New types of Vent-'olin discovered at Shoreline

I come into work today and we have 16 patients on the board. Just to give you an idea of how hard us night shift RTs have to work at times, I have to take care of all these patients, plus ER, and plus anything else that comes up during the night.

I've been doing this long enough that I would consider myself an RT expert at prioritizing my therapies. I do this by asking one simple question when I come on duty after a few days off, especially if I don't already know the patients:

"Do any of these patients actually need the treatments?"

I know by now which RTs I can trust in their assessment and which one's tell me that a patient needs treatments when in all reality they don't. Either way, on my first day back I pay extra attention to my assessments, and determine for myself which patients need treatment and which one's don't.

Then I circle the names of the patients who do need them.

Now, that in mind, of the 16 patients I currently have here tonight, I have circled three of the names. That means, if I get busy in ER, or with a code, or if OB has a bad baby or something, I don't have to stress out about 13 of the patients -- they don't need their treatments anyway.

That in mind, my coworker Dale must have been fed up with this, because when I came to work yesterday he handed me a piece of paper. On this piece of paper he had three new 'olins for me to add to my list.

Following is what was written on that piece of paper:

Toolateolin: Most effective treatment for hopeless conditions. Use should be initiated by RN only. Drug has demonstrated no untoward effect when used for pulmonating edema, pneumothorax, cardiac tamponade, severe chest trauma, upper airway obstruction, nor agonal breathing. Like Xoponex, this drug comes in varying doses for cardiopulmonary arrest, v-tach, prolonged apnea, multi system failure, end stage mets, pulmonary infarct, rigor mortis or any other condition threatening imminent mortality.

Tryagainolin: A version of Toolatolin (as described above). Used continuous for prolonged periods should result in relief for all involved,with exception of patient & RT.

Waytoolateolin: A version of Toolatolin (as described above). Used continuous for prolonged periods should result in relief for all involved, with exception of patient & RT.

Note: Repeated use on multiple patients of Toolatolin, Waytoolatolin or Tryagainolin may result in changes. Normally witty RTs may respond to reasonable treatment requests with caustic cynicism. Normally, cynical RTs may respond to idiot requests with unconcealed anger. Normally, angry Rts may become despondent and resort to tears after self mutilating their heads on the closest brick wall

Further precautions: Treatments with Toolatolin, Muchtoolatolin and Waytoolatolin must be carefully documented. Charted comments such as “this treatment was a worthless waste of time” or “patient remained apneic post treatment,” may prove to be uncomfortable for doctors, RNs and RT department supervisors resulting in further enhanced working conditions or threatened continued employment.

After working last night, and seeing for myself just how ridiculously and unnecessarily busy we are here, and getting irritated with all the unindicated breathing treatments, and actually getting so irritated that I wrote on many of the unindicated treatments comments like: "This treatment not indicated," or "no signs of bronchospasm," or, "This pt. not sob before tx, still not SOB after tx," or "treatment had no effect."

Also, after spending half the night in the emergency with a critically ill patient who did not need treatments but nonetheless I had to do several of them on her, I completely understand now what instigated Dale's creativity.

Thankfully this occured before the day shift went home. However, if Jane had already clocked out, I would not have left this critically ill patient to do other treatments that were not indicated. No person is entitled to that kind of stress.

And this, my valueable readers, is exactly why I am a major proponent of bronchodilator reform.

IPPB still in use at hospitals; still ineffective

Upon coming back to work today I find we have a patient on IPPB. I haven't done an IPPB on a patient in at least four years, and I'm surprised those darn things still work. After all, they were used in the 1960s as a ventilator at this hospital.

In fact, if you watch that old show from the early 1970s called "Emergency," on one of the episodes you will see the IPPB being used as a ventilator. I used to love that show when I was a kid.

One of these days those things are simply going to break down and I don't know what our doctors are going to do when they think one will help a patient stay in the hospital longer. After all, all studies done since the late 1980s show that all IPPB is good for is over-inflating the good alveoli.

"The patient is complete white out on the left side," Dave said.

"So, who ordered IPPB?" I asked.

"Oh, Dr. Arse."

"Why? Isn't it contraindicated for pneumo?"

"Well, it's not a pneumo," chuckles, "it's crackles. But don't worry, it should only do minimal damage to the patient. As soon as you're done with the treatment his good alveoli should deflate to normal size and he should be fine. It should only prolong his stay here one to two days."

"Okay," I said, "at least there's a good reason behind it. I'd hate to be doing an ancient procedure for nothing."

"Yep."

"What's doctor Arse going to do when our IPPBs finally break down due to wear and tear, and the company no longer exists to send in replacement parts?"

"Well, those machines are made to last a lifetime, kind of like Duracel batteries; they keep going and going and going. Then again, if they do happen to break down, I guess Dr. Arse will just have to retire."

"I think we should have hiden those things in the basement with the mist tents and told the doctors that we don't have them anymore, then they'd be forced to use some more effective therapy."

Dave chuckled, "Well, then they'd just give continuous inflatolin treatments."

Okay, so that's how my night started. It must have been a rough week for him.

On a side note here, the IPPB machine we have is so old and outdated that I can't even find a picture of it to post for you here.

Respiratory Therapy is not a retirement job

Unlike some nursing departments at our hospital, my RT department has a very low turnover rate. In fact, even while I've been around here for ten years, there is still only one full time person under me in seniority, and I've been next in line for a day job for at least eight years.

However much I love working with the sagacious Jane Sage, she told me two years ago that she was going to retire in two years. Recently I called her on this, and she said that she was going to retire in two years.

"Um," I said, "that's what you said two years ago."

"I suppose I could retire, but I think I'd be better off retiring at social security age, which for me is 62."

That would probably work out good for her as far as money is concerned, but the fact that she has bags under her eyes, and the fact that she limped into the room, are not good signs. "I don't want to sound rude," I said, "but you look exhausted. I think you could use a good retirement."

"I'm 60 now," she admitted, "and I could probably retire comfortably now if I wanted to."

"Well, why don't you. I know you are the most sagacious RT in this department, and I don't know how we'd survive without you, but you need to do what's best for your body, and your sanity."

We had this discussion just before I went to Florida, and I was extremely burned out from all the running around I was doing working solo nights. My feet ached. My brain was fried. And I probably looked as bad, at 37, as she did at 60.

I said, "I never thought I'd admit this, but I think I'm finally ready to accept a day job should one come open. I'm really burned out of wording nights. I'm to the point, or to the age, where it's really running me down."

"Yeah, you look pretty beat."

"So you better watch out, Jane. You better watch out every time you step in front of a window and I'm in the same room."

"What are you gonna do," she said, smiling, "push me out?"

"Absolutely, for your good and mine. It's time you retire, and it's time I go to days."

As much as Jane and I love our jobs, I certainly don't think a human being is meant to do this job until they are 60. There's a lot of mental aspects to this job I think a person at 60 can handle just fine, but the physical end is pretty rough on the body. We have to do a lot of walking. It's physically demanding.

Mike is one of my RN co-workers who has told me so many times that he's going to work until he's 72 that I now have no choice but to believe that he's not simply pulling my leg.

