Definitions to be added to our lexicons

BDCHF = BiPAP Deferred Congested Heart Failure. BiPAP will prevent fluid from entering the lungs. Indicated for patients with poor kidney function who require large fluid boluses (i.e. for low blood pressure). A bonus is the BiPAP might cause the anxiety needed to raise blood pressure. Note: Ignore silly RT rants about BiPAP decreasing venous return and possibly lowering blood pressure).

DCHF = Deferred Congested Heart Failure. The patient was wet when admitted, but the doctor won't figure it out until the patient has been treated with bronchodilators for three days.

Diagnosis: PACHF = Physician Induced Congested Heart Failure.

Float away:  Pulmicort/ Albuterol dilate airways so foam pneumonia just floats away.

Nosocomial COPD. A fake diagnoses in order to meet criteria for reimbursement.  Requires Q4 breathing treatments regardless that patient is breathing normal and has clear lung sounds. 

Nosocomial CHF.  a.  Fluid overloading patients who don't look quite right but need to be admitted.  b. loading patients with fluid during surgery and sending them up to the floor claiming they are fine.

Schnockered:  Drug induced sleep

Asthma or COPD: Which one do you have?

Many times in the course of my job as an RT, and now a few times on these pages, I am asked what the difference is between COPD and Asthma.

They do have many things in common, as they both are diseases of the direst suffering. They both cause stress, distress and anxiety for those suffering from it. Yet, they also both cause anxiety for family members of those suffering from these diseases.

Yet, as my fellow asthma experts and I explain in this this Q&A, while these diseases may be similar in that they both cause episodes of air trapping, the mechanisms involved with both diseases are unique. Likewise, the effects of these diseases on the patient is unique as well.

So, that in mind, I thought would provide some basic definitions here to help my readers understand the difference between Asthma and COPD.

Asthma: This is a disease of chronic inflammation of the air passages (bronchioles) of the lungs, and is associated with acute episodes bronchospasm leading to shortness-of breath that is reversible with time and/or medicine.

While their lungs are chronically inflamed, an asthmatic can go days, weeks, months, even years without symptoms.

Because of the chronically inf lammed airways, when an asthmatic is exposed to his asthma triggers, his lungs swell up even more, produce excess sputum, and become narrowed (bronchoconstriction). In other words, the airways are sensitive or "twitchy" to asthma triggers resulting in spasms of the air passages in the lungs (bronchospasm). This results in air becoming trapped inside his lungs, making him feel like a fish out of water during these episodes.

These acute episodes of bronchospasm can be treated with either time or medicines such as beta-adrenergic medicines like Ventolin and Xopenex. They can also be treated by controlling the inflammation with anti-inflammatory medicines like corticosteroids.

With new anti-inflammatory medicines like Advair and Singulair, this chronic inflammation can be controlled so that episodes of asthma are "prevented" and/ or easier to treat.

Asthmatics generally do not need to use oxygen, and it is rare that oxygen levels decrease except for in severe episodes. Therefore, oxygen is not needed outside of hospitals.

While we know what triggers asthma, and we do suspect it is a genetic disorder, what causes a person to develop asthma is unknown (although there are theories).

Chronic Obstructive Pulmonary Disease. According to HealthCentral.com, 80% of current COPD cases are caused by smoking, however they can be caused by inhaling other hazardous chemicals. There are three types of COPD: Emphysema , chronic bronchitis and in some cases Hardluck Asthma. COPD is not reversible, although if a person is removed from the exposure of hazardous chemicals (i.e. stops smoking), the disease may stop progressing.

Oh, and by the way, yes you can get COPD from second hand exposure to smoke. I have a few patients who have never smoked in their lives yet still have this disease.

And, yes, you can get COPD from second hand exposure to smoke.

Most COPD patients have some degree of dyspnea on a daily basis, which may be partially reversible with beta-adrenergic and corticosteroid therapy.

As the disease progresses, many will require oxygen usage at home.

Emphysema: Basically, this is where a person is exposed to hazardous chemicals (Alpha 1-antitrypsin deficiency) and therefore tissue in the lungs literally erodes away. According to HealthCentral.com:

• The walls of the alveoli become inflamed and damaged; over time they lose elasticity (the ability to stretch and shrink), and pockets of dead air (called bullae) form in the injured areas.
• These pockets are formed by damaged alveoli that merged, and have become irregular in shape.
• The pockets interfere with the normal working of the lungs, making breathing out more difficult.
• Inhalation (breathing in) is not impaired. Until the late stages of the disease, oxygen and carbon dioxide levels are normal.

The result here is, as the disease progresses, the person has less and less lung volume to work with. In many cases, these patients are thin smokers, are pink, and due to the loss of lung elasticity, their shoulders are always high and hunched. We RTs refer to them as pink puffers.

Chronic Bronchitis: This is a disease where a person is exposed to hazardous chemicals (mostly cigarette smoke, but not always) and this results in a loss of cilia that is normally in the airways and is used to bring up sputum. As the disease progresses, sputum becomes trapped in the patients lungs, making it difficult for these people to expectorate. They quite often develop a chronic cough (smokers cough). As a result, they become highly prone to lung infections such as pneumonia.

