time."
"Wow. That must have been hard to be away from your family at such a young age."
"Really it wasn't so bad. Somehow I knew that making this small sacrifice now was going to make the rest of my life better. And you know what?
"What?" She smiled.
"I didn't go back to the hospital for ten years after I got out.
---------------------------
(This morning)
"You know," Leanne said this morning as I was finishing up her treatment, " I feel much better after talking to you last night. I really think this is the best thing to do."
I said, "I really think this will benefit you."
"I think it is too."
I wrapped up the neb. "Anything I can get for you?"
"No." She hesitated, then said, "I really like you guys and all, but I hope I don't have to see you again for a while."
"In a grocery store. If I see you again I want it to be in passing."
She smiled.
"I can't breathe! I can't breathe!"
I did not recognize her as Leanne because she looked so miserable. She sat on the edge of the bed, all 300 pounds of her, with her arms to her side holding her shoulders up. She was extremely labored. She was literally gasping for air like a fish out of water.
My first instinct was to get her in bed because I could just see her coding and falling to the ground. Nurse Boo helped me set the bed up and put her feet in bed. Then I started a treatment.
"Go get your biPap," the doctor said. BiPap on an asthma patient? I had heard of it before, but never tried it. I know some asthmatic RTs who contend they would never let someone put a BiPap on them when they were SOB.
It was a rental doctor I had never seen before. "Let's try BiPap!" he ordered again.
He was impressed because I just happened to have my LTV 1200 plugged into the wall right next to the bed. Within a minute I was holding the mask on the patients face. I figured if I attached it to her head she'd feel even more trapped and claustrophobic. In other words, I had a good feeling this BiPap wasn't going to work.
"Put that thing on her!" the doctor ordered, and he grabbed it from me and put the straps around her head. She isn't going to tolerate this, I thought. To my amazement she made no attempt to yank it off.
That was when I realized this was Leanne, and she's only a couple years older than me. She had a history of asthma and did wear a BiPap at home. So that would explain why she tolerated it so well. She also had a history of fluid retention, so I was thinking CHF. And, considering she had audible upper airway congestion, that's kind of what I was thinking.
The doctor disagreed with me. "This is status asthmaticus, he said, "I want you to keep the treatments coming; just give continuous." I did. I set the treatment inline. Nothing we were doing seemed to be doing any good.
"She's really bad," nurse Lee said. "We're going to have to intubate."
I knew from past experiences with nurse Lee that she has a tendency to get over excited in intense situations, and I see too many doctors jumping the intubation gun. I also knew from past experiences that I did not want this patient to be intubated. It was personal. This patient had asthma. I have asthma.
"Let's just be patient," I said, knowing no one was listening. The doctor was already leaning on the airway box. Stay away from that, I thought.
-------------------------
(Nine years ago)
It was in my first year at Shoreline Hospital. Her name was Erin. She came in with status asthmaticus. I knew her personally as a nurse and because she took care of me when I had my asthma attack and had to stay the night. Her Internist happened to be here that day, gave her all the essential medicines like Epi, Steroids, bronchodilator, etc., and sent her to CCU despite the fact she was still quite labored.
Thirty minutes later she was doing much better, "Looks like she escaped the tube this time," Dr. Peterson said that day.
Two weeks later Erin came back in. She was equally as labored as her last visit. This time, however, Dr. Peterson was unable to come in. Dr. Samson ordered the essential medicines like Epi, Steroids, continuous bronchodilator, etc, and decided to intubate.
Wait!, I thought. Don't intubate this patient. Let's be patient and give her time to recover. Let's give the medicine some time to work. It worked 2 weeks ago when Dr. Peterson was here. I was a new RT at this time. I did not say what I was thinking, what my gut instinct told me to say. I regretted this for years to come.
Erin got intubated. It was a horrible intubation. She fought vigorously and turned blue when we sat her back. As soon as I placed the mask on her I could see vomit building up under it. We set her on her side. She vomited all over the side of the bed. Since she was overweight, she was an awful intubation.
In CCU she fought the vent like no patient I have ever seen since. Dr. Peterson ordered a tidal volume of 700, but the vent breath stopped at 300. The high pressure alarm blared with every breath. I turned the tidal volume to 250, and the high pressure was still barely under 60.
Dr. Peterson was not happy. More than likely I was new and hadn't earned his trust. "I ordered 700."
"I can't give 700."
"Is something wrong with your vent."
"No." I had intensely been studying my machine and nothing was wrong, I was sure of it. The vent was doing its job, I was certain. She was in severe bronchospasm. She had asthma. She was tight. She was airtrapping. She needed low tidal volumes. Why the hell is this doctor insisting I give her 700 tidal volume?
He paralyzed the patient. Still, a low tidal volume was needed. Dr. Peterson was insisting something was wrong with my vent. I was sweating.
I went to the nurses station and called sagacious Jane. I explained the situation. "What do I do," I said. She assured me what I was doing was correct, and then came in to help me.
She ended up doing a 1 on 1 with Erin the rest of the night, that's how bad she was. I felt bad because I wished I had told the ER doctor my recommendation that we not intubate. At least if I had said something and he still intubated, I wouldn't have this on my chest.
She ended up spending a month on the vent. At one point we were told she might have brain damage because we had taken all her sedatives away and she wasn't waking up. It was very sad. We were told she might not make it.
Then one day I walked into her room and her eyes were open. The next day I was explaining to her the weaning process.
------------------------
The doctor decides to intubate Leanne against my wishes. It was actually an easy intubation despite what I had expected. I set the LTV 1200 up to give ventilator breaths and did a blood gas. The ABGs read: pH 7.24, CO2 56, PO2 90 (on 100% FiO2), HcO3 25.