"Why don't you set your money aside so you can retire early, like, say, 58 or 60?" I said to him one night.

"Because the government wants me to retire when I'm 72."

"You always do what the government says."

"Yes."

He tried to convince me that there was no way I could afford health care if I retired early. One time I tried to convince him otherwise. The other 20 times I just sat there and smiled.

Jim, the guy I never saw when he worked here because he worked the nights I didn't, told me that he retired from some company like Bell Telephone with an excellent retirement. He told me he got bored in retirement, especially because his wife was still working. So he wanted to get a job where he could go anywhere in the country because his wife had a traveling job, so one of his friends recommended he become an RT.

What the hell was he thinking? How could anyone be bored in retirement? How could anyone want to be an RT as a retirement job?

I used to golf. When I got married I quit golfing because it was expensive and I wanted to save up this money for the benefit of the family. But I told my wife that I am going to start golfing again when I'm 40.

"Why?" she said bluntly.

"Because I need to prepare for my post retirement job."

"Sounds good to me," she said.

Retirement living is like college -- in reverse

One thing that I'm reminded of every time I see my dad is that I absolutely do not want to work as long as the government wants me to, until I'm 62. I want to retire when I'm 58 and golf the rest of my life away as my dad is doing, and as grandpa did.

My dad leaves Michigan in October and drives to Florida where he lives on this really nice retirement community. Wrapped around the nice homes in the community is a golf course, where my dad and many of his retired friends "work."

The milieu there is akin to the college setting, only the opposite. Instead of getting up late and staying up late, most members of this community go to bed early and get up early. And when I'm there I have no trouble adjusting to the difference, especially since my home sleep schedule is so messed up because I work the nocturnal shift.

Four-o-clock every day is happy hour. This is a time when all of us gather on the back porch of mom and dad's house and enjoy the warm breeze to the tune of a drink or two or three. Then we pack around the dinner table and enjoy some of mom's good home cooking.

After dinner dad and I usually go back outside and watch some TV while the kids watch cartoons on the living room TV and the women do whatever women do.

I pull up one of the other chairs and set my feet on it and get myself real, real comfortable as dad clicks on the TV. Usually it's Fox News or the history channel.

"Everybody watches Fox News," Jim from across the street says as he strolls onto the porch, the screen door slamming behind him.

"Hey, Rick," he says to me as he cordially takes my hand with a firm grip, and then plops into a chair by the TV with an equanimatous smile spread across his aging face. I look at dad, and he too has a happy expression on his face, the countenance of a happily retired man without a responsibility in the world other than when his next golfing match will be.

Some light bantering occurs, but nothing too serious. Some light conversations about politics ensue, and it mostly goes along the lines of this, as my dad said: "Ah, it doesn't matter so much what they do, so long as they don't take this away from us."

By "this" he is referring to the way he lives his life. He's relaxed. He's happy. He enjoys the warm weather instead of the freezing snow. He gets to golf any time he wants. Every day at 4 he enjoys happy hour. He smiles. He laughs.

Then, as I'm feeling happy (not drunk but happy) after two or three glasses of wine, I find myself yawning. "I think I'm getting tired," I say.

"Well, you can go to bed anytime you want here. In fact, your mother is probably in bed already."

"Yeah, well, how about one more drink."

"One more." Dad agrees.

So we enjoy the warm Florida outdoors a while longer. My yawns become more frequent. A few more of dad's friends come and then go leaving me and dad alone again.

"Yep," dad said, "Don't get old son, on second thought, get old, it beats the alternative."

I laughed, and then time went by without as much as a word as we enjoyed the moments.

"Well, I'm going to bed, dad," I finally decide.

"You're on vacation," he said, "you can do whatever you want."

Inside I see that the kids already have their pajamas on. I look at the clock, and it reads 7:30 p.m.

In the morning I wake up to the Weather Channel, every day, at around 6:30. And it's real loud. I don't think dad has a clue how loud it is, or he'd probably turn it down. Neither my wife nor I ever say anything.

"Your up early, dad."

"Yep, gotta get to the clubhouse early so I can get a good t-time. Then I go to work," golf, "and then I take a nap, and then it's happy hour."

"Well, I'll see you when we get back from Disney."

"Yep, you have fun." He gave me that "yep, been there done that," look and smiled as he exited the house.

I told him how Disney was nice the first time just to see what it was like, but the only reason I do it any more is for the kids. I only griped when we went to Animal Kingdom, of which I think is nothing more than a glorified zoo.

But the kids are the perfect age for any Disney park. It was as though they were living in a magic world while they were there. And my 4 YO was so cute as she hugged and kissed every character. That part was cool. And that's the only reason I go anymore -- for the kids. No offense Disney, but this 37 year old RT has had enough of the magic.

We decided last summer that we wouldn't go this year so we could save our money, but as winter loomed we decided better of it. "You know, our kids are going to grow up fast, and your parents aren't getting any younger, we might as well just go."

And she was right. Right around February cabin fever set in with a vengeance, work was swamped, and we were antsy to get on the road.

That's about how it is every year for us

Dad and mom, on the other hand, do this every day. As we pack our bags, load up our car, and drive away with mom and dad waving, we are headed back to two more months of cold and snow, and 21 years before I turn 58, the age both my dad and his dad before him retired.

Mom and dad, on the other hand, will enjoy happy hour with whatever friends come over that day, enjoy moms good home cooking, go to bed at 7:30, and get up at the crack of dawn to to go to work, er, golf.

What a life.

Working as an RT is pretty cool, but the idea of golfing for a living sounds far cooler -- or warmer considering I'll be in Florida.

And hile I don't want to wish my life away, nor do I want to rush my kid's growing up, I'm certainly going to enjoy golfing for a living once I turn 58.

Monday's class: My response to your queries

Before I went on vacation I wrote a post responding to ten Google and Yahoo searches that linked someone to my site.

The reason I did this is because I know that 62 percent of those who click on my site stay here for less than five seconds and, in many cases, if they'd have just hung around a bit in the RT Cave they would have found the answer they were looking for.

So, with that in mind, here are my honest and not politically correct responses to all your queries. While some queries are so goofy they may lead to a facetious response by me, I will be completely serious when the question is a respectable one. I promise.

1. Respiratory therapy inserting catheters: God, I hope it never comes to that.
   
2. I hate respiratory: Why is it that this keeps coming up? I wonder how much time this person spent on my blog.
   
3. Signs a person might need to use an inhaler: You can do so by using a peek flow meter or by knowing the signs of an impending asthma attack. Another great place to find information about asthma is asthma mom, and National Jewish Medical and Research Center. The later hospital and a research center that specializes in pulmonary diseases. I know three people who spent time their for their asthma. It's an excellent place.
   
4. How to know when an asthma attack is occurring: See question #3.
   
5. What is it like being a respiratory therapist?: The best way to find the answer to this question is to check out what the RT bloggers have to say. It's a great job where you get to meet many wonderful people in need of help with their breathing. Some will need a simple breathing treatment, and others more intense therapy. The greatest parts of being an RT, in my opinion, is being part of a great team. We work together with Drs and RNs to the benefit of the patient. As with any job where you work with people, it can be very challenging at times -- yet rewarding too. This could be an idea for a future post. Stay tuned.
   
