slideshow widget

Saturday, December 21, 2013

In the medical industry, feelings supersede evidence

The following is a guest post by Will Lessons, retired RRT who still works an occasional shift.

So you do a bunch of useless breathing treatments and you feel pretty useless while doing them, and when you're done you feel like you accomplished nothing except burnout.  And then you sit down and get a page, "Treatment in 33343."

You become irate.  You were just in room 33343 and the patient was fine, he just had an audible wheeze.  So now you have to go do another useless breathing treatment on this patient because if you tell the nurse the truth you are being lazy.  If you tell the nurse the truth you might hurt her feelings.

I've decided that that's one of the main reasons we RTs have put up with so many useless procedures all these years: it's because we have empathy.  We care about the feelings of the doctors and nurses who demand RTs do what is not needed.  We get irate and burned out, but we just do it anyway because we don't want to piss off the stupid and ignorant doctor and nurse.

So nothing gets done.  We, in turn, become the hospitals bitches.  Over time it's become just common knowledge that if the nurse or doctor don't know what else to do, they just call respiratory and have respiratory do something to the patient.  This makes the nurse and doctor feel good.

Then the doctor and nurse tell the patient the therapy RT does will allay their breathing trouble, when there is no evidence. Yet in the medical industry, feelings supersedes evidence.



Anonymous said...

Wow. Poorly written and makes our profession seem unprofessional. Rick, why can't I find your credentials on the NBRC website?

Rick Frea said...

First of all,if you read the article, you'd see it was written by my friend Will, not me. Second of all, in order to be honest about the profession, pen names are useful. It's a technique used by many people, including the infamous Ben Franklin, who didn't want his boss, his brother, to find out that he was writing. The only way a medical professional can be honest about his profession (non-politically correct, per se), a pen name comes in handy. On a third note, based on my own experience in the profession, I would agree with everything Will wrote (writes) is 100% accurate. If you read any history of medicine, you would also find what he writes verified many times over.

Anonymous said...

I did read the article and I never mentioned that YOU wrote the article. Re-read my comment again. I said the article was poorly written and makes our profession seem unprofessional. Let me qualify that statement as to why. The patient had an audible wheeze that didn’t improve with the treatment. The experienced respiratory therapist becomes “irate” because he receives a page. Why? The patient didn’t improve. What did the experienced therapist do to contribute to the care of the patient? Give the magic 2.5mg potion? What did he do after it didn’t work? Go back to the department? Put your credentials to use. Inform the nurse or physician before you go to the department that your patient has audible wheezes that do not improve with a treatment. Then make some recommendations. Put your competency in full gear. Recommend a peak flow; chest x-ray; steroids – anything!! Don’t just walk away and wash your hands because you gave Albuterol. Pathetic. Be contributory. Add to the care. Get involved. You have more to offer than just 2.5mg of Albuterol and calling nurses and doctors “stupid” and “ignorant.”

Additionally, the title and conclusion of the article is non sequitur. If anything, all I saw was Will’s feelings superseding evidence because he would rather go back to the department rather than problem solving. He knew Albuterol wouldn’t work, but did little to offer any other solution or proactively alert the nurse ahead of time of the pre/post bronchodilator treatment that was ineffective.

I’m not saying the RT was lazy; but I am saying that this is a GREAT example of being sloppy. Put your credentials to use and quit blasting the very people you work with. Participate in the care, don't isolate from it in your department.

Rick Frea said...

You know, I was thinking about this discussion while working this morning. I've decided it is not unprofessional to respectfully disagree with your boss, or a doctor, or anyone for that matter. There have been many times I have said to a nurse or doctor, "I'm sorry, but I disagree with what you are ordering me to do." This is not unprofessional, it's expected and necessary.

Rick Frea said...

I have to say that you are right, every thing you said. Ideally a therapist should do just what you said. I can't argue with it. However, in most cases, all that stuff you mention is already being done, the doctor just throws in a breathing treatment for good measure. Explaining that the treatment is not necessary to certain people is like beating on a dead duck. I think this is one of the reasons so many RTs become apathetic over time.

Anonymous said...

Let me get this straight. Tonight I have ten patients, all in no respiratory distress, none who need Duoneb and Pulmicort, but all getting it. So, you're saying that because the doctor orders something that's not needed it becomes my job to tell the doctor how to do his job?

Anonymous said...

The doctor IS doing his job. Could it be that the patient is not in respiratory distress because of the ongoing breathing treatments? Does your patient have a history of lung disease? Have you looked at their chart? Do you know your pharmacology? Pulmicort is a maintenance drug, not a rescue drug. It's not given to treat respiratory distress. It's preventative. Also, Duoneb doesn't always have to be given when a patient is in respiratory distress.