According to HealthCentral.com:

• Irritation of the bronchial tubes (from smoking, air pollution, etc.) causes mucus production. The mucus is cleared through coughing.
• Constant coughing causes damage to the bronchial tubes. The tubes swell and thicken, leaving less room for air flow.
• The reduced airflow into the lungs usually leads to lung damage that results in emphysema.

If I had a choice between these three diseases I'd much rather have Asthma because not only is reversible. While asthma attacks can be preventable with new asthma controller medicines, COPD is also preventable in most cases by simply staying away from hazardous chemicals, or by not smoking or not being in the presence of those who do smoke.

Usually asthma is caused in your youth, so most people who get it have adjusted to that lifestyle before they become an adult. However, adult onset asthma may be equally frustrating as COPD, because it requires a person to change his lifestyle, which may be extremely difficult.

Like asthma, COPD can be controlled if the person quits smoking, avoids living in places that irritates his breathing, is compliant with his medicine, and eats right.

Most mild and moderate asthmatics can live a normal life if their asthma is treated appropriately. If a patient who is diagnosed with COPD quits smoking in the initial stages of the disease, life expectancy can be normal. While it is not possible for the lungs to regenerate tissue, further damage can be spared.

However, if COPD is diagnosed in the later stages, or if a person refused to quit smoking, the disease may progress and result in a shortened lifespan.

So, there you have it. Now you know the difference between COPD an d Asthma. If you'd like to learn more check out MyAsthmaCentral.com or Stopsmoking/COPDConnection.com

I am no longer an RT, I am an Internal Therapist

I am no longer an RT, I am now an IT. I am in and of myself, and with a few other top notch RTs, a new type of respiratory therapist (to see the other six types of RTs click here).

We are an extension among the Learner (optomist) RTs, and we are always making an effort to go above and beyond the call of duty.

In short, I am IT. I am the one person nurses call in times of crisis, and they trust and rely on my expertise and clinical judgement to determine their course of action to the benefit of the patient.

I am a patient internal specialist. Sure I know respiratory therapy inside out, I also know the rest of the body and how it relates to breathing. The following are some recommendations I might suggest:

1. Anxiety: Xanax or Ativan
2. Wet lungs & poor urinary ins & outs: Lasix or Bumex
3. Dyspnea not controlled with Ventolin: Morphine
4. Perceived Bronchospasm: Ventolin or Xopenex
5. Stridor or Croupy cough: Racemic epinephrine and/ or systemic corticosteroid

Often times -- more often then not -- the nurse will heed the suggestion of the IT and call the physician with the recommendation. Often times -- more often than not -- the physician will heed the recommendation of the RN and the IT, who are working together as a team.

The RN and the IT together are a member of the Patient Internist Team (PIT). They work together as part of the PIT to the benefit of the patient. Regardless of their feelings for the patient, they do what is in the best interest of the patient, and that is using their skills and wisdom to the best of their ability, and heeding the wisdom of other members of the team, including IT.

So, by definition, what is an Internal Therapist:

Internal Therapist: A type of respiratory therapist who participates in critical thinking in an attempt to assist the nurse and physician in resolving the patient's crisis. They consider the concept of holism, the body as one unit working together, and therefore understand that the whole body effects the function of the lungs, instead of only thinking in terms of the lungs. The internal therapist does not diagnose, he or she deduces the best possible cause of the symptoms and the best possible solution.

You don't become IT overnight. It takes two years of RT education, an RRT degree and many years of RT experience. Plus, it takes a special individual. He has to have the ability to prioritize, to think outside the box, to do extensive critical thinking, and to use common sense.

Along with that, he has to have the special ingredient: he has to have the ability and the desire to never stop learning. He has to learn from reading respiratory and nursing books and magazines, he has to learn on the job.

Yet, at the same time, he remains humble. Because above it all, he knows that medicine is based on science, but at the same time it is an art. And while science is all based on perfection, every patient is far from perfect, and each should be treated as an individual -- as art.

So, I am still a licensed and registered respiratory therapist (RT), I am now a fully qualified IT. I am IT. I've been this way for a while, though. It didn't just happen over night. At what point does the transition occur? I have no idea. That, too, is an individual moment.

Are you an Internal Therapist too? Are you a member of the PIT?

Humility is the key to success as an RT

I would like to ad something to what I wrote yesterday. That along with all the great things about being an RT, the politics gets pulled right along. And the best way of dealing with politics is good old fashioned humility.

Sometime in life we have to do things we don't want to do. One of the biggest reasons for this is pure-D-politics. As much as we hate politics, we all get caught into it on a daily basis whether we want to or not.

Yesterday I wrote that I have learned that it is best to keep my mouth shut than to have the nurse telling me I'm a lazy RT who is just trying to get out of work. I'm not trying to get out of work, just being honest. That, my friends, is politics.

One of the things I have realized about the drug Albuterol, is that it basically has no side effects. It might make a person shaky, but that's a mild problem. It may make the occasional heart palpate, but that incidence is far and few between now that the "bronchodilator" has been so chemically refined.

And doctors know that. So, they decided long ago that it is better to give a bronchodilator than risk being seen as doing nothing. It is easier to just give the bronchodilator, than to assess the patient and waste your time thinking.