6. I'm sick with a cold in my chest bronchospasms: Sounds like you should go see your physician, or get one if you don't have one.
   
7. When to intubate: Here is a good link to check out. Cardiopulmonary arrest is an obvious indication for intubation. And during surgery patients are often intubated to keep them alive during the operation. Other times it's mostly a judgemental call made by the doctor and the care team, which includes us RTs. Here are some other indications: Ventilatory and Oxygen failure that might occur with asthma, COPD or pneumonia; to protect the airway of a comatose patient or patient who has lost his gag reflex; signs of impending failure where the airway will need to be secure, such as a trauma or burn patient.
   
8. Holter wheeze: You lost me.
   
9. What kinds of potassium does nursing homes give patients: I have no clue why this query was linked to my sight. I would have to refer you to one of my fellow RN medblogs for this. Check out the links to the right.
   
10. Can a peak flow meter be used for anything else: They are typically beneficial and helpful for helping asthma patients. Other than that, I suppose you could experiment. You could use it as a cool children's toy. You could have a competition during the last day of school to see who can blow the highest number. The winner gets a lolly pop.

That concluses this session.

The skyrocketing healthcare cost debacle

Over at Respiratory Therapy Driven is posted an interesting post noting the high prices for various respiratory therapies, followed by an interesting discussion.

I no longer get to see the prices of therapies at our hospital because charges are automatically dropped when we chart, however I know that prices compare from hospital to hospital, and they all seem to charge way too much.

It seems ridiculous that each day in a hospital room would cost over $800, or almost $2,000 for an ICU bed per night. Or that one day on a vent would cost as much as $1,500, or that a BiPap charge per day $800.

However, after I think about it further, perhaps some of this cost can be justified because they do include services. And all you RTs and RNs know full well that one patient might require much more attention than just the usual Q2 or Q4 vent check. Some patients can be easy, but others can be down right challenging.

And then there is the liability involved. If the hospital gets sued there could be millions of dollars on the line, and the hospital would have to be able to cover this cost. Thus, the prices get jacked up a bit more.

And then there is the increase in supply of patients coming to the hospital since the inception of Medicaid in 1965. The general rule taught in economics 101 is that when people perceive something as free they tend to seek it.

Another basic economics 101 rule is that when demand for a product increases and supply stays the same the price goes up. This simple law of economics would explain why the cost of medicine has skyrocketed since 1965. Top that off with frivolous lawsuits and you can see why healthcare costs continue to rise.

I can buy a nebulizer for less than $100, a box of Ventolin for around $20, and give myself breathing treatment to myself for free. I can buy a ventolin inhaler for $20 and each puff is free.  When I can do this myself for this low of a cost, why then does it cost as much as $350 for QID Albuterol and Atrovent nebulizers?

Likewise, why would doctors continue to order Nebulizers when they aren't indicated?  Studies show that nebulizers work the same as MDIs, so why not order MDIs on stable patients? Most patients can do MDIs on their own for free, minus the initial education and cost of the inhaler.

And, if the cost of Nebulizers treatments is so high, why then do not more hospitals have more treatment protocols to cut down on useless breathing treatments? Would not this drive down the price?

Some of the cost of a hospital stay can be justified, as I mentioned the risk involved, but also for the simple reason of being able to pay competitive wages to doctors, nurses, ancillary staff, and all the other people needed for a hospital to function.

Likewise, hospitals have to be able to cover the cost of keeping up to date on all the expensive new technologies in order to stay ahead of the game and provide the best care possible for its patients. In this regard, the high cost might be understandable.

I read somewhere that the cost of medicine used to be trivial before the government got involved, mostly because once people realized they could get medical attention for free in emergency rooms, they flocked to emergency rooms.

At the same time, regardless of the indication for an emergency room visit, hospitals are not allowed by Federal law to turn any person down for treatment.

Even illegal aliens get free health care in the U.S., and they have no billing address of which to send a bill to either. All of this, as per economics 101, drives up the cost of medicine for all of us who pay, and makes it challenging for those without health insurance to pay for hospital services.
Some people contend that the U.S. needs to create a federalized health care program in the mould of Canada and Europe. I for one am not convinced that this would solve the problem, and you can check out posts I've written on my other blog regarding Federalized Health care and decide for yourself (and feel completely free to disagree with me, but be nice if you decide to leave a comment.)

A good discussion on this topic in the arena of ideas is something that is much needed, and with the coming presidential elections, all options should be on the table. The only way to solve a problem this big is via debate, regardless of how hard this might be.

Still, $40 for a sat check is quite ridiculous. At our hospital doctors get paid $40 for just reading an EKG. I calculated once that if one doctor read all the EKG in a year, he would make $40,000 a year. And that was ten years ago.

Yet, 40 years ago people could simply walk into a hospital and pay cash for services rendered.
(CHECK OUT MY POLL)
(Here is a doctor's perspective on the high cost of medicine, and an RT from Canada.)

New indication for Albuterol Nebulizers

I've learned tonight that there is one more indication for using Ventolin that has been overlooked. I never would have thought of this myself, and it took for a brilliant nurse here at Shoreline to point it out to me.

I was called to a patient's room to give a breathing treatment. Four hours earlier I had given a treatment to this patient, and observed agonal breathing with long periods of apnea. The patient was obtunded. The patient was also a DNR patient (do not resuscitate).

I was already grumbling under my breath as I approached the nurses station, and hoped that I could prevent myself from stating my opinion verbally.

"You guys called for a treatment?" I said as I approached the nurse's station. Three nurses looked up from their respective computers and squinted at me.

"Yes," one of the nurses said. "We need a treatment on Mrs. Millen in 212-2."

You mean you WANT a treatment, I thought. This patient never needed any of my services. "Is the patient having bronchospasms?"

"I'm not sure," she said as she hopped out of her chair.

"Then why do you think she needs a treatment?" Why did I just ask that? I'm only asking for trouble.

"THE PATIENT ISN'T BREATHING," she wailed. "SHE NEEDS TO BREATHE."

"It ain't gonna make her breathe," I mumbled ruefully under my breath as I walked away from the station toward the room. I looked back at the station and couldn't determine by the nurses actions whether or not she heard me. The other two nurses still hadn't budged.

Wow! It's an Albuterol epiphany. Not only does this medicine resolve bronchospasms, it also works to actually cause a person to take in a normal inspiration.

Voila. We have a new 'olin. What should we call it? Ventilatolin (not to be confused with Ventilatorolin). If you need the isomer version, then we have Breathonex.

My coworker prefers to call it Itstolateolin. That works too.

I've learned to keep my mouth shut

I walked down to ER just now to do an EKG and found out there were three of them. So I set out to do them when a nurse's assistant asked me if she could do them for me, "I want some practice," she said.

"Cool," I said. "Do you need me to help you?"

"No. I just want some practice, that's all." She smiled brightly.

This was awesome. Instead I leaned on the counter by the nurses station and listened to the political talk. One thing I've learned in my 10 years here is that RNs and doctors sure aren't shy about talking about politics.