A physician isn't seeing his patients Q4 or QID like you are. You're expected to be his eyes when he's gone. Contribute. If the patient doesn't need the scheduled frequency for Duoneb, recommend a change in the frequency. PRN? But, don't do anything stupid and recommend to change the Pulmicort to PRN- that would imply you know little about that drug.

The point is- contribute. Offer recommendations and give reasons as to why. Knowledge based recommendations/reasons. No, you're not telling the doctor how to do their job. The pulmonary system is ONE aspect of the patients care. The physician isn't only writing orders regarding the pulmonary system. He deals with other systems, medications, ancillary's, discharge planning, etc. All he's asking you to do is contribute to the pulmonary system. Don't think that when you make a recommendation, you're telling him how to do his job. Give me a break.

Will Lessons said...

Wow, I'm impressed with all the responses on my post. I'm sorry to say this, but the truth can come as a shock. The truth is, most nurses and physicians have no clue what albuterol does. If someone has underlying asthma, then the albuterol will do some good, but still only if the patient is short of breath to begin with. Albuterol is a rescue medicine, not a preventative medicine. It will have not travel to the lung parynchema to reduce inflammation that is pneumonia, it will not absorb pulmonary edema from lung, it will not reinflate a collapsed lung, it will not suck out a pleural effusion, and it will not cure stupidity, to quote one of Rick's posters. I'm not saying all of what RTs do is a waste of time, but about 90 percent of ordered breathing treatments are.

Will Lessons said...

And you cannot tell the physicians who ordered this stuff that it's of no use. They are convinced in their heads that it will help their patients. Or, in some cases, they order it just so the patient feels like we're doing something. Or, in many cases, they order it just to make sure the hospital gets reimbursed. Many times I've tried to educated a nurse or physician, and it goes in one ear and out the other. After a couple years of trying to be the single person to improve it all (and yes I took the route you are describing for many years), I finally realized I'm not going to be the RT savior. In order for this problem to be resolved (and yes, it is a problem when you give a patient meds he doesn't need, at the expense of burning out those who give it), it has to be done at the core of the medical profession.

And, by the way, RTs don't have time to do all the stuff Mr. Anonymous says. By the time we are finished doing one round of treatments we have to start another. It's no wonder there is so much apathy and burnout in the RT profession.

Anonymous said...

20 pts on tx's today. 18 are duoneb and pulmicort. 16 are pneumonia pts. No courage to tell the hospitalist on today that none of them are needed.

Anonymous said...

Everyone knows Albuterol doesn't cure Pneumonia. The physician may not be ordering those treatments to treat pneumonia. But pneumonia can cause the airway smooth muscles to constrict and cause bronchospasm. Albuterol is a smooth muscle relaxer which will help with the affects of Pneumonia. The physician has a right to order it as a preventative drug. Yes, it's classified as a rescue drug, but if you have asthma, you know you can take Albuterol before a bronchospasm episode as a preventative, like when athletes take it before they play sports because of the various triggers to bronchospasm.

Therefore, if a patient has a history of pneumonia-induced bronchospasm (the kind where smooth muscles constrict) why can't the physician order the "useless" drug? They can. Study your literature.

As for the other anonymous person, your mentality is what hurts our profession. Competency, compassion, and courage. That mentality lacks all three.

Lack of competency - because you have bought into the lie that you think we physicians only order Albuterol to cure pneumonia.

Lack of compassion - as a result of poor competency, it affects how you administer treatments - with apathy.

Lack of courage - can't talk to the physician about a recommendation in the care. The recommendation doesn't have to be "stop therapy." As an RT, there are other modalities to help with Pneumonia.

As a physician, I want to see an alternative suggestion to the plan of care instead of "he doesn't need breathing treatments." Recommend flutter, pulmonary toilet, aerosolized antibiotics, PEP, etc. stop thinking we think Albuterol works at the parenchymal level. We know it's a beta 2 agonist that relaxes bronchial smooth muscles. We also know that the triggers to airway muscle constriction is endless, and the affects of Pneumonia can be one.

As I said, put your credentials to use and stop blasting the very people you work with. You have more to offer than just "Albuterol doesn't work."

Rick Frea said...

They can and they do, which is exactly what's wrong with the medical community. It's called ordering medicine based on feelings, not facts. At a cost of $125 or more for every breathing treatment, x four treatments a day, x a 7 day stay, that's $500 wasted every day, or 3,500 a week. If someone needs prophylactic b2 agonist therapy, that's what serevent and formoterol are for.

@RTAlaska said...

He just said what the majority of RTs are thinking...hhhh. It's an unfortunate truth but so refreshing to hear such honesty.