According to this ABG she was starting to fail. That's when I realized the nurse and the doctor were probably right about intubating this patient. I was basing my decision on not to intubate on emotion rather than experience and knowledge. And she was so panicked she might not have turned around had we not intubated. As it was, we had no choice but to intubate.
I suppose we can't be perfect all the time. Two days later she was off the vent and back to her usual cheery self.
While the ER doctor assured me she was "a classic case of status asthmaticus," and I agreed with him, I still suspected a CHF component too, although she wasn't treated as such until she was up in CCU and I was at home sleeping.
--------------------------
(last night)
In report I was told she had been crying. She was scared about going to pulmonary rehab. By the time I enter Leanne's room to give her a treatment she's her usual cheery self, however I see the pulmonary rehab packet on the bedside table.
Leanne had been a regular patient since she spent time on the vent two weeks back. I always tell people working at a hospital is no different from working at a grocery store, you have your regular customers.
She asked me if I read any good books lately, and so we discussed our favorite books. Then somehow we ended up discussing a show she was watching on the history channel and, before we realized it the treatment was no longer misting.
"Oh, I guess that's done," I said. "When I have fun patients I try to make this thing last longer." She smiled. I proceeded to put the neb away while she talked.
I grabbed my clipboard and was standing by the door. "You know," she said, "I'm really leery about going there. I have a 17-year-old at home. I don't want to leave him."
"You know," I said, "I can relate to you here. When I was a kid I was a regular patient, kind of like you right now. I'd spend at least 2 weeks a year in the hospital. When I was 14 I got so bad my doctors didn't know what to do, so they shipped me to an asthma hospital in Denver."
"Really."
"Yep. Only I didn't get to go for just 18 to 24 days. I was initially scheduled to be there 6-8 weeks. It ended up taking them nearly 6 months to straighten me out. And it really wasn't that bad really. I learned a lot about my disease. You see they did all the best asthma research in the world there, and they put me on all the most up to date asthma medicines at the time."
"Wow. That must have been hard to be away from your family at such a young age."
"Really it wasn't so bad. Somehow I knew that making this small sacrifice now was going to make the rest of my life better. And you know what?
"What?" She smiled.
"I didn't go back to the hospital for ten years after I got out.
---------------------------
(This morning)
"You know," Leanne said this morning as I was finishing up her treatment, " I feel much better after talking to you last night. I really think this is the best thing to do."
I said, "I really think this will benefit you."
"I think it is too."
I wrapped up the neb. "Anything I can get for you?"
"No." She hesitated, then said, "I really like you guys and all, but I hope I don't have to see you again for a while."
"In a grocery store. If I see you again I want it to be in passing."
She smiled.
Thursday, October 18, 2007
Ventolin is the medicine used by Angels
"You're my little Angel." She was a middle-aged, dark-haired lady sort of stocky but not really fat. "You're my little Angel. You saved my life." Who in the world are you, I thought as she proceeded to give me a big hug. "I thought I would never see you again, my little Angel."
"Well, uh, hi," I said, "Nice to see you again.
She stepped back and proceeded to peer at me with a big gaping smile. "You probably don't remember me, but I had surgery. I thought I was going to die. When I woke up yours was the first face I saw."
She was right, I had no clue who she was. "Yeah, I remember."
Church was about to begin, so we both took our seats.
--------------------
Work has picked up tremendously in the past three days. We now have 13 patients on the board, and 2 of them are indicated. That aside, I was sitting in my office in the middle of the night, my feet up on the desk, peering out at the parking lot with its dull orange halo of light set against a pitch black background. The window was open and a cool, refreshing breeze was wafting through the room. It was awesome.
We probably have one of the best respiratory therapy caves in the world, with ours having a huge window with an excellent view. In fact, probably 95 percent of the office and patient rooms in this hospital have views of hospital additions. Otherwise called walls.
That was the best part of the night. It lasted about five minutes. My pager went off. "Need a treatment in 206." He was watching TV. He was "a little" short of breath and I could hear audible stridor.
"He's wet," I said to the nurse.
"How do you know without listening to him, " she asked.
"He just looks wet to me." I had the patient sit up and listened to his backside. No wheezes, but the patient did sound coarse throughout. Then I listened to the neck: It was coarse up there. "And 80% of wet patients have that upper airway congestion you hear."
"Really?"
"The noise you hear in his chest is not a wheeze, it's upper airway congestion you hear radiating throughout the lung fields. Here, listen to his neck."
She did. "Oh."
"What are his I&Os?" I started a treatment just just in case, and we preceded to the nurses station to check out the chart. The patient was 2000cc over in the past 24 hours.
As I was finishing up the treatment she gave Lasix.
-------------------------
Overhead page: "Respiratory Stat to 244."
Upon entering the room the lady was standing aside the bed leaning on the bedside table, naked but for a gown flowing freely in front of her. "I can't take it much longer," she said.
I could hear audible, bubbly crackles, "She's wet."
"You think so."
"I know so." I listened to verify. "I'm positive. Have you called the doctor."
"I already did." I was impressed. "I have Lasix to give her. I don't know why, but Dr. Brave ordered a treatment too."
"That's okay, I have no problem with trying a treatment." Not like it's hard putting a pipe in someones mouth, or in this case a mask over it. Then again, nothing like putting an extra 8cc of fluid into an already wet lung.
--------------------
I was trying my best to get my 2:00 breathing treatment done when I was called to ER to do a breathing treatment.
"Why does this patient need a treatment," I asked RN Sarah.
"Because she has pneumonia."
By this time I'm exhausted from running around ragged all night, and have had enough of doing senseless therapy when I have two critical patients upstairs. "Pneumonia isn't an indication for a breathing treatment," I grumbled.
