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Monday, October 15, 2007


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.


Anonymous said...

I must say, your hospital sounds eerily like one I worked at in Maine. I worked there for two years, my job satisfaction dropping like a stone daily, until I decided to make changes. For a year, I volunteered on a committee and helped author a ventilator weaning protocol, which I was very proud of--and the protocol was much better than our "four alternating pulmonologists who hate each other" system that was in place.

Anyway, the protocol was approved but then nobody ever ordered it. I was crushed, so I quit and moved on to better horizons. But your story reminds me very much of those days, and I give you two thumbs up for heading the charge towards better practice!

jesus_of_suburbia said...


I'm a second year respiratory student. My current clinical site is a teaching hospital swarming with residents. Protocols more or less don't exist at this facility. Except for the Surgical Heart Unit, where it's given to nurses. They are also given ABG protocol. No, that was not a typo.

Needless to say, as a student, doing a rotation in that unit is a very demoralizing/disheartening experience. I usually go into a "why the hell did I get into this?" depression for a few days. Maybe it wouldn't be so bad if these were like the most seasoned nurses in the hospital. However, a disturbingly significant amount of them are just about fresh out of school.

How the hell are you allowed to work in any kind of intensive care unit when there's a pretty good chance you've never ever observed a code during your clinical time? Now you are in a heart unit, given drug, ABG and ventilator protocol!? I don't want to dog on nurses. I respect them. But like, come on, you know?

Funny thing is the nurses at this hospital aren't allowed to touch the ventilators. Only respiratory and attendings can physically change settings. So, the RT's basically act as babysitters.

Apparently, the last guy who headed up the respiratory department was a real joke. Fortunately, the lady in charge now, seems like she's got a pair.

What I don't understand about ventilator protocol is that if managing a vent is so unimportant that you can just hand it off to someone with the little to no vent experience (i.e. residents, or in my special case, nurses), why not give it to US? You know, we have all sorts of neat expertise about this stuff. Wouldn't that be like, the natural choice?

I hear all this shit about "We want clinicians. We don't want techs". Well, apparently you do want techs. You can't expect a clinician to be happy about following your stupid albuterol/atrovent orders or having to explain to you why it would be a dumb idea to take a patient off the vent to give him/her IPPB.

Re: wuss therapists.

I really hate these p*ssies that are so petrified when given some extra responsibility. You do know you are already working with a life support machine? Don't you?

I already see the makings of wuss therapists among so my classmates.


just respiratory

Sorry for the rant.

Freadom said...

Like me, you will never be happy being a button pusher. If you have an option, there are many hospitals out there that will provide you the challenge you need.

If not, if you are forced to work for this institution, perhaps you can be the one to make a difference.