There are RTs that do this. There are RNs and doctors who are victims as well. When an RT does this, they are called treatment jockeys (more on this tomorrow). When doctors and RNs do this, they are just doing their jobs.

None of this would be possible, however, if not for the fact that this drug has been so refined. This refining has made the perfect medicine for bronchospasm.

But, with all good things must come the bad. The bad is that the refining has taken away our need to second guess whether a treatment is needed. "Oh, there are no side effects, so let's just give this treatment and see what happens."

And, if the RT complains, it's because he or she is lazy. So we RTs have learned to do our own PR and do not complain where others can hear us (well, most of us don't, or most of the time we don't). Then we just shut up and give the treatment.

You want to know why I really give the treatments even though I don't think they are
indicated?

Because in life nothing is certain, and nobody is perfect, and I could be wrong.

And, even though sometimes I am quite certain I am right, humility, keeping the peace, is often more important that being right.

Allow me to quote something Biblically. This is not from the Bible, but it comes from a religious pamphlet, so it's pretty close to the Bible: "Lowliness of mind, or humility, can help you suppress the urge to insist on being right in a disagreement."

So, I suppose, what it comes down to is humility. And, to put it simply, humility is the key to success as an RT, especially when it comes to maintaining a good rapport with the rest of the people we work with.

This brings us to RT Cave Rule #25:

RT Cave Rule #25: The key to maintaining a good rapport with the other people we work with is good old fashioned humility. It's okay to not let people know that you are right.

And now for RT Cave Rule #26:

RT Cave Rule #26: A good RT will admit when he is wrong.

Allow me to add to this post one quote I read in a good book that fits in well here. In fact, I'll just make this another RT Cave Rule:

RT Cave Rule #27: "When a person complains, he is saying more about himself than about the person he is complaining about." Therefore, the most respected people in life are those who do not complain.

Thus, it is just better to bite your lip and get yourself burned out doing frivolous therapies than to complain.

There are exceptions to this rule, however. If there weren't exceptions, there would never be change brought about, and we would not have protocols. There are those among us who have the ability to get their way. They are the smooth talkers.

So, if you are not a smooth talker, like I'm not, you're better off using your humility and just keeping the peace.

An RT co-worker of mine likes to refer to us RTs as keepers of the piece. He says that one of the main jobs of us RTs is public relations. We are the PR department.

Which isn't so bad I suppose.

That, my good friends, is the deep thought of the day.

RT Cave Lexicon

Dragons: These are the bosses or hospital administrators. If you want to learn more about these unique individuals click here, click here and then click here. These individuals all where suit coats, and will usually present with smile and, of course, they will want a hug or a hand shake. They love money. Everything is all about money. They want every i to be dotted and every t crossed so as to make as much money for the hospital as possible. They want to keep the worker bees just Happy enough so they want to keep working, they also want to make sure money keeps flowing in.

Queen Mother Bees: These are all the supervisors. They take the heat from the worker bees so the dragons don't have to deal with piddly little things; like things that don't involve money. One of their biggest responsibilities is doing the schedule, and they often get pounded by unhappy bees if the schedule is not to the respective bees liking. While they get paid just a smidge more than worker bees, they get paid way less than the dragons. Yet, while these are usually aspiring dragons, they do not complain. Now, it also must be noted that Queen Mother Bees are often in a money mindset just like dragons. For example, you are not allowed to have overtime, because the farther under budget she keeps the department, the bigger the dragon's bonus at the end of the year. This is probably the most stressful job in the hospital and the least respected, as while the worker bees come at her with their problems, the Queen is also getting constant "heat" from the dragons to keep the department under budget. This is actually a lose lose job. But someone has to do it.

Worker Bees: These are all the Peon RNs, RTs, environmental experts, computer whizzes, x-ray techs, lab staffers, and all the other individuals who swarm around the hospital making the place look good so the dragons can make their annual bonuses.

Anal RTs in the RT Cave

Usually after 9 p.m. I am by myself, and usually, it seems of late, that all the treatments are due right around 10:p.m. when I'm all alone. Since I'm alone, I usually start at 9:30 and chug along, and expect that by 10:30 I'll be done with all my treatments.

However, it usually doesn't work that way. Being in the field of RT, and having that dam beeper, you can never plan ahead as to when it might go off. And just as I start chugging away at my evening treatments is when ER calls. It's to the point now that I can almost bet on it.

Ideally, on nights when we have seven or more treatments due at 10:00, I think we should have 2 RTs working. However, this trend of being busy will end some day (hopefully soon as far as I'm concerned, however the RT bosses are happy by it), and I'll be so slow around 10 p.m. that I'll be looking for things to do.

So, this gets back then to the inability to plan ahead in this job. Unlike my application for overtime two posts ago, you cannot plan for overtime; you cannot plan when you are going to be busy. It can come at any time of the day or night. It can last up to one hour or three months. You never know.

Last Sunday, when I had that Cerebral Palsy patient come in and I had to spend the majority of my time with him that night, I pretty much didn't do any other treatments. I had to rely on the nurses to call me when a patient needed a treatment, and in a few cases they did the treatment for me. It was that kind of night.