"Yes it is!"
"No it isn't."
"Breathing treatments are for short of breath."
"Breathing treatments are for bronchospasm. Ventolin doesn't even get down to the alveoli where the pneumonia is. It's particle size fits in the bronchioles to open up the bronchioles and resolve bronchospasm."
"Ventolin is for shortness of breath."
"Do you ever give Lasix for bronchospasm."
"Just give the treatment, Rick," she said smiling. She obviously knew I was swamped. That's one of the nice things about working in a close nit hospital like this is we usually don't hold grudges when one of us has a bad moment.
I gave the treatment.
"Do you feel any better after this treatment?" I asked the patient.
"No."
-------------------------
Finally I got out of ER back up to the floors to check on my patients. The man I described earlier had already peed out 500cc. The lady was back in bed and "much more comfortable." By morning they were both fine.
"You are my hero," the lady said when I entered her room in the morning. Her nurse was at the bedside checking her sugar. "You gave me that treatment and now I feel so good. That stuff you give is a gift from God."
"Thank you." I said. "It's so nice getting a compliment. I really appreciate it."
"Well, you can give me a treatment anytime you want."
"You'll be getting them every four hours." Whether you're short of breath or not for now on.
I checked, and the patient had peed out over 2 liters during the night, and started to return to the room when the nurse met me in the hallway.
I said, "Did you see I got credit for her breathing better."
She said, "Yeah, you prick, my Lasix had nothing to do with it."
We laughed.
"Well, uh, hi," I said, "Nice to see you again.
She stepped back and proceeded to peer at me with a big gaping smile. "You probably don't remember me, but I had surgery. I thought I was going to die. When I woke up yours was the first face I saw."
She was right, I had no clue who she was. "Yeah, I remember."
Church was about to begin, so we both took our seats.
--------------------
Work has picked up tremendously in the past three days. We now have 13 patients on the board, and 2 of them are indicated. That aside, I was sitting in my office in the middle of the night, my feet up on the desk, peering out at the parking lot with its dull orange halo of light set against a pitch black background. The window was open and a cool, refreshing breeze was wafting through the room. It was awesome.
We probably have one of the best respiratory therapy caves in the world, with ours having a huge window with an excellent view. In fact, probably 95 percent of the office and patient rooms in this hospital have views of hospital additions. Otherwise called walls.
That was the best part of the night. It lasted about five minutes. My pager went off. "Need a treatment in 206." He was watching TV. He was "a little" short of breath and I could hear audible stridor.
"He's wet," I said to the nurse.
"How do you know without listening to him, " she asked.
"He just looks wet to me." I had the patient sit up and listened to his backside. No wheezes, but the patient did sound coarse throughout. Then I listened to the neck: It was coarse up there. "And 80% of wet patients have that upper airway congestion you hear."
"Really?"
"The noise you hear in his chest is not a wheeze, it's upper airway congestion you hear radiating throughout the lung fields. Here, listen to his neck."
She did. "Oh."
"What are his I&Os?" I started a treatment just just in case, and we preceded to the nurses station to check out the chart. The patient was 2000cc over in the past 24 hours.
As I was finishing up the treatment she gave Lasix.
-------------------------
Overhead page: "Respiratory Stat to 244."
Upon entering the room the lady was standing aside the bed leaning on the bedside table, naked but for a gown flowing freely in front of her. "I can't take it much longer," she said.
I could hear audible, bubbly crackles, "She's wet."
"You think so."
"I know so." I listened to verify. "I'm positive. Have you called the doctor."
"I already did." I was impressed. "I have Lasix to give her. I don't know why, but Dr. Brave ordered a treatment too."
"That's okay, I have no problem with trying a treatment." Not like it's hard putting a pipe in someones mouth, or in this case a mask over it. Then again, nothing like putting an extra 8cc of fluid into an already wet lung.
--------------------
I was trying my best to get my 2:00 breathing treatment done when I was called to ER to do a breathing treatment.
"Why does this patient need a treatment," I asked RN Sarah.
"Because she has pneumonia."
By this time I'm exhausted from running around ragged all night, and have had enough of doing senseless therapy when I have two critical patients upstairs. "Pneumonia isn't an indication for a breathing treatment," I grumbled.
"Yes it is!"
"No it isn't."
"Breathing treatments are for short of breath."
"Breathing treatments are for bronchospasm. Ventolin doesn't even get down to the alveoli where the pneumonia is. It's particle size fits in the bronchioles to open up the bronchioles and resolve bronchospasm."
"Ventolin is for shortness of breath."
"Do you ever give Lasix for bronchospasm."
"Just give the treatment, Rick," she said smiling. She obviously knew I was swamped. That's one of the nice things about working in a close nit hospital like this is we usually don't hold grudges when one of us has a bad moment.
I gave the treatment.
"Do you feel any better after this treatment?" I asked the patient.
"No."
-------------------------
Finally I got out of ER back up to the floors to check on my patients. The man I described earlier had already peed out 500cc. The lady was back in bed and "much more comfortable." By morning they were both fine.
"You are my hero," the lady said when I entered her room in the morning. Her nurse was at the bedside checking her sugar. "You gave me that treatment and now I feel so good. That stuff you give is a gift from God."
"Thank you." I said. "It's so nice getting a compliment. I really appreciate it."
"Well, you can give me a treatment anytime you want."
"You'll be getting them every four hours." Whether you're short of breath or not for now on.
I checked, and the patient had peed out over 2 liters during the night, and started to return to the room when the nurse met me in the hallway.
I said, "Did you see I got credit for her breathing better."
She said, "Yeah, you prick, my Lasix had nothing to do with it."