"I'm trying to find something to do my thesus on," Milhouse said.

"I have a good idea what would make a great thesus," Sarah said.

"Well, give it to me."

"I think that instead of the government letting people come to the ER for free they should make them pay two dollars. That way they'd think twice about coming in here."

"It's true we treat a lot of useless stuff here."

"I mean, most of these people can afford cigarettes and beer, so why wouldn't they be able to afford two bucks for health care." She smiled wryly and looked around the room as though hoping no unintended ears were open.

"Amen!" I said, softly enough so that no one heard me. The conversation went on, and despite how bad I wanted to participate, I just stood there.

I've learned to listen and not participate to these types of discussions around here. I put in my 10 cents into a conversation in ER the last election cycle, and I had one of the nurses in tears.

Trust me, I didn't mean to. I didn't say anything bad about her, I would never do that. I was just stating my opinion. I was just having fun.

I've learned to keep my lips sealed and just listen, unless I know the poeple I'm talking with and know they are cool about discussing politics. Some people, however, are sensitive to politics, and I don't want to be the one to tick them off, especially when I have to work with these people.

And for that reason I try to keep my mouth shut. The key word is try.

RT Cave Rule #38: You're better off not discussing politics or religion at work unless you know the people around you agree with you, or can handle the discussion. If there is even one person present you're not familiar with, then don't discuss these topics period.

An RTs worst nightmare

I certainly picked a good night to come back to work -- a full moon. Hopefully a full eclipse of the moon brings me some good luck as opposed to the usual bad luck normally associated with full moons.

I'm sure I'm not alone in dreading the first day back after a long vacation. But was especially dreading coming to work tonight considering the last six days I worked were pure hell, and the last hour of the last day before my vacation were the worst ever.

When I say the worst ever, I mean it. Think about this a minute: As an RT, what is your worst nightmare?

Mine is that I'll stare at a piece of equipment when a critical patient is depending on me, as are the nurses and doctor, and not have a clue what to do.

The EMTs informed us enroute the patient would need to be intubated as soon as he arrived in the ER, so we had all our stuff ready. And when he arrived he was blue, moderately labored, but I had seen people in worse condition not be intubated.

Whether or not the patient would be intubated was completely dependent on the doctor on duty. In my opinion, probably 90% of doctors would have intubated this guy right away. But, we weren't dealing with any normal doctor this night, we had doctor Krane, one of the best doctor's in critical situations.

Instead of panicking and intubating, she ordered me to set up BiPap. Considering how the patient looked, I rushed upstairs to grab the infamous Vision BiPap system instead of using the LTV 1200 that was setting next to the bed for such circumstances.

To be honest, the only reason I didn't use the LTV was because I forgot it was there. Up to this date, I had never had a problem using it as a BiPap, although I had read about problems other RTs at other institutions had had with it.

Once the Vision was set up, the patient's SpO2 jumped from 40% on a NRB to 98% with only 60% FiO2 dialed in. And, within a half hour, the patient noted that he was breathing fine.

But, his X-Ray was whited out. According to Dr. Krane, the patient was in ARDS possibly secondary to bilateral pneumonia, but, she said, even that was difficult to diagnose at this juncture. And, secondary to being hypoxic so long, the patients cardiac enxymes were starting to rise, indicative to cardiac damage.

The patient needed to be shipped. No problem, right. As soon as the EMTs arrived the patient would be out of my hands, especially since the EMTs in our area now have their own ventilators.

When the EMT arrived pushing the LTV 1200, I felt completely confident this would be a quick and easy transfer, until Bill said, "Gosh, Rick, I've never set this up as a BiPap before."

"I have," I said confidently. "I'll set it up for you."

I pushed the button, and the damn thing would not go into BiPap. Bill and I felt equally stupid. Finally I gave in, and called my boss, hoping she would remember. What she told me was exactly what I had already been doing.

"Well, come down here anyway," I said to Boss, "We could use a fresh brain."

Bill and I laughed at that, considering he had been up for 24 hours at this point, and if it weren't for this transfer he'd probably be on his way home by now. And I was in the last half hour of my 12 hour shift. I was quite beat, as it was a swamped night. We were both burned out.

Just as Boss arrived in the ER I realized what hadn't before, and Bill and I removed the vision mask from the patient and set the LTV BiPap on the patient. According to the vent, everything was working fine. But the patient was panicking. "Take this off. This isn't working," he chimed.

The nurses were trying to fix the mask, but I knew the problem was with the machine, even though all indicators showed it was working. The patient was getting the dialed in VT, RR and pressure.

I felt especially stupid because I was the one who trained every one in my department and the EMTs how to use this vent as a BiPAP. I suppose my mistake is that I disregarded warnings that it didn't work well as a BiPAP more so because I had used it on other patients and it had worked just fine then.

I checked the internal settings. Everything was set appropriately. The machine was simply not working with this patient.

Then a lightbulb went on in my head:

Flow. It's not giving the patient enough flow. Isn't that the big complaint about using the LTV as BiPAP. This patient isn't getting enough flow

"It's not the mask, you guys," I said. "This isn't working. Take the mask off."

I set the Vision back up, and the patient was fine. "Ah, much better," he said.

It had occured to me then that we had never tranferred a patient before on BiPap. We had always just intubated patients. But, as Dr. Krane assured the RNs, "This patient is doing fine on BiPap, he doesn't need to be vented."

And she was right. He was awake, alert, orientated and breathing fine on the BiPap. So long as he didn't need to be suctioned, and so long as he wasn't a candidate to vomit, he would do just fine on the BiPap.

But, we needed to transfer him.

"Can we send him on the Vision?" Bill said. He lifted it right off the stand. "I think this will fit in the rig."

Sometimes in this job we have to jury rig.

A snowy end to a warm vacation

Well, your RT Cave RT is still alive and well, but a bit slow to get back into the swing of things after a great vacation in Florida.

In my last post I wrote how I was dreading the ride home. It's far better when we are driving toward the warm weather, as every time we step out of the Dodge Caravan the weather is that much warmer. On the way home it's the opposite: colder and colder.

The ride home wasn't so bad until we re-entered Michigan. With every mile driven the snow seemed to come down thicker and thicker from that point. It was bad, but nothing we hadn't driven through before.

As we passed through the last city about an hour from home it was snowing pretty heavily, but we could still see the roads pretty clearly, and traffic was rolling along.

"If we don't stop here," my wife said, "we're definitely driving all the way home, because I'm not stopping 20 miles from home."

"Sounds good to me," I said. "I'll leave the decision to you, considering you're the driver."

"As long as we get home before dark," we said together. We were both anxious to get home, and, needless to say, the kids were getting on our nerves by this point.

Our plans were dashed as we neared the Near Ego exit, about 40 miles from home. An emergency vehicle was parked in the middle of the expressway, and a volunteer fire fighter was directing traffic off the highway.

My wife rolled down her window as we passed the firefighter. "What's going on?"

"An accident," the man said.

"That was a dumb question, hey," she said while rolling up the window and looking at me. "So, now what do we do? Do we wait here for the accident to be cleared, or do we travel in unfamiliar territory?"

"I have no idea," I said.