Now, in my defense, by Sunday night, the night in question, I had already had the same patients all weekend, and knew who needed treatments and who didn't. So, when I got busy with this one patient, calling in help to do treatments that aren't indicated in the first place didn't seem to me like a good idea. So, instead of worrying about the un-indicated treatments, I focused on the patients who needed my services and was happy to care for them.

Actually, it got so bad at one point that I walked upstairs with a pack of Albuterol amps and handed them out to the nurses in case their patients called for a treatment, or actually got short of breath. As it turned out only one patient called for a treatment, and he was one of the patients who liked his treatments, but did not need them.

So mooring comes. The ventilator that was supposed to be cleaned during the night was still in shambles in the back room. Stock was dwindling in number as I did not do my job of stocking during the night. And not one of the four QID treatments were started.

Now, none of this would have been a concern of the RTs who work with me on my weekend, but since Monday the other weekend core of RTs work, the A-Team we call them (Anal), the little things matter. And, when I gave report, and it came to light the QIDs were not started, my relief said, "So, why didn't you call someone in to do the QIDs? Now they are all due and I have this vent to take care of."

Keep in mind here that she works solo until the 9-9 RT comes in. "Oh, I'm sorry," I said, being political, "It never even occurred to me. None of these people need treatments anyway, so I wouldn't worry about it."

"But these treatments need to get started," she said anxiously. "What am I supposed to do."

"Just take care of the vent. I'm telling you, none of these people need these treatments. They will be perfectly fine to wait until the Jake comes in at 9. Don't worry about them; trust me."

What I said went right over her head. These are the kind of RTs that have to have every treatment done at exactly the time the doctor ordered them. The Q4s have to be done exactly every four hours, and the Q6 treatments exactly every six hours. That's fine with me that's how they run their ship, but it makes for very little flexibility and high stress if ER calls or something else comes up. These people run around ragged and stressed all day.

Me, and the rest of the people who work on my weekend, are more laid back. We assess our patients so we know who needs them, and we give Q4 hour treatments a half hour leeway, and Q6 hour treatments an hour leeway. That is, unless they really need them. Then we don't dink around.

The Anal RTs are well aware that the treatment might not be indicated, but that doesn't matter: if the doctor ordered it Q4, then it must be done Q4. If the departmental policy says that QIDs have to be started by the noc shift, then that is how it must be. Anything else is grounds for anger and anxiety.

My point is, you can't plan ahead in this profession. You can't be so stuck on the idea of doing Mr. Robinson's treatment at exactly 10:10 because the person who worked before you did Mr. Robinson's last treatment at 6:10. It's only the Anal RTs who work this way, and they tend to be stressed to the max when things don't go as planned.

I suppose, though, that we all have our own way of working, and in the end, we all get the job done because we are all elite RTs. It's just that some of us are flexible and prepared for the interruptions, and don't let them bother us, and other RTs, the Anal RTs, have that anxious edge to them unless things go exactly as planned.

They are great people and fun to work with, and when you follow them you know that all treatments are going to be done, and all equipment stocked, and after hours they might be just as fun to hang out with as any other RT. But the anxious edge to them will be apparent, as they say things like:

"Man, you are going to be busy tonight," or "It was swamped today," "You better have brought your running shoes," or, "I think you better call in for help tonight."

I know, based on experience working with these guys, that I have to get a good report and organize my own worksheet and make my own judgement as to whether I can handle it by myself or not. Chances are, their anxious statements will be way overblown. Not always, but most of the time it is not as busy as they make it appear.

That, my fellow RTs, is the thought of the day.

A more detailed description of slippage

So long as we are on the topic of slippage (I wrote about it here), perhaps we should expound on this a bit. We are all expected to maintain a certain level of dignity. We are all supposed to maintain a certain level of modesty. We are all supposed to maintain a certain level of respect for our superiors, friends and co-workers.

Slippage: failure to maintain an expected level, fulfill a goal, meet a deadline, etc.; loss, decline, or delay; a falling off -- dictionary.com

When we are out in public, many of us try to maintain a certain level in our appearance. When we go to work, for example, we are expected to look our best, to smell our best, to wear our best smile and personality. We are supposed to be the utmost professionals when we are amongst our co-workers and, most important, our patients.

When things happen that we disagree with, when a doctor orders something we think is going to harm the patient, it is our job to bring this to light in a professional manner. When a doctor orders something stupid, it is expected that we will not complain. It is also expected that we will not complain when we disagree with an administrative decision. We, as expected, will be the utmost professionals and, to put it lightly, just do as we are told.

The gossipers will gossip. The unhappy people will complain. As I am doing my rounds through the hospital I hear these things going on, and I wouldn't necessarily call all of it slippage. There are certain people who are hotheads, and they tend to argue with every single person every single time something meets their disapproval. I would not call that slippage. I would call this disrespectful, perhaps.

When someone does something that is expected of them, it is not called slippage. When the hot head gets hot, it is not slippage because that is the standard that person has set for himself. Sure, he might not be very popular, but his being a jack ass is not slippage. When the complainers complain, when the gossipers gossip, that is not slippage either, unless it comes from an unexpected source.