We laughed.
Wednesday, October 17, 2007
Accidental Extubation and spontaneous ARDS
I was having a wonderful conversation with one of my favorite patients when my beeper sounded: "We need you stat in ER."
"Shit!" I said ruefully, "You're breathing okay right now, right?" She looked fine, but I had to be sure.
"Yes, you go right ahead." She was such a great patient and, unlike some patients, I trusted her judgement.
I stopped the treatment and rushed to ER. I busted through the double doors, a strong horrible stench hit me, and Bee the nurse shouted from across the room:
"They need you in Cat Scan!"
"Cat Scan?"
"Yes. Cat Scan. A lady is coding."
"Oh, shit!" Not knowing for sure an airway box was in CT, I grabbed one and busted back through the double doors and started walking fast. Ahead, a skinny man in surgery scrubs burst from the CT room.
"Oh, RT, get me a size 8," he shouts. "Now!" I realize now it's Bob the acerbic anesthesiologist.
"Okay, just a minute."
"No, I need it now!"
"Hugh!" I busted open the box and started shuffling through it looking for the tube while still walking. This is ridiculous, I thought. "You'll have to wait till I get in there."
"No we need it now."
"What's going on here," I said as I enter the room with Dr. Bob breathing down my neck. He was standing beside me now like a little kid, panting for his ETT. I handed it to him.
"We extubated her," one of the surgery nurses said. She was bagging. What in the hell? I thought. How could somebody be extubated in CT when I didn't even know there was an intubated patient. Hello, I'm the lone RT working, I'm supposed to know this kind of stuff. And there's no code, as Bee told me.
Bob crouches by the head of the patient on the CT table, shouts for the nurse to stop bagging, and easily slides the tube in.
I secure the ETT with an ETT holder. "So, what happened again."
"We brought her from surgery. She started wriggling, seizing, and, well, you know."
Then it clicked. I thought this was an ER patient. I thought this was a patient they were working on and didn't tell me about for some inexplicable reason. Why an intubated patient from surgery would need a CT I had no clue. I did not inquire. Then I noticed the old gooey ETT lying askew on the side of the patients head: it had tape on it. Aha.
"So, Bob, maybe next time you'll put one of these in before you transport your patient," I joked, pointing at the ETT holder. To my amazement he smiled.
The excitement was over, and I was starving. I had lunch on my mind. The beeper went off: "Need you in ER."
"Shit!"
I stumbled through the ER doors, grabbed my sheet, grabbed my EKG machine, and headed for my patient. On the way, however, I was overcome again my a horrible stench. I looked into a room and saw a thin, scraggly bearded man sitting up on his bed. He literally looked like something that was scraped off the street. Turned out he was.
I pray to God I don't have to do an EKG on that guy, I thought, and proceeded to my patient. I did a quick EKG and, back at the nurses station, hand it to the doctor. He reads it. "Hey, Rick, could you do an EKG in room four?" He said, kindly, and with a smile.
"Oh sure." I grab the machine and start for room four when it hits me: it's that guy. Why is it every time there's a gross patient they always seem to find a way to get RT involved. I suppose if he's homeless he could be malnourished. His electrolytes could be off, which equals indication for EKG.
"Could you tell me about this patient?" I ask the nurse out of range of the patient.
"Well, we just plucked maggots off him," she whispers.
"Maggots?"
"Yeah, he had poor circulation in his legs. About two or three months ago he went to a doctor and the doctor had his feet wrapped. When he came in, he had garbage bags wrapped over the bandages," she made as though she were going to puke, "It was awful."
"I'd hate to have your job."
"So did I." She smiled.
"So now you want me to get involved." I took a deep breath, and proceeded to do the EKG.
An hour later I was upstairs because Dr. Young ordered a STAT BATH. I reluctantly volunteered. Mickey, a former EMT of 30 plus years and who was now an ER assistant, also volunteered. He had a good idea that we place a sheet in the tub so we could use it to get him out and into the wheel chair. It turned out to be a great idea. It was a horrible job, but a great idea.
I digress though. I was off the next week. When I came back, almost immediately after I received report, I was called stat to room 208.
"What's going on?" The patient was in low fowlers, obtunded and appeared to be laboring. He was gray. I checked his sat, it wouldn't pick up. Of course this was before the rapid response team was in effect. "Does he have a pulse? Have you checked a pulse."
"Yes," the nurse assured me. "His pulse in 90 and his BP is 120/80."
"Does he always look this way, obtunded I mean."
"No. He was fine my last check." Mental note: acute mental change.
"Okay, well that's a good start. But he sure don't look good. Is he a DNR? Did you call the doctor?"
"He's not a DNR. We did call the doctor." I look at the patient again. Now I realize this was the guy with the maggots. I thought about asking if they checked his sugar, but second guessed myself. This would later come back to haunt me.
The patient looked like shit, so we all conclusively decided that I should place the patient on an NRB and do an EKG and a blood gas. What's the old saying, better to do now and apologize later. The patient bled so bad I had blood dripping on the floor. After holding it 5 minutes I gave the job to the nursing supervisor.
The ABG said: ph 6.98, PO2 45 (before NRB), CO2 35 and ? bicarb. The machine did not pick up the bacard, probably because it was so low. My initial conclusion, although I'm not the doctor I usually try to make an educated guess, was this man was in respiratory failure secondary to sepsis. Because he was leaking so bad I'm certain he's in DIC.
By now Dr. Young, our surgeon, was in the room. He's one of those quiet little guys with poor bedside manners. "That's a venous blood."
"No, it came out pretty good."
"It's venous blood. Look at that pH. It's venous blood."
"I'm quite sure it's not venous blood."