I had never taken this exit before, and the wife had once. We knew there was an old highway somewhere near here. So, here we were so close to home, so close to a nightfall we dreaded, and we were driving down barely visible side roads unfamiliar to us.

It's one thing to direct traffic off the main highway, but don't you think they should at least tell you how to get back on?

Well, they didn't. And, by the time we found a ramp ten miles down the snow was falling and blowing so hard we couldn't even see the expressway, traveling 15 MPH through pure whiteness. We could just barely see the markers on the side of the road.

For you guys not familiar with driving through blizzards, you do not want to stop even if you can't see, because you might not be able to get started again on the thick snow. You just keep chugging along as best you can, and hope no car has stopped in front of you, because if that happened you'd smack right into it.

"Wifey," I said finally, "We are definitely stopping at the next hotel."

She didn't argue. We were only 20 minutes from home pulling off the expressway at a Comfort Inn. At first we weren't sure we'd even be able to see the exit, but again we were thankful to the road markers.

The kids were not happy -- that is, until they found out the hotel had an indoor pool.

Actually, staying at this hotel was kind of a relaxing end to a nice vacation. We swam in the pool, loafed in the hot tub, slept in, did the pool thing again in the morning, and waited for the snowplows to go through before topping off the vacation.

Today I learned that a semi had jack-knifed on the expressway and there were several cars involved, and that's why we were roughted off the expressway.

Anyway, I suppose I shouldn't be telling people we had to whimp out so close to home, but at least we're all alive and well.

The arduous trip home

It seems we check the weather channel while here in Fla more times that time rest of the year combined. We'll be on the road the next few days gambling with the weather.

If things don't go our way we'll make it a two day trip instead of two. We're not making a big deal of it either way, considering the boy had two snow days last week and is ahead of his class (probably) on his homework. His mother is very good about making sure he keeps up while we're away.

Well, the next time I report I'll be back in Shoreline. Hopefully my nice neighbor kept my driveway plowed. If now, I might be digging through 10 feet of snow to shovel out my house.

I'm not joking there. I was told the snow was as high as the railings on the steps to the front door. Should be fun.

Heck, we have fun no matter what we do.

Burnout meter near empty

Nothing like a nice, long and warm and sunny Florida vacation to empty out the burnout meter. As of this moment, the meter is three quarters of the way empty.

Well, normally after an entire week Florida you'd think the burnout meter would be completely wiped clear to zero, but my feet are still aching after two long days at Disney and today at Universal.

It was fun, especially seeing the smiles these past few days have placed on my children's faces, but, as most of you guys probably well know, sometimes even vacations can be a lot of work.

Tomorrow is our last day here in Florida, and we're planning on doing nothing but sitting around relaxing and enjoying the warm weather. It's projected to be in the 80s.

Considering the weather was so bad at Shoreline that school was cancelled twice this week, we're going to enjoy it all the more.

On the day we arrived in Fla last Saturday my wife's sister called and reported that it was -4 degrees back home. And, while it was only 42 degrees yesterday morning here, we still wore shorts.

But, hey, we're from Michigan, and we can handle it. And there's no way we're going all the way to Fla and not wearing shorts.

Even on that 42 degree morning it warmed up to 70 by noon, and that was the coldest it got. Great weather here, people. We're thinking we'd like to move here.

What were our ancestors thinking settling in Michigan? You ever think of that? Why your ancestors didn't settle someplace warm year round?

I'd like to meet asthmatic Teddy Roosevelt

A friend of mine posed a really cool question: If you could go back in time and have a drink with any president, who would you choose? What would you ask him? What would he ask you?

My friend said it would be cool to meet with Grant, get him drunk, and listen to some pretty cool war stories.

Another pal said it would be cool to meet Thomas Jefferson and get his take our most recent interpretations of his writings. I wonder what he would think of America today. Would he be proud, or would he think we totally blew his words out of the water?

I think it would be cool to meet any president, however, the president I told him I would most like to meet and have a drink with would be Teddy Roosevelt. And I wouldn't even care to discuss politics at all.

You see, I have asthma. And Teddy had asthma. I want to know how he did it; how he managed to live with this disease when there were practically no medicines for it back then. It must have been tough, especially when he was a kid.

There were some medicines, like asthma cigarettes. Did he use these? Did he use some form of rare aerosol therapy? (If you like history, you should check out that last link. It's really cool.)

He would ask me about living with asthma in the year 2008. I think he would be surprised at how many people have it now, and flabergasted at all the new medicines and medical technologies.

I've done a lot of research on this, and have found very little on this topic. Oh, there's a ton of information on Teddy, but not much on his asthma.

One book mentioned it briefly, and indicated that his family did not provide him with any asthma remedies at that time. So does that mean he didn't at least trial of the inhalation therapies available at that time, however primitive they were.

While he struggled with asthma as a kid, and nearly died of it once, he ended up moving south where it was warm and dry. And, as an adult, he had fewer episodes.

Still, I would like to know, Teddy, about your asthma experiences and how you coped with them. I'm very curious about this.

Reporting in from Florida

When my son was four he was a saint traveling. I suppose he spoiled us, because my daughter isn't so tame. While my son is content to play his Nintendo DS, or read a book, my daughter wants something new to do every ten minutes or so.

One of the greatest forms of child entertainment ever invented for people who like to travel with their children, like us, is the portable DVD player. You just plug it into what used to be used for lighting cigarettes and voila, instant entertainment.

Thirty minutes into the ride and we found our DVD player wasn't working, so we already had to make a pitstop -- at Walmart.

So, we made it. It's warm and sunny.

Snowy days will not be missed while I'm in Florida

The first thing I did this morning was use the snowblower to clean off the snow from my driveway, and it's not stopped snowing all day, so right now you can't tell that I even did anything but waste my gas.

As I look out the window right now I see that the wind has picked up a bit, and the snow appears to be falling in every direction all at once from an overcast skyline. It's kind of like an optical illusion. It's so white today that as I look at the house across the street I can barely tell where the road is, even though the snow plows trudged through my subdivision only a few hours ago.

It's the thick, fluffy, pretty kind of snow actually; the kind that coats the tree bark and lies pleasantly on the branches; the kind that lies thickly on the pines, causing the branches to droop quite a bit.

I can see the top part of a huge snowball my son and daughter made together over a month ago. It was so large when it was first made that it was durable enough to last through not one but two rainy days when most of the snow melted. It's nice having those rainy days, because it makes it feel like spring.

The 35-40 degree temperatures on those days is a nice break from weather in the teens, or worse, the one day this year when temperatures dropped to sub zero. There are only a few of those days I can remember in my lifetime, and this year presented us with one of them

However, those warmer days were but a mere aberration in what has become a very long winter. And those extremely cold days will make us appreciate springtime, which we hope is just around the corner with the coming of baseball season. And, as pitchers are to report to camp within the next week or so, we know that spring can't be far away.

As cabin fever sets into maximum gear, it's spring that we long for. Sure, those days on the snowmobile, or sledding with the kids, or watching the kids make snowmen, were a joy. But none of that beats the warm, fresh breezes blowing through the wind on a pleasant spring day, when the snow is just about gone.