Slippage, therefore, is when a person does something he that is completely out of character. Slippage might be what you would call it when a person who is normally quiet and reserved bursts out of his shell and tells you all the things he hates about his job; or a person who is respected in the community gets drunk and starts talking about how many women he has gone to be with.

Ah, to find a perfect example, one might simply look at the headlines in the newspaper. When Ted Turner ran his mouth the other day and said the world is going to be destroyed in ten years because the world is overpopulated, I would not call that slippage because we expect such nonsense from him.

Then again, when Mel Gibson rattled on about how he hates the Jews when he was drunk one night, that is slippage. We did not expect such filth from him. Sure, we might have suspected that he held such opinions, but he had made an effort to maintain a certain level of dignity, or respect prior to that one night, and had kept his mouth shut.

When you keep your mouth shut you greatly decrease your chances of slippage. When you do not drink or do drugs, you greatly diminish your opportunities for slippage. However, we all have our moments. I have had my moments. You have had your moments. We all remember our parents, or someone we loved, having their moments too. Our friends definitely have their moments too. That's life.

When our perfect example of equanimity, Dr. Cool head, got ticked off because he was working all weekend and was called every hour on a very stressful weekend at Shoreline Medical, and he blew up at the kind nurse who called him for the first time ever at 4:00 a.m., that would be a good example of slippage. It was totally out of character for him.

I can give you two of my own personal examples of slippage. For example #1, you can see my blog entry from yesterday. For example #2, I can tell you this normally reserved, humble, and greatly respected RT had just spent the greater part of the night with one young lady in respiratory distress and had just headed upstairs to take care of more short-of-breath patients, when he was paged to go back to the ER and set up a holter monitor.

Many times he had thought to himself how ridiculous it was for a doctor to order an outpatient procedure to be done in the emergency room, but, ou of respect, he grumbled to himself but not to the middle person who gave the order, and definitely not to the doctor and, most important, he was the utmost professional in front of the patient.

But not last night. Last night he provided a perfect example of slippage. Last night he stormed down the the emergency room and told the nurses and the doctor point blank that he would not be setting up "that stupid thing that shouldn't even be ordered in the emergency room."

"You mean you don't have a holter monitor," one nurse said.

"No. I have no clue if we have one or not. What I'm saying is I'm not setting one up right now period. I have a sick patient right down here that I've spend the majority of the night with, I have a Q1 hour treatment upstairs, I don't have time to spend a half hour setting up a holter."

"Well, can you just bring the holter down if you have one."

"Are you going to do it?"

"No. That's your job."

Ah, slippage. What alcohol did for Mr. Gibson's mouth being burned out did with mine. Slippage.

Later in the night, after I had reasoned with myself and had reluctantly dedicated a portion of my time to set up the holter (and was the utmost professional with the patient of course), I met these emergency room nurses up in the CCU when they transferred a patient up there.

"Hey, and thanks for your help," I said. "Oh, and sorry I was so grumpy last night."

"Oh, I didn't think you were grumpy," one of the RNs said, smiling.

"Oh yes I was," I said.

"Oh yes he was," said the second RN. "I've never seen him get upset before. He's always so calm and cool."

"It was a little slippage," I said.

We all participate in slippage from time to time. I would like anyone who has not participated in slippage to raise his or her hand. If you haven't' slipped before, that would mean you are perfect. And, as the old saying goes, perfection in itself is a flaw.

Which brings us back to that infamous RT Cave rule: We night shifters never hold what one of us does or says as a result of exhaustion or burnout against one another. Because we all slip from time to time.

So long as we don't slip too far.

A little tounge slippage due to pure exhaustion

I missed an RT Wisdom yesterday. This is my blog, and I have the right to skip a day of blogging if I choose. However it lays there in the back of my mind, that yearning to stop what I'm doing, to rush to the Internet (that awful addiction). Yet there are other responsibilities that preclude fun.

There is no boss here to make me blog every day. And, unfortunately, no profit loss either. I have a post written for yesterday, actually. I just didn't have the time to post it yesterday. It was one of those days. It was one of those nights. It was another night from hell. It was a night with a lot of slippage.

Today, instead of educating anyone on some deep RT Wisdom, I'm going to take a moment to write about slippage. It has something to do with the 2 a.m. syndrome that any of you night shift RTs and RN and DRs will be fully aware of, but you day shifters may well not be aware of.

And, there is this thing called amnesia too, which occurs when a night shifter goes to days for a long enough period of time. He, or she, forgets what it was like to work nights. It's called former night shift suppression syndrome. How's that for a cool name that popped up extemporaneously to my humble RT mind.

When you are so busy at work and your boss has to come in at 2:30 in the morning for two straight days to do all the useless breathing treatments so you can take care of the critical patients, you know your busy.

When you have one person doing the work of two, as this humble RT did Thursday through Sunday, it makes for arduously long nights. And, strangely enough, on the final two days of a long, long, long stretch, even though there were two of us through most of the night these past two nights, the journey was still arduously long -- go figure.

It's amazing how much more you can accomplish when you have fresh legs, body, and an invigorated mind and spirit, as opposed to fatigued legs, burning feet, and wearied spirit. With even fewer tasks at hand, the ability to get all of them done in a timely manner is severely hampered.

