Critical Thinking: When It's Okay To Tell Doctors What They Want To Hear And Then Disobey Them To Do What You Think Is Right

So, we RTs are responsible for setting up ventilators. We assist with intubation, secure the airway, and then have someone bag while we set up the ventilator. At my hospital our hospitalists trust us to determine the best settings. And then, sometimes, when we have a very difficult patient, a specialist from Big City Hospital calls us to talk about fine tuning the ventilator. 

And this is fine. You talk back and forth. And this can allay our stress and the stress of the hospitalist. However, sometimes it doesn't help at all. A recent such episode involved the fact that a patient kept high pressuring despite being on a low tidal volume. The peak pressure was hitting 40 and the PEEP was set at 5. So this meant that the driving pressure was 35. And so the concern here was how to get the driving pressure down to 30, or as low as possible. 

And so my phone pings. It was the Video ICU calling from Big City Hospital. A nurse there said that the vICU doctor wanted to talk to me about the ventilator. And this kind of stressed me out because I was spending time trying to figure out how to get the pressures down and to get the high pressure alarm from stop going off without in effect lowering the high pressure alarm, which I had set at 50. 

I had informed the hospitalist and attending nurses that the problem, I was sure, was not the ventilator but the fact that the patient was not sedated enough. Plus it also might have something to do with the fact the patient had bad lungs to begin with. I don't think I need to get into the details of the patient's condition to make the point I want to make by this post. 

So, the hospitalist and the nurses respected what I was saying. And efforts were being made to better sedate the patient. And, of course, I'm continuing to reach into the information stored in the gray matter of my mind all the while staring at this machine to see if there were some adjustment I could make on my end to remedy this situation -- and I pretty much came to the conclusion that there were not -- the problem was on the patient end. The patient needed to be better sedated -- and efforts were being done by the team to do this. So, we were fine. Once the patient was sedated, we would be fine -- the patient would be fine. So, no stress. 

And then the hospitalist hands me his phone. He said, "The vICU doc wants to talk to you." 

And so I take the doctor's phone and place it up to my ear. And this is where I remember that there is a video camera on the wall behind me. And so the vICU nurse and doctor could see everything we were doing. They could see us, they could see the ventilator, they could see the patient. So, I realized they must have been watching as we struggled to get the patient under control. 

A male voice came through on the phone, belonging to a vICU doctor whose identity I wasn't aware of at the time. The doctor was eager to propose various solutions to address the problem at hand. Despite having already attempted the adjustments he suggested and knowing they were unlikely to work, I went ahead and made the tweaks. This approach allowed him to see firsthand the ineffectiveness of those particular adjustments.

In the end, he insisted, "You need to switch vents; the current one must not be working."

As if my stress level wasn't already at its peak, my face likely turned red with anger. I vehemently asserted, "There is nothing wrong with this ventilator. The problem lies in the lack of synchronization with the patient due to issues on the patient's end. My ventilator is functioning perfectly."

Yet he insisted I change the ventilator. 

"Sure, I said. 

Once he was satisfied, he asked for me to hand the phone back to the hospitalist, which I did. But I made absolutely zero efforts to change the ventilator, as I knew that was not the problem. And, as I expected, within the next 20 minutes efforts to properly sedate the patient succeeded. And the pressures came down to the acceptable range. 

Here's another scenario I often share with young Respiratory Therapists. Imagine you receive a patient transferred from surgery, and the surgeon instructs you to set the patient up on a tidal volume of 1000. You respond with a respectful 'Yes, Sir!' but, per your protocol and assessment, you decide that a tidal volume of 500 is safer for the patient. In these situations, it's crucial to balance following orders with making decisions in the best interest of the patient, using your expertise and protocols to guide your actions.

I've found myself in this situation numerous times, and my colleagues share similar experiences. It's a practice we humorously call 'pleasing the doctor'—nodding along, and then doing what we know is safest for the patient. As respiratory therapists, we are the experts in airway management, a responsibility that goes beyond the scope of surgeons or other doctors less familiar with ventilator care. This isn't about singling out surgeons; it's about emphasizing the importance of our expertise in ensuring patient safety when it comes to managing ventilators.

The key takeaway here is the importance of trusting your instincts and expertise. In critical situations, there's a delicate balance between following your gut instincts and managing the expectations of the medical team. It's crucial to recognize when to adhere to established protocols and when to assert your professional judgment.

In this instance, while doctors can prescribe treatment plans, the choice of a ventilator ultimately falls within the respiratory therapist's domain. Trusting your knowledge of the equipment, critical thinking skills, and experience is paramount.

Addressing alarms doesn't always mean the equipment is faulty; it requires a thoughtful analysis of the entire clinical picture. Sometimes, managing the situation involves not only technical adjustments but also effective communication to assure the medical team.

Moreover, in the complex landscape of healthcare, there are moments when telling doctors what they want to hear becomes a strategy to maintain harmony, allowing you the space to execute what you believe is right for the patient. It's a delicate dance of managing expectations, ensuring patient safety, and upholding the integrity of your role as a respiratory therapist.