I will be in Florida as the pitchers report. I will not go to see them, however, as my children are at the age where they prefer to go to Disney Land and then to Universal Studios. I can't imagine I would enjoy Disney Land so much if it were not for the huge smiles and laughter that place lands on the faces of my children, and wife.

Universal Studios, in my opinion, is much cooler. Not cooler as in the temperature on the other side of the window to my right, where all I can see is a white, snowy blanket covering everything, but cool as in awesome.

And, as we leave for Florida, I'm not going to miss this weather one bit.

Ever dread going to work one more night?

Do you ever have a day you simply dread going to work? That's about where I sit right now as I write this. My wife worked last night, and she said it is a complete zoo there. And she was not referring to OB, even though they too are busy.

I do feel a certain amount of joy that I will be needed. And I do feel joy knowing that I will provide a solution to some person's problems tonight, be it a patient or a nurse or both. I do feel joy in knowing that I will be really working tonight and earning my keep, as opposed to those many days recently where I had so much time as to watch several TV shows on the Internet.

However, I dread the idea that I will be beeped every time I sit down to chart, and I dread the idea that when I sit down to chart again I will again be paged, and when I sit down to chart again I will be paged. I know this sounds redundant, but that's exactly how my nights have been lately.

I have already promised myself that no matter how frivolous the reason for paging me is, I will not complain. I will be happy. I will smile. (fingers crossed)

Well, I say that, but we'll have to wait and see. Usually when I get irritated at getting paged for stupid things, like a treatment that is not indicated, or an EKG on a patient that came in because she stubbed her toe, I grumble and gripe to myself if at all, and by the time I get to my destination I never say anything to the nurse.

And, expecially when I enter the patient's room, I know that I left my attitude, if I had one, at the door. I'll have to remind myself about this more than once tonight, as I still am burned out from the weekend from hell. And we had a wee bit trouble sleeping last night after sleeping until 1:00 yesterday. Whoops. I shouldn't have done that.

Oh well. I can say oh well, and I can rest pretty assured that I will stay in a relatively good mood tonight if only for the simple truth that I know I will not have to return to work tomorrow for my regularly scheduled final night before my six day off stretch. I say this because tomorrow I'm taking off so that I can leave for Florida Friday morning. Yippee.

Yet, a part of me still dreads that I have to work one more night. The burned out sensation that runs through my veins and has worked its way to through my muscles to the core of my bones, especially in my feet, wants me to stay far, far away from that place.

Songs like "One More Night," will rail through my head, reminding myself that it will be over soon. But soon, sometimes during hellish nights, seems like a long time while it's happening.

Do you ever dread going to work like that? I'm not talking about hating your job, but just wishing you could take that final day off, like a Friday per se for people who work normal eight hour shifts with no weekends.

Ever? I bet you do.

Snowmobiles make sledding twice as fun

When we were kids we had plenty of hills behind our house to go sledding on. There were small ones for when we were little, and then their were big and steep ones for when we were older.

We even had one hill with a great big jump on it if you were brave enough to try it, because right after you landed you had to quickly jump off your sled or run into a big pine tree.

Whichever hill we used, we always had to trudge back up. This was probably one of the best ways we stayed fit and trim during the long winter months.

When my son was four I remember taking him sliding at my parents home on the same hills I used to slide on when I was that age, and I had to carry him up the hill. This was a blast for my son, and it was great seeing him so happy. However, after doing this four or five times I was exhausted.

Those days are gone. Yesterday I took my 4 YO daughter to one of my nursing freind's homes to go sliding (the son was at school), and instead of hauling our kids back up the hill we tied the sled to the back of a snowmobile. Not only was this a blast for the kids, it was a blast for us adults too.

And when we were done sliding we took turns letting our kids drive the snowmobile. Of course we had to put our thumbs behind the gas to prevent the kids from going to fast, because they have a natural tendency to do just that. It was a blast.

We didn't get the work out we used to, and that coupled with the hot chocolate and brownies that were dished out afterwords might even cause us to add a few pounds instead of the opposite.

Nonetheless, this was a great way for the both of us to relax and forget about life for a while; to forget about how busy it was at work over the weekend; to forget that we have to go back to that place sought to forget the next night.

Good co-workers make our job easier

Sorry for the rant in my last post, but it really is the truth. I received some much needed empathy from my RT blogger friends, and I suspected as much. I imagine some of you guys work equally as hard probably on a regular basis.

One person smpathised with me and wrote that it's nice to be around fellow RTs when you have busy nights like this. She said, "There is something comforting about walking past another RT in the same hell and muttering 'Kill me now' under your breath. That smile or quick laugh makes everything okay."

I do miss that being the lone night shift RT at Shoreline. I have to give so much credit to my co-worker Jane Sage who works the 9 a.m. to 9 p.m. shift. Even though she was as burned out as me, she stayed until 11 p.m. every night this past weekend, even though she had to be back to work at her regular time the next day. Having her there was literally a stress saver.

And as Dee Brown walks into the RT Cave in the morning and observes me playing a game on the Internet and smiles instead of complaining that I didn't start all the QIDs or do any of the morning EKGs, I feel joy. We are a team. We RTs stick together in our frustration when we have hell nights.

Yet, while I work the bulk of my hours as the lone RT, I know that I have many wonderful RNs here at Shoreline to say "shoot me." We are equally busy. While I walk the 20 miles on my own, the RNs may be caught in a pile of poop provided by just one patient. Those nights can be equally hellish.

One really great thing about working at a small town hospital, and I think one of the reasons I've stuck with this particular hospital as long as I have, is that the RNs have a certain degree of empathy for us RTs when we are busy -- and vise versal.

There have been two ocassions I walked down to ER this past weekend alone and dropped a handful of Duoneb amps on the counter and said, "You guys are on your own." While I might have been blunt, they had empathy for me and did not complain.

There were several occasions when the ER nurses did my EKGs without as much as a grunt. And there was one time I was in ER and a nurse did my EKG just to be nice. She knew it was my fourth swamped night in a row.

I smiled and said, "This is the happiest I've been all weekend. You ER nurses are the best."

Of course if I were in the unit it would be, "You CCU nurses are the best." You know what I mean. You have to be political.

And politicalness is important when you are the lone shift RT, because when the nurses like you, they can make your job a heck of a lot easier than if they didn't -- and vice versal I suppose. However, I pride myself in knowing that I get along with all people. It's better that way.

One of my co-workers who recently resigned used to buy pizza every Saturday night of his weekend on. Once I asked him why he did this, and smiled and said, "If I make a mistake I want to have many friends to back me up."

Last night the nurses organized a pot luck, and all I had the energy to bring was a bag of chips. And my co-worker and I were so burned out we ate the whole bag while giving report.

However, the nurses weren't going to let me skip out on the midnight meal. Midnight meals are cool; a big stress reliever. Even while I had only a moment to munch, the aura of the moment, the hanging out with my co-workers in the lunch room, was all the comfort an RT needs.

Grrrrrr

Nothing like a little Calvin and Hobbes to sum it up for me.

But that headline there about sums up my weekend from hell. And I still have six hours left.