"It's venous blood." He looks at the patient. "Why did you call me? He's fine."
"He's not fine. He's labored," the RN says.
"He's fine. Why do you call me for this."
Now the Internist on call enters the room. He looks at the ABGs, "Those are venous."
No they are not, I think but do not say. "Look, even if it is venous blood the pH will still be similar to arterial blood. Look, this guy is in failure."
"He's fine." Both Doctors leave the room. Fine, the only reason they don't want to come in here is because this guy is homeless and he's gross, and they don't want to be bothered.
I never leave the room. The nursing supervisor and I discuss the patient, and we both agree something is obviously wrong. And, five minutes later, the patient codes. Both doctors come back into the room. And, guess who comes in to intubate? Dr. Bob.
He slides the ETT in easily and, before I have a chance to secure the ETT, the head nurse said, "We need to boost him down the bed: one, two, three...
"WAIT!" I shout as they scoot the patient away from me, as my hands and the ETT stay in the same place. The patient is now extubated.
"What the fuck!" Dr. Bob yells. He reintubates the patient in a swift moment. He holds the ETT while I secure it with an ETT holder. "Next time you intubate a patient, be sure to secure the ETT with one of these before you move him," he said, pointing at ETT holder.
He smiles and exits the room. He got me back.
I redrew the ABG. By the time I got back the patient was dead.
The second pH was 7.00. I was right. And, after reading the autopsy a few days later, I learned I was also right about the sepsis. The autopsy also identified ARDS. Oh, and his glucose was 18 which, I learned, if a patient is not on insulen means liver failure.
This was one of those cases I couldn't get out of my mind. What did we do wrong? I wished I had asked about the sugar check. I thought about labs. I checked, and the patient didn't have any labs ordered the day before, nor sugar checks, both of which would have set off alarms.
A week later I ran into Dr. Peterson, an Internist who came into the cave to read EKGs. After I explained the situation to him he said:
"Patients do not go into spontaneous DIC or ARDS. It simply does not happen. And this would never have happened with one of my patients. You don't simply send someone to the floor and not order any tests, regardless of who the patient is."
I never did get into trouble for drawing ABGs without an order. Perhaps because those two doctors knew I was right.
"Shit!" I said ruefully, "You're breathing okay right now, right?" She looked fine, but I had to be sure.
"Yes, you go right ahead." She was such a great patient and, unlike some patients, I trusted her judgement.
I stopped the treatment and rushed to ER. I busted through the double doors, a strong horrible stench hit me, and Bee the nurse shouted from across the room:
"They need you in Cat Scan!"
"Cat Scan?"
"Yes. Cat Scan. A lady is coding."
"Oh, shit!" Not knowing for sure an airway box was in CT, I grabbed one and busted back through the double doors and started walking fast. Ahead, a skinny man in surgery scrubs burst from the CT room.
"Oh, RT, get me a size 8," he shouts. "Now!" I realize now it's Bob the acerbic anesthesiologist.
"Okay, just a minute."
"No, I need it now!"
"Hugh!" I busted open the box and started shuffling through it looking for the tube while still walking. This is ridiculous, I thought. "You'll have to wait till I get in there."
"No we need it now."
"What's going on here," I said as I enter the room with Dr. Bob breathing down my neck. He was standing beside me now like a little kid, panting for his ETT. I handed it to him.
"We extubated her," one of the surgery nurses said. She was bagging. What in the hell? I thought. How could somebody be extubated in CT when I didn't even know there was an intubated patient. Hello, I'm the lone RT working, I'm supposed to know this kind of stuff. And there's no code, as Bee told me.
Bob crouches by the head of the patient on the CT table, shouts for the nurse to stop bagging, and easily slides the tube in.
I secure the ETT with an ETT holder. "So, what happened again."
"We brought her from surgery. She started wriggling, seizing, and, well, you know."
Then it clicked. I thought this was an ER patient. I thought this was a patient they were working on and didn't tell me about for some inexplicable reason. Why an intubated patient from surgery would need a CT I had no clue. I did not inquire. Then I noticed the old gooey ETT lying askew on the side of the patients head: it had tape on it. Aha.
"So, Bob, maybe next time you'll put one of these in before you transport your patient," I joked, pointing at the ETT holder. To my amazement he smiled.
The excitement was over, and I was starving. I had lunch on my mind. The beeper went off: "Need you in ER."
"Shit!"
I stumbled through the ER doors, grabbed my sheet, grabbed my EKG machine, and headed for my patient. On the way, however, I was overcome again my a horrible stench. I looked into a room and saw a thin, scraggly bearded man sitting up on his bed. He literally looked like something that was scraped off the street. Turned out he was.
I pray to God I don't have to do an EKG on that guy, I thought, and proceeded to my patient. I did a quick EKG and, back at the nurses station, hand it to the doctor. He reads it. "Hey, Rick, could you do an EKG in room four?" He said, kindly, and with a smile.
"Oh sure." I grab the machine and start for room four when it hits me: it's that guy. Why is it every time there's a gross patient they always seem to find a way to get RT involved. I suppose if he's homeless he could be malnourished. His electrolytes could be off, which equals indication for EKG.
"Could you tell me about this patient?" I ask the nurse out of range of the patient.
"Well, we just plucked maggots off him," she whispers.
"Maggots?"
"Yeah, he had poor circulation in his legs. About two or three months ago he went to a doctor and the doctor had his feet wrapped. When he came in, he had garbage bags wrapped over the bandages," she made as though she were going to puke, "It was awful."
"I'd hate to have your job."
"So did I." She smiled.
"So now you want me to get involved." I took a deep breath, and proceeded to do the EKG.