And, while this RT finally has a moment to rest and to eat his dinner at 2:30 in the morning of the final night, and his boss is sitting in the other room taking off her coat and hat and is organizing her paperwork, she says, "You know, I'm really tired."

"Ah," I think to my humble RT self, "I'm not going to go there. I'm not going to say one word, even though I wanted to say something like, "You're tired. I just worked the night shift six of the last seven days. You're tired?" At this point, I stifled the slippage.

Instead I smiled and said nothing, because I wanted to keep the peace. I'm cool that way.

However, later on I said, "Man, I think every one in this department is really burned out. I know I am, and I..." She interrupted me before I had a chance to blurt out the rest, which was going to be, "and I know you are too." I had not intended for what followed to occur. I did not intend the slippage.

She interrupted with a lecture, and when the RT is burned out it's one thing, but when the night shift RT is burned out, when this RT has every bone exhausted to the core to the point his body feels like mush -- a wet noodle walking, the fetters normally shackled to his voice box and
tongue loosen, and he simply says what's on his mind. I like to call this 2 a.m. syndrome, because I see it a lot on night shift.

But remember the old RT Cave Rule: Night shift people do not hold it against other night shift people. We know we are tired. We are a team, and therefore we do not get mad at one another. We don't hold grudges. We can't hold grudges.

Boss used to work nights, so perhaps she had a little of this rule left in her, or so I hoped. I prayed the former night shift suppression syndrome did not go to far into her bones, now that she not only advanced to days, but drifted further away when she drifted in the land of The Bosses, where the focus shifted to money. She has, as I describe in this link, become a dragon. And dragons, while they will never admit it, lose their ability to empathize with peon RTs and RNs that they once upon a time worked with. They, like all their fellow dragons, think like dragons.

That aside, what came next was a little slippage.

She said, "I don't buy that. You guys have no right to be burned out. You guys were so slow for so long that I think you simply forgot how it is when you have to work. You forgot how to work. Don't give me this that you guys are burned out. I came in and helped out last night and it felt great. I felt really good about myself. I think you guys forgot how to come in and enjoy yourselves when you have to actually work."

Okay, so here comes the slippage; the 2 a.m. syndrome at full force. It wasn't an angry statement. There was no ulterior motive here, it was simple slippage.

"Um," I thought for a second about not saying anything, but this was the moment I had been waiting for since the last time she brought this up (see this post). I had discussed this with my co-workers, and we all agree on one thing, which is...

"Boss," I said, "if it weren't for all the useless breathing treatments that we do around here, I wouldn't be burned out at all. If it weren't for all the useless breathing treatments on our board, I'd have been able to spend a few minutes with my ventilator patient tonight, or some more quality time with the truly sick people on this board. Instead, I'm running around taking care of people who don't need to be taken care of." There. Got that off my chest. It had been hanging on there for a few weeks.

Her response: "We need those treatments to make money for this department. If we don't make money, you would be out of a job. You guys sit around complaining about getting no work when it's slow, but when it gets busy you complain."

"I never get no work. You know how it is, nobody wants to work night. The lone RT shifter never gets to stay home, not even when it's slow. And I don't mind that really. I certainly don't complain when it's slow. I love it when it's slow. " I get to blog when it's slow.

Like I wrote earlier, she is an administrator, and administrators (dragons) think in terms of money. It's all about money. And which it should be. However, and I didn't say this, but the hospital does not get reimbursed for any of the treatments we do after the initial treatment. We are making no money at all on those treatments.

Despite thinking this, I said, "Look, Boss, I love working. I love my job. I love being an RT. And I love helping people. And I love it that you're here helping me out." Nothing like a little flattery to get you somewhere. "And when I'm waking someone up at 2 in the morning to give them a treatment they don't need, I certainly don't feel joy in that. If anything, I feel stupid." Wow. That was a good line.

"Well," she said. "I don't even want to go there. I don't even want to be having this discussion right now."

"Me neither, Boss, I hate it. I hate that I have to defend myself against the charge that I no longer feel proud of my job, or joy in my work. I feel proud every time I succeed at getting a blood gas, I feel joy every time I suction successfully. I love it when I get to use my brain and determine if someone needs a treatment, an EKG an ABG. I love to use my experiences and my education to benefit poeple. That makes me proud to be an RT. Doing a bunch un-indicated treatments so we make money makes me feel stupid."

"Well," she said, "I'm sorry you feel that way."

"Which is ironic," I forced a laugh so she didn't think I was being too much of a prick, "because I am fully aware the bottom line is money. I understand that completely. It's just that if you want me to feel ultimate joy in my job, or any sort of euphoria, you will talk to the doctors about letting us decide who gets treatments. Heck, if it's slow, I'm sure we'll find a way to add a few extra treatments to the board. And I wouldn't mind doing useless breathing treatments, so long as I decided that.

"It's not that it's hard to slap a neb into someones mouth and give them a treatment. It's that we are swamped right now, we have a lady on BiPap that I've been with for four hours tonight alone, and a vent patient I need to spend time with, and two patients getting Q1 hour treatments who have to have the nurse call me every time they need a treatment because I'm tied up doing frivolous things."