It's one thing to be busy just in ER. It's one thing to be busy just on the patient floors. It's one thing to be busy just in the critical care. But when they are all paging you one after the other all weekend long, it's.... Grrrrrr.

Every person who could posibly have gotten sick this weekend did. I've taken care of everything from sick kids (see my last 2 posts) to adult vents.

Actually, about the only thing I haven't had is a code, but I have had at least five occasions when a patient has come close. And even a code would be better than trudging from one room to the next, from floor to floor to...

Come to think of it. Is there a reason that emergency rooms and critical care units are so far apart in hospitals. That's how it's been at all the hospitals I've worked at.

I think they do it this way to wear out us RTs. I don't think hospital builders think of how far RTs have to walk. No wonder my feet are killing me. I read one place that an RT walks on average 20 miles a day. I bet there's some validity to that.

And, here's another observation, whenever I have a ventilator in the unit (not like they put them anywhere else, but you know what I mean), ER is almost always busy. It's like clockwork. Just as you start a treatment in the unit, ER calls. Then you get to ER, and CCU calls you back.

Then when you sit down to have something to eat, they both call you at the same time, and then you get a third page that a patient on the floor needs (wants) a treatment.

I suppose it wouldn't be so bad if there were two of us, but it's just me. And, for whatever reason, I never call in help. It's not so bad being swamped the first two nights, but by the third night, when things still haven't slowed down, you start to drag your feet.

I'm sure you guys know what I'm talking about.

Now, on the fourth night, I'm... Grrrrr. I'm a freight train coming through, get out of my way. If you order a stupid procedure, I might slip up and tell you what I think. I will try to hold back, but I don't know if I will be able to.

And, if those two RSV kids in ER right now end up getting admitted, I think I might break down and cry.

Okay, so I won't do that. But I could.

That pretty much sums up how I feel right now as the lone night shift RT.

Grrrrr...

Here are the lastest recommendations for RSV kids

Thanks to Ventworld.com, I've managed to come up with the latest guidelines on bronchiolitis and RSV as written by National Guidelines Clearinghouse at http://www.guidelines.gov/ and based on all the latest scientific research and studies.

These are not new to us RTs in the RT cave, but this is the first time I've actually been able to find all this information in one place. I guarantee you I will leave this lying around the hospital for everyone to read. Perhaps I can enlighten some people.

I would love it if our pediatricians would read this latest research and opt to change their guidelines, however I will not get my hopes up. Doctors at Shoreline, and those of other small town hospitals in this region, prefer to work with antediluvian research.

First and foremost, RSV SWABS are not recommended. I mention this in bold because we RTs have to do RSV swabs at Shoreline. Do other RT departments get stuck with this job? I have no clue.

Likewise, chest x-rays, cultures, capillary or arterial gases, rapid influenza or other viral studies are not recommended because "these studies are not generally helpful and may result in increased rates of unecessary admission, further testing, and unecessary therapies."

Likewise, chest physiotherapy and cool mist therapy (mist tents) are also not recommended "as they have not been found to be helpful."

Oxygen on these children, according to up to date studies, is only recommended if the SpO2 is "consistently less than 91%," and oxygen should be weaned when the SpO2 is "consistently higher than 94%."

This is what I tried to point out to an ER RN yesterday and she tried to debate me that I was wrong. I was not wrong. However, to give her credit, our policy is to place and keep all kids who are unable to maintain an SpO2 under 95% on oxygen.

And, surprise, that means they get admitted.

Here is the part of the protocol that might just cause some doctors to completely reject these new guidelines, because it's just not possible that Ventolin would have no effect on lungs that sound that bad.

But, the new recommendations regarding Albuterol is that it "not be routinely used" for the treatment of RSV and bronchiolitis. I must note here that I did not add the emphasis.

Look, as we RTs have been saying all along, we have no problem trying a breathing treatment. And these guidelines recommend trying one. But, if there are no observable changes noted as a result, then this therapy should be discontinued.

If a child is suspected of having asthma, or is at high risk of asthma, then lets place the child on prn breathing treatments, and give them as indicated, rather than just because.

Note the following: "Although in some cases bronchiolitis may be a prelude to asthma, in the majority of cases the use of inhalation therapies and other treatments effective for treating bronchospasm charicteristic in asthma will not be efficacious for treating airway edema typical of bronchiolitis."

Take that and smoke it in your peace pipe.

Keep in mind, however, that studies have shown Vaponepherine (Racemic Epinepherine) to have a beneficial effect on some RSV kids. So this provides another option for doctors to trial on these children, and discontinue if it has no observable benefit.

What is highly recommended is suctioning. And, to our surprise, our pediatricians listened to us when we recommended this a couple years back, and now we even have booger be gones.

This only makes sense, considering RSV involves secretions in the airway, mostly from sinus drainage caused by a virus isolated (in 75% of the cases) in the middle ear.

Secretions is what causes the SpO2 to drop in some kids, not bronchospasm. And that is why it is recommended to suction before feedings, as needed and prior to breathing treatments if they are indicated.

These guidlines are so impressive to me I almost wonder if they were written by a respiratory therapist.

The following was noted regarding suctioning:

"Suctioning itself may improve respiratory status such that inhalation therapy is not necessary... Suctioning may improve the delivery of the inhalation therapy" if the treatment is given.

I can't believe I'm actually reading this. This is incredible. We RTs have known this for years, and when doctors find this out, well, they'll probably chant something like, "Well, everybody has their opinion."

Setting up continuous pulse oximeters on children under one-years-old is pretty much standard practice around here. However, new research shows that the use of "continuous oximetry measurement has been associated with increased length of stay of 1.6 days."

And, therefore, it is recommended that the child's SATs be checked occasionally, but not continuously because some doctors use it as the sole criteria for admitting children and for keeping them in the hospital "one more day."

There you have it folks. That's the up to date state of the art recommendations by the worlds top pediatricians of the nations top children's hospitals. But, they must have it wrong, because that's not how we do things at this hospital.

Tired of people defending old, worn out policies

I'm going to get myself fired if I don't learn to keep my mouth shut, which is ironic because I'm not necessarily a talker. However I've had it with all the B.S. and I'm starting to have a difficult time keeping my thoughts to myself.

"Hey Rick," the doctor called to me as I was passing through ER. "Will you check a sat on the baby in room 5. We've been having trouble getting one."

"Sure thing."

Upon entering the room the child was sleeping comfortably in his mother's arms. I had already completed a blowby treatment on him about a half hour earlier and, needless to say, the treatment was not indicated. I also did an RSV swab on the kid, and that was ordered because the kid had a little snotty nose and a congested cough. That I also think was not indicated, and I'll discuss that tomorrow.

I looked up at the monitor and saw that the SAT was picking up just fine. I looked at it, turned around, and the doctor was gone but the nurse was standing right there.

"What'ja get," she said cheerfully.

"I get 94%. He should be good to go."

"He already bought himself a ticket upstairs."

"What!"

She looked at me with a look of surprise. "That's not a good enough SAT for him to go home with."

"94% is perfectly fine to go home with."

Her smile disappeared. "No it's not."

"Yes it is."

"Um, no it's not." She smiled to let me know no hard feelings.