An hour later I was upstairs because Dr. Young ordered a STAT BATH. I reluctantly volunteered. Mickey, a former EMT of 30 plus years and who was now an ER assistant, also volunteered. He had a good idea that we place a sheet in the tub so we could use it to get him out and into the wheel chair. It turned out to be a great idea. It was a horrible job, but a great idea.
I digress though. I was off the next week. When I came back, almost immediately after I received report, I was called stat to room 208.
"What's going on?" The patient was in low fowlers, obtunded and appeared to be laboring. He was gray. I checked his sat, it wouldn't pick up. Of course this was before the rapid response team was in effect. "Does he have a pulse? Have you checked a pulse."
"Yes," the nurse assured me. "His pulse in 90 and his BP is 120/80."
"Does he always look this way, obtunded I mean."
"No. He was fine my last check." Mental note: acute mental change.
"Okay, well that's a good start. But he sure don't look good. Is he a DNR? Did you call the doctor?"
"He's not a DNR. We did call the doctor." I look at the patient again. Now I realize this was the guy with the maggots. I thought about asking if they checked his sugar, but second guessed myself. This would later come back to haunt me.
The patient looked like shit, so we all conclusively decided that I should place the patient on an NRB and do an EKG and a blood gas. What's the old saying, better to do now and apologize later. The patient bled so bad I had blood dripping on the floor. After holding it 5 minutes I gave the job to the nursing supervisor.
The ABG said: ph 6.98, PO2 45 (before NRB), CO2 35 and ? bicarb. The machine did not pick up the bacard, probably because it was so low. My initial conclusion, although I'm not the doctor I usually try to make an educated guess, was this man was in respiratory failure secondary to sepsis. Because he was leaking so bad I'm certain he's in DIC.
By now Dr. Young, our surgeon, was in the room. He's one of those quiet little guys with poor bedside manners. "That's a venous blood."
"No, it came out pretty good."
"It's venous blood. Look at that pH. It's venous blood."
"I'm quite sure it's not venous blood."
"It's venous blood." He looks at the patient. "Why did you call me? He's fine."
"He's not fine. He's labored," the RN says.
"He's fine. Why do you call me for this."
Now the Internist on call enters the room. He looks at the ABGs, "Those are venous."
No they are not, I think but do not say. "Look, even if it is venous blood the pH will still be similar to arterial blood. Look, this guy is in failure."
"He's fine." Both Doctors leave the room. Fine, the only reason they don't want to come in here is because this guy is homeless and he's gross, and they don't want to be bothered.
I never leave the room. The nursing supervisor and I discuss the patient, and we both agree something is obviously wrong. And, five minutes later, the patient codes. Both doctors come back into the room. And, guess who comes in to intubate? Dr. Bob.
He slides the ETT in easily and, before I have a chance to secure the ETT, the head nurse said, "We need to boost him down the bed: one, two, three...
"WAIT!" I shout as they scoot the patient away from me, as my hands and the ETT stay in the same place. The patient is now extubated.
"What the fuck!" Dr. Bob yells. He reintubates the patient in a swift moment. He holds the ETT while I secure it with an ETT holder. "Next time you intubate a patient, be sure to secure the ETT with one of these before you move him," he said, pointing at ETT holder.
He smiles and exits the room. He got me back.
I redrew the ABG. By the time I got back the patient was dead.
The second pH was 7.00. I was right. And, after reading the autopsy a few days later, I learned I was also right about the sepsis. The autopsy also identified ARDS. Oh, and his glucose was 18 which, I learned, if a patient is not on insulen means liver failure.
This was one of those cases I couldn't get out of my mind. What did we do wrong? I wished I had asked about the sugar check. I thought about labs. I checked, and the patient didn't have any labs ordered the day before, nor sugar checks, both of which would have set off alarms.
A week later I ran into Dr. Peterson, an Internist who came into the cave to read EKGs. After I explained the situation to him he said:
"Patients do not go into spontaneous DIC or ARDS. It simply does not happen. And this would never have happened with one of my patients. You don't simply send someone to the floor and not order any tests, regardless of who the patient is."
I never did get into trouble for drawing ABGs without an order. Perhaps because those two doctors knew I was right.
Monday, October 15, 2007
I will never be content to be a button pusher
"What's the point of having a weaning protocol if nobody is ordering it," Dave argued during one of our department meetings about a year after our ventilator weaning protocol was initiated.
Dr. Marah, who championed the protocol to the doctors and is partially responsible for it becoming official, got wind of what Dave said. She said, I am told, "I will take care of this."
Now I've never had a problem with Dr. Marah, but I know a lot of nurses who can't stand her, especially if they have to call her. She's one of those Dr.s who will tell you what she thinks of you without a second thought. I'm sure every hospital has a doctor or two or three like that.
But when it comes to taking care of her patients, she's top notch. And, as part of the Keystone Committee at our hospital she is well aware of how highly the Keystone project recommends ventilator protocols. Studies have shown such protocols to greatly reduce bloodbourne infections and ventilator aquired pneumonia.
Not only that, but they get the patient off the ventilator quicker. I haven't seen any of the studies for our hospital yet, but since this protocol has been enacted patients don't seem to linger on vents for weeks on end.
The moment the patient is placed on the ventilator the weaning process should begin. The mouth should be cleaned out a minimun of every 2 hours, and inline suction should be used instead of the old lavage, suction and bag method our doctors used to demand.
The head of the bead up, cuff pressure at not less than 20 cmH20 like we used to be tought, but greater to maintain a good seal. Tidal Volumes should be low. Our protocol calls for a VT 6-10 cmH20/kg ideal body weight instead of 10-15. That's a change from just 10 years ago when I was in school.
