Trust Us, But Don't Trust Us

The Neonatal CPAP Paradox of Regional Hospitals

One of the biggest frustrations in modern healthcare isn't usually the patients. It's the policies.

When I first started working as a respiratory therapist, our small-town hospital was remarkably self-sufficient. We handled most of what came through our doors. If a newborn needed respiratory support, we had equipment and staff capable of stabilizing that baby while decisions were made about the next step.

Then healthcare changed.

Hospitals merged. Systems grew larger. Decisions increasingly came from people sitting in offices hundreds of miles away. Some of those changes were good. We got better equipment, better pay, and renovations that never would have happened if we had remained independent. I have no problem admitting that.

But some decisions still leave me scratching my head.

One of the first things the experts at the larger hospital did was take away our neonatal ventilator.

The reasoning, as I understood it, was that we didn't have enough neonatal volume, enough specialists, or enough physician coverage to safely manage those babies long term. Fair enough. I can understand that argument even if I don't completely agree with it.

The practical result, however, was that whenever a newborn needed respiratory support, we often found ourselves standing at the bedside with a NeoPuff, manually holding a mask on the baby's face while waiting for the transport team.

Sometimes we waited an hour.

Sometimes two.

Sometimes longer.

I have personally stood there for up to four hours holding a mask on a newborn while waiting for the "baby buggy" to arrive.

Over the years, staff repeatedly asked about neonatal CPAP equipment.

The answer was always no.

We were told we weren't set up for that level of care. We didn't have the experience. We didn't have the specialists. We didn't have the support structure.

Again, fair enough.

Then one day we got neonatal CPAP equipment.

Problem solved, right?

Not exactly.

The new policy was that we could put the baby on CPAP—but the respiratory therapist still had to remain at the bedside the entire time.

At which point my confused little respiratory therapist brain started asking questions.

For years, we were told we couldn't do CPAP.

Now we can do CPAP.

But we still can't leave the room.

So what exactly changed?

If we were not qualified to manage neonatal CPAP before, why are we qualified now?

And if we're qualified now, why does the RT still have to stand there continuously?

The whole thing feels like one of those workplace situations where a problem is solved and not solved at the same time.

It's a little like being told you're not trusted to drive a car, so the car is taken away. Ten years later you're handed the keys back, but you're informed that a supervisor must remain in the passenger seat at all times and you're not allowed to leave the driveway.

Technically, you have a car again.

Practically, nothing has changed.

To be fair, I'm sure there are policy reasons, liability reasons, accreditation reasons, and administrative reasons behind every one of these decisions. Somewhere there is probably a committee meeting and a three-inch binder explaining it all.

But from the bedside, where respiratory therapists actually take care of patients at three o'clock in the morning, it can feel a little absurd -- a lot absurd.

And healthcare is full of those moments.

The people writing the policies believe they're simplifying things.

The people following the policies are often left wondering if anyone noticed how complicated they just made them.