She didn't say anything. Perhaps she was shocked because I'm normally quiet and complain very little. I'm not complaining, though, just stating facts. I ended it there. I couldn't go on anymore if I wanted to. I was drained. I wanted to keep the peace. I had to keep the peace. I did keep the peace. However, the seeds were planted for a later discussion. We went out then and tackled the rest of the shift together as a team.

It was very enjoyable having a fellow RT with me on night shift. It was cool having someone get one ABG while I got the other. It really was. I suppose it's this kind of joy, the companionship of fellow RTs, or the longing for it, that has us night shift RTs ultimately going to days. There is nothing like a good old-fashioned RT teamwork. Nurses are great, but there is nothing like being among our own kind.

That, my fellow blogger friends, is the thought of the day, or thoughts of the day. What do you think? Perhaps I'll have to start a new RT Cave lexicon with all my new definitions.

The five different types of COPD patients

In RT school we are taught that there are three different types of COPD patients: emphysema, chronic bronchitis and asthma.

In the hospital we tend to leave asthma out of the COPD definition, and the general consensus is that if they smoke it's not asthma.

However, some doctors still diagnose smokers with asthma. I suppose that's their prerogative.

Personally, I am under the belief that if you are an adult with asthma, it is chronic asthma, and falls under the category of COPD.

Emphysema patients are referred to as pink puffers, because they tend to have smaller frames are are not cyanotic. Chronic bronchitis patients are referred to as blue bloaters, because they tend to have larger frames and are often cyanotic.

However you want to define COPD patients that's up to you. Based on my experience working with COPD patients over the years, I have come up with a list of the five different types:

Happy: About 80% of COPDers fit this category. These patients tend to be among the most pleasant of all patients, more so because they are professional patients with a chronic illness and have accepted it. They rarely ask, "Why me?" Happy COPDers generally are of two types: they are either talkative or phlegmatic.

Talkative: About 80% of Happy COPDers are talkative. Some of the best conversations I've ever had with a patient have been with a talkative COPDer. Before their "time is up" they want to share as much of their experiences and knowledge as possible.

When you give a treatment to one of these patients they might not let you leave. They will talk openly about their illness and family life. By the time the patient is discharged you will have a pretty good idea of what kind of a person he was, and what kind of a life he led, prior to getting sick. Usually they are very interesting and intelligent.

If you are talking with a COPD patient, and the patient starts describing an event that occurred in 1945, he is probably a talkative COPDer.

Phlegmatic: About 20% of Happy COPDers are phlegmatic. Whatever you want to do, they don't care. They talk little and have very pleasant and modest dispositions. The majority tend to be men.

If you walk into the room and find the patient has his feet up on the end table while watching TV, you know he is a phlegmatic

If you walk into the room and find the patient is moderately labored and still appears cool and calm, he is most probably a phlegmatic.

Melancholy: About 20% of COPDers fall into this category. They love to be waited on hand and foot. These patients have not accepted that they are sick, and have a tendency to be unpleasant
and very bossy.

When this patient wants a drink, she will say something blunt like, "Drink!" or, "Gimme a drink." Many might pretend they are incapable of lifting the glass so you have to do it for them. If you hear the words like please or thank you, you are probably not dealing with a melancholy COPDer.

Exaggerated: Would you believe it if I told you that a certain percentage of patients actually WANT to be in the hospital. The exact percentage is unknown, but it is estimated to be around 20%, and includes both Happy and Grumpy COPDers.

What happens here is that family members are tired and need a break, so the patient feigns his symptoms to get admitted.

If you need to give a series of Duoneb treatments in ER, but once the patient is on the floor she declines a treatment because she wants to sleep, then you should think exaggeration.

If she is lying in low fowlers and appears to be in no respiratory distress when you walk into the room, but as soon as you grab your stethoscope you hear an audible forced expiratory wheeze, you should think exaggeration.

If she is so bored the day after her admission that she is assisting her elderly room mate walk to the bathroom, then you should think exaggeration.

There are two different types of exaggeration of COPD. When emphysema and chronic bronchitis patients are faking it, the diagnosis is generally exaggeration of COPD. Faking asthma patients are referred to as exaggeration of asthma.

It is important that exaggeration of COPD not be confused with exaggeration of asthma. The differences may not be easily identified once the patient is in the hospital, but must be obtained through questioning, or it may simply be assumed.

Now, I know your science teacher told you not to assume, because when you assume you make an A-S-S out of U and ME. But in this rare instance, it is often necessary in order to make a proper diagnosis of the type of COPDer.

Exaggeration of COPD is when the patient is faking because their family members taking care of them are tired and need a break. So it may be assumed that 100% of exaggeration of COPD patients do not come from nursing homes or assisted living centers.

Exaggeration of Asthma is when the patient is faking because he is stressed and in need of a break from his family. He loves it that when he comes to the hospital he receives special attention and sympathy, and gets waited on hand and foot.

Now, while most of my opinion in establishing this data was obtained at one small town hospital, I believe my sample size and length of study (12 years) was large enough to obtain an accurate stereotype of all COPDers.

However, it must be noted that their is a +/- 6% margin of error on my percentages.

If you disagree with this assessment, or you have an observation of your own, please feel free to let this RT know.