Doing all this has proven to be of great benefit to improving patient care and outcomes, and Dr. Marah was not about to let this protocol drift into oblivion as so many other protocols have.
Dr. Pike must have been a little jealous, because when it came time to hire a Dr. to the job of championing the rapid response team, he was more than eager to take up the job. So now, not only do we have a ventilator protocol, we have a rapid response team as well.
Here's something interesting. For the past three months we've been extremely slow here at Shoreline Hospital. We aren't necessarily a small hospital, but we aren't a big hospital either. We are kind of right in the middle. So to be as slow as we have been is very abnormal.
I discussed this yesterday with my co-worker Jane. She said:
"I think we're so slow because we are doing all the right things. Especially since the enactment of the rapid response team, we are catching things early, and preventing patients from becoming critical care patients. Overall, we are educating patients better, treating them well in the emergency room, and sending them home."
"So you think this slow spell is going to last forever," I asked.
"It very well might."
I don't think so. I think a month from now we'll be running around ragged and people will be complaining about getting too much overtime. In the meantime, we've written more protocols we hope to find champions for.
I am confident this will no longer be a problem.
Either way, it is this hope that we will continue to become a better hospital that keeps me going. I will never be content to be a button pusher.
Dr. Marah, who championed the protocol to the doctors and is partially responsible for it becoming official, got wind of what Dave said. She said, I am told, "I will take care of this."
Now I've never had a problem with Dr. Marah, but I know a lot of nurses who can't stand her, especially if they have to call her. She's one of those Dr.s who will tell you what she thinks of you without a second thought. I'm sure every hospital has a doctor or two or three like that.
But when it comes to taking care of her patients, she's top notch. And, as part of the Keystone Committee at our hospital she is well aware of how highly the Keystone project recommends ventilator protocols. Studies have shown such protocols to greatly reduce bloodbourne infections and ventilator aquired pneumonia.
Not only that, but they get the patient off the ventilator quicker. I haven't seen any of the studies for our hospital yet, but since this protocol has been enacted patients don't seem to linger on vents for weeks on end.
The moment the patient is placed on the ventilator the weaning process should begin. The mouth should be cleaned out a minimun of every 2 hours, and inline suction should be used instead of the old lavage, suction and bag method our doctors used to demand.
The head of the bead up, cuff pressure at not less than 20 cmH20 like we used to be tought, but greater to maintain a good seal. Tidal Volumes should be low. Our protocol calls for a VT 6-10 cmH20/kg ideal body weight instead of 10-15. That's a change from just 10 years ago when I was in school.
Doing all this has proven to be of great benefit to improving patient care and outcomes, and Dr. Marah was not about to let this protocol drift into oblivion as so many other protocols have.
Dr. Pike must have been a little jealous, because when it came time to hire a Dr. to the job of championing the rapid response team, he was more than eager to take up the job. So now, not only do we have a ventilator protocol, we have a rapid response team as well.
Here's something interesting. For the past three months we've been extremely slow here at Shoreline Hospital. We aren't necessarily a small hospital, but we aren't a big hospital either. We are kind of right in the middle. So to be as slow as we have been is very abnormal.
I discussed this yesterday with my co-worker Jane. She said:
"I think we're so slow because we are doing all the right things. Especially since the enactment of the rapid response team, we are catching things early, and preventing patients from becoming critical care patients. Overall, we are educating patients better, treating them well in the emergency room, and sending them home."
"So you think this slow spell is going to last forever," I asked.
"It very well might."
I don't think so. I think a month from now we'll be running around ragged and people will be complaining about getting too much overtime. In the meantime, we've written more protocols we hope to find champions for.
I am confident this will no longer be a problem.
Either way, it is this hope that we will continue to become a better hospital that keeps me going. I will never be content to be a button pusher.
Protocols
It's 2:05 in the morning, and it's been another fine night. Since it's my fourth night in a row I decided I had better do something useful, so I finished a ventilator management protocol I've been working on.
Jane (fake name) is the therapist I replaced. She's been working here 20 years and is a veritable respiratory therapy encyclopedia. Yesterday I learned about the WOB patient # provided by the Servo i. I showed her what I learned.
"I knew that already," she said, fake blushing.
About 15 years ago she wrote protocols for everything, and they all got shot down but for a watered down version of her oxygen protocol.
So when she decided to write a ventilator protocol a few years back, the rest of us didn't say it, but we all thought she was wasting her time.
This time, however, she received the support of one of our Internists, who championed the protocol to the other doctors, and, lo and behold, we have ourselves a ventilator protocol.
Well, actually it's just a weaning protocol, but it's a giant leap.
Why is it we want protocols? Is it because we want the extra work or the extra responsibility? I'd have to say no to that. Is it because larger hospitals have them and sometimes we think we are ten years behind the times? Perhaps.
I'll tell you why I want protocols: because I have an education, I have ten years of experience to draw upon and, most important, I'm at the bedside and the doctor is not.
Some people I work with fear protocols.
"It's just gonna create more work," my co-worker Dave complained when I showed him the breathing treatment protocol I recently finished. "And the biggest offenders aren't going to follow it anyway."
Well, that attitude won't make this a better department. I thought since Dave is the biggest complainer of Q-forever breathing treatments, he'd be all for a protocol. I thought wrong.
There are another group of therapists of whom fear protocols. They are the one's comfortable with being a button pusher.
In all the protocols we have written, Jane and I have included an escape clause. In the "Call the doctor if" section, we added, "If you are unable to determine the appropriate therapy."
Likewise, for the doctors that might not like the idea of ceding authority, we added the clause, "If a doctor does not want to use this protocol, he or she can write an order for No RT Consult."