I feigned a smile, but I was in rare form. "Yes he is."

"Not according to our pediatricians."

"The new thing is that a child can go home with any SAT over 91% if he's in no sign of distress, and this kid is fine."

The kid was fine. My daughter was 100 times worse than this kid, and we never even took her to the hospital.

"Well, our doctors, Dr. Hee and Dr. Haw, want a SAT to be 95% or better."

"Well, at a real hospital 94% is normal." Okay, so I didn't say that. I said, "At the big children's hospitals they have done research and determined that anything better than 91% is acceptable on a child this age." The kid was 2 months.

"Here it's 95%."

Tell me what the difference is between 94% and 95%. I didn't say it. I wanted to give her a smile as if to say no hard feelings, but I didn't. Instead stearnly turned around and exited the ER. I didnt' want to hurt her feelings, but I also wanted her to know I was serious. I was right.

One of the reasons I don't get vocal like this too often is that I have a conscience, and I don't want to hurt the other person's feelings. At the same time, I think it's high time our doctors and nurses read the latest research.

This is exactly the reason I keep up on my reasearch. Is it possible I know too much? Would it be better for me if I simply stopped learning? Is that what they want? Do they want me to stay stupid?

After all, a stupid RT asks no questions. A stupid RT cannot question a stupid doctor order or, in the case of this 95% SAT, stupid policies.

Stupid and outdated policies are really getting to me lately. And nurses and doctors who continue to live by and defend these old and outdated policies are likewise getting on my nerves.

I am very much aware that every doctor has his or her own opinion, and I know that each hospital has the right to have its own protocols. However, I think some good old fashioned common sense should be used in cases like this.

I could be wrong. What do you think?

Working nights solo can be challenging at times

I came into work last night anticipating on working on my fantasy baseball rankings, and it ended up being reminiscent of how it used to be here at Shoreline every night: busy.

My co-worker normally stays until 9 p.m., but all I had were a bunch of 10 p.m. treatments I figured I'd knock off in no time. But, lo and behold, as soon as he left all hell broke lose. Every patient who could possible go bad did.

And, as what usually happens when you have ten treatments due and two patients in failure, the emergency room paged: "We need another now treatment on room 1," the pager read, "and then Q30 minutes after that."

"This is completely ridiculous," I grumbled under my breath, and then looked up at the middle-aged lady I was currently giving a treatment to and watched as her body jiggled up and down as she laboriously struggled to move air.

I didn't know what else to do, so I dropped the pager. This reaction prevented me from whipping it across the room. I looked at my patient, and watched as she closed her eyes and rested her head on the pillow. She was pooping out. I decided right then and there I was not going to leave her.

I grabbed the phone on the endtable and dialed ER. When the unit secretary answered, being political was the last thing on my mind.

I grumbled, "Dr. Krane really wants Q30 minute treatments on this lady?"

"That's what she ordered," Diane said very politely.

"You have got to be kidding me," I said. "I already gave two treatments to that lady,and neither of them were indicated. And now she wants this."

"Well," she said, "You'll have to take it up with the doctor."

"If you guys think she needs the treatments, then you guys are just going to have to do it, because I'm swamped up here."

And that was the truth. Not only was this lady failing, so to was her neigbor. And that's not to mention all my treatments were due, and so was my vent check, and someone on East kept paging me because the Vision BiPaP keeps beeping.

A half hour later ER paged again: "Duoneb needed in ER."

They know I can't get down there right now. Why are they paging me agian?

I grabbed the phone. The unit secretary answered, and I asked to speak with an RN.

Moments later a female nurse said, "Hello."

"Listen," I said, "could you guys do me a real big favor and do that treatment for me. I'm really swamped up here."

"We would," she said, "but the doctor ordered Duoneb."

"How about if you just give Albuterol."

"Because the doctor ordered Duoneb." She was not going to give up.

"I'll be down there soon with some Duoneb for you." I was not in the mood for a debate, so I hung up.

If that's not the dumbest thing an RT ever heard. If a treatment is ordered because a patient is short-of-breath, why make them wait 20 minutes for an RT to give Duoneb when a vial of Albuterol is right there in the med cart just because the doctor ordered Duoneb.

However, I handled it. With excellent RN and RT care both my critical paitents averted a vent thanks to a wonderful drug called Lasix. I knocked off all the treatments, including ER. And, while doing all this, I was being paged various times for odd procedures like setting up suction, which you'd think RNs would know how to do.

And, just as I sat down in the RT Cave to eat my dinner, ER paged again: "EKG and ABG in ER."

So I trudged down there and find a 9 YO girl laboriously breathing. It's not often that we have to take care of a little kid here, and it's always a little bit of a shock to see such a little person lying there in my need, instead of an adult.

For the record, I never did an ABG on a kid before. In all my years doing this, I was never asked to. I took my time, kept my cool, succeeded, and walked the gas to lab. I expected it might be a little off, but here's what the results were: pH 6.90, CO2 17, HCO3 2.7, PO2 162 on 2lpm.

Gulp!

The RNs and I were tossing out possible diagnosis' from sepsis to cancer, but as soon as the doctor saw the gas she said, "We need to get a sugar."

That's when you think, "It was so obvious. Why didn't I think of that?"

The little girl's sugar was sky high.

There was nothing else for me to do with this patient, so I headed back to the cave thinking I'd put my aching feet up, when my beeper went off again.

That's how it was all night until about 4:00 when I finally made it to the cave to chart. And my boss just happened to be there. And, instead of asking me how I was doing, she provided me with some criticism about how we RTs have been making too many mistakes filing EKGs lately.

"Yes maam," I said. I really wanted to tell her to just leave me alone, but I didn't want to get into defense mode. I don't know about you guys, but 4:00 in the morning when I'm on my first day back to work, completely exhausted and swamped, is not the time I want to receive criticism from anybody.

"Wow," she said, smiling. "You are the only one who didn't blame someone else."

I looked at her stunned. I had expected many reactions from her, but this reaction caught me completely off guard. "Really," I said.

Instead of charting, which I didn't want to do anyway, I participated in a nice discussion with The Boss. And, as any of you night shift workers can attest to, when you are exhausted this late in a night shift, you tend not to hold anything back.

"You know," I said, "I never thought I'd say this, but I think that I've finally reached the point that I would like to go to days when a position comes open. I think I am just burned out from ER is what I'm saying."

She gave me a look I didn't know how to read. "I used to like ER when I worked nights."

"You know, boss, I really love taking care of vents and critical patients. That's why I love the CCU. And I love taking care of the critical patients in ER, it's just... I'm tired of the B.S. down there.

She gave me another look I could read. I don't want to say she rolled her eyes, but it was close to that. And then the subject conveniently changed. She was thinking this: "We make money on all those useless doctor orders."

It's neat how the mindset changes when you no longer have to actually do the stupid doctor orders.

And, just as my morning treatments were due, the the beeper went off.

Actually, this is how it used to be all the time here. While we are a small hospital, we have a large area we cover. I wonder if this is the start of a new trend, or an aberation.

Either way, working nights solo can be a challenge. But stupid doctor orders do not take precidence over critical patients.