So there, everybody is happy. The protocols should pass with flying colors. Well, so far we have 2 protocols passed, an ER treatment protocol that's being championed by the ER Medical Director, and now 2 others waiting in line.
As for my Mechanical Ventilator Management protocol, the one where we'd get to change ventilator settings based on SpO2, EtCO2 and/ or ABGs:
"As much as I'd like to have this one," Jane said, "and as much as I think the patient would benefit, I think our doctors will take one look at it and laugh."
Either way, we have fun doing this stuff.
Jane (fake name) is the therapist I replaced. She's been working here 20 years and is a veritable respiratory therapy encyclopedia. Yesterday I learned about the WOB patient # provided by the Servo i. I showed her what I learned.
"I knew that already," she said, fake blushing.
About 15 years ago she wrote protocols for everything, and they all got shot down but for a watered down version of her oxygen protocol.
So when she decided to write a ventilator protocol a few years back, the rest of us didn't say it, but we all thought she was wasting her time.
This time, however, she received the support of one of our Internists, who championed the protocol to the other doctors, and, lo and behold, we have ourselves a ventilator protocol.
Well, actually it's just a weaning protocol, but it's a giant leap.
Why is it we want protocols? Is it because we want the extra work or the extra responsibility? I'd have to say no to that. Is it because larger hospitals have them and sometimes we think we are ten years behind the times? Perhaps.
I'll tell you why I want protocols: because I have an education, I have ten years of experience to draw upon and, most important, I'm at the bedside and the doctor is not.
Some people I work with fear protocols.
"It's just gonna create more work," my co-worker Dave complained when I showed him the breathing treatment protocol I recently finished. "And the biggest offenders aren't going to follow it anyway."
Well, that attitude won't make this a better department. I thought since Dave is the biggest complainer of Q-forever breathing treatments, he'd be all for a protocol. I thought wrong.
There are another group of therapists of whom fear protocols. They are the one's comfortable with being a button pusher.
In all the protocols we have written, Jane and I have included an escape clause. In the "Call the doctor if" section, we added, "If you are unable to determine the appropriate therapy."
Likewise, for the doctors that might not like the idea of ceding authority, we added the clause, "If a doctor does not want to use this protocol, he or she can write an order for No RT Consult."
So there, everybody is happy. The protocols should pass with flying colors. Well, so far we have 2 protocols passed, an ER treatment protocol that's being championed by the ER Medical Director, and now 2 others waiting in line.
As for my Mechanical Ventilator Management protocol, the one where we'd get to change ventilator settings based on SpO2, EtCO2 and/ or ABGs:
"As much as I'd like to have this one," Jane said, "and as much as I think the patient would benefit, I think our doctors will take one look at it and laugh."
Either way, we have fun doing this stuff.
Saturday, October 13, 2007
The Beeper
It's dark in here with the lights out. It's quiet too except for the soporific drone of all the electrical appliances.
Oops! I just used the Q word.
Beeeeep.
Right on cue.
"EKG in ER," the beeper reads.
Be back in a few...
###
Okay, I'm back. I just got complimented on my EKG skills.
"You did it so fast I didn't know you started," the lady said.
I hear that a lot: that I'm fast. I never really thought anything of it until I happened to see one of my co-workers push the EKG cart into a room as I was passing through the ER. I thought I'd wait for her so we could walk back to the cave together. I waited at least 15 minutes.
The next morning at shift change my beeper went off. My relief volunteered to to do the EKG for me, and rushed off to ER to do a "quick EKG." I was anxious for him to get back so I could give a quick report and go home. Twenty minutes later I was half asleep and still waiting.
BEEEEEP
###
Ever hear of the button on the butt theory. All the people that can possibly annoy you have placed all these invisible buttons on random chairs, and I think there's one on the chair right here in front of this computer in the respiratory therapy cave.
As soon as I finished with my 7th EKG in three hours I decided to go for a walk. No point chancing sitting on that button again. But, here I am again. The lights are off. The door is shut. I'm thinking of putting my feet up.
BEEEEEEEP
###
I suppose someone out of high school could do some of the things I do, and EKGs is one of them. However, on nights like this where we only have five patients on treatments, and none of them needing to be awakened for them, it's nice to have something to do now and again.
I suppose that's why I started this blog.
All the nurses seemed to be busy as I strolled the halls toting my holy water we call Ventolin. You know what I mean don't you? They Believe that Ventolin cures everything. That's why I call it holy water.
One of my co-workers, Doug, calls it Scrubblin-Bubbles. "Yeah, it acts like soap. It works just like that stuff called Scrubblin Bubbles you buy in the store," he told me one day. "Ventolin goes into the lungs, suds up like a bar of soap, and literally scrubs all the corners of the lungs clean."
I laughed. I still laugh every time I'm doing a treatment just because a patient has crackles, or a history of CHF, or cardiac wheezes, or just because the patient has lung cancer.
"Any noise in the lungs warrants a breathing treatment," Doug said. "It doesn't matter what the noise is or what the cause. It doesn't matter if the patient is SOB or not. Look at all the post-op patients that get treatments just because. Ever hear about the study of post-op patients and Ventolin?"
"No."
"There was a study of 100 post-op patients. They were all given breathing treatments and they all got better and went home eventually. Now you know the reason behind all these post-op patients getting treatments."
"We should come up with a name for it."
"There is a name for it," he grumbled, "It's Preventolin."
I laughed.
Don't think we're usually like this, slow I mean. Literally, I have no therapies due until 6 a.m., and none of them really need it. Right now it's only midnight. I don't know what you do on a slow night, or if you even have them, but I'm going to put my feet up and enjoy.
And I'm going to pray the beeper stays qui... I mean silent.
BEEEEEP
Then again, perhaps God has other plans for me.
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