See the 11 types of asthma patients

Respiratory Therapy School: What you need to know about complainers inside the RT Cave

I'm going to expound here on RT complainers, however, it's hard to talk about complainers without sounding like one myself. Likewise, it's hard to discern between constructive complaining and non-constructive complaining.
I've had to rewrite this a few times with that in mind.

Before you read the following, I want you to know that I really do like my job as a respiratory therapist. And, I think this is an excellent job for people to go into, especially if you want to take care and treat patients with respiratory illnesses.

It's a really great job. At times it can be challenging. At times your adrenaline will be rushing especially when you have a critical patient, and what you do or don't do could determine whether or not that person lives or moves on to meet his maker.

Many times you will be able to work with doctors determining what route to take in caring for a patient. And, of course, sometimes doctors might not want your help. Okay, so it's that way with any job.

I think the job of RT is a great job for anyone who wants a job and needs to start working right away. That's why I chose this field. You get to start working as soon as you start school. Then, as you become certified and registered, you get your pay raises.

This is an ideal job for people who want to use RT as a stepping stone to moving onto other medical related fields, such as PA or DR. To be honest, I think all doctors should be RTs first. This is an ideal job for former stay at home mom's, construction workers or others who want an easier life, and asthmatics who want to work in a clean environment.

Basically, this is a great job for anyone who wants to start a career later in life and wants a guaranteed return on his investment. This is a great job for anyone who wants a career you can take with you no matter where in the world you live.

When you start working you may meet the complainers. I was lucky and didn't meet them until my third student rotation. I later found out that they often go into hiding when RT students are around.

You know them, because they are abounding in every profession. Don't let them get you down. Because you know that your job is what you make it.

You also should know that if they really hated their jobs they could easily get another one. You might tell them that at some point, but then they'd complain about you too. The truth is, they don't want to change careers. They are content with what they are doing, they simply find release in complaining.

They do not want to change jobs for reasons I stated earlier, that this is probably their third chosen career, they are getting up in age and don't want the stress of changing careers again, or they have families and don't have the resources or time to go back to school. Those are the most common reasons.

Herewith, I am going to make an attempt at explaining the RT complainer to you, because they are different from complainers of other career paths. Your teachers in RT school will not tell you any of this, so I am.

I've read a few posts this past week about RTs complaining too much about their jobs. In the post I linked to above I stated that about 60% of RTs are complainers, and someone corrected me by stating that she thinks it's more like 80%. Either way, they are abounding.

One of the biggest complaints I hear is: "What's the point of increasing my RT knowledge when doctors don't let me use it?" This is what I will focus mostly on in this post. I will not delve into "the hospital admins make decisions regarding us without consulting us," or "you'd think at a hospital they'd at least have good health insurance." I won't go there.

We'll focus on RT knowledge. As I stated above, greatest complaint regarding RTs is the result of them being over educated for the job.

Of course, you know why you should always try to increase your knowledge, because if the opportunity presents itself you want to be prepared. If a doctor is looking for ideas about what to do for a patient, you can say, "Hey, I read somewhere that..." He will be impressed with you.

The biggest advantage to improving your education is that if the career opportunity presents itself, and you are prepared and ready for it, you can apply. Now I've never had such opportunity, but if it ever comes up I will be ready.

But what's the deal with this "what's the point of learning" complaining?

The bottom line here is this: Most of us RTs feel that we are overqualified for our jobs. We have 2-plus years of education plus whatever experience we've accumulated on the job plus knowledge we obtain through continued education, all of this making us specialists in the respiratory diseases and how to fix them.

And yet, in many hospitals, we are not allowed to use this knowledge because many doctors do not want to give away any of their autonomy.

I will give you a few examples from my own personal experience.

1. Non-constructive complaining:

I feel absolutely stupid going into a room of a post-op patient with no signs of respiratory distress and telling that person I have to give a breathing treatment. There is no reason for it, and it's frustrating.

Many RTs bicker about this. It's best to keep your mouth shut.

2. Non-constructive complaining:

When I have a ton of therapies, and 70% of them are not indicated, and I still have to do every one of the non-indicated treatments while making sure my treatments on my SOB patients are never late, while still taking care of ER and STAT therapies, this can be taxing on me. It can cause unnecessary burnout.

I describe this in a recent post, "R. By the time I got to work I was already burned out, and I took it out on my co-worker. Not a good idea.

We all have our opinions, and the chronic complainers will let us know about them on a regular basis. But when I complain, it's usually when I'm burned out.

3. Constructive complaining and non-constructive complaining combined:

What if we have one patient who is SOB, and I know I have the cure for his ailments right in my pocket, but I have to wait a half hour for the doctor to respond. I have to stand idly by while my patient suffers. As a fellow asthmatic, I can't stand this part of the job.

I think I am justified in not being happy about this.

I find myself grumbling and griping, "Why hasn't the doctor called back yet?"

My solution to this problem is what I call my "Act now and apologize later protocol." I have never been written up for doing this. Never. So that solves that complaint. However, isn't this something that should be complained about.

This example could possible by non-constructive, if I grumble and gripe too much.

4. Constructive complaint:

In "Grumpiness stays in the RT cave" I detail another complaint that's really not a bad thing to complain about. I write about a nurse who called for a treatment on a patient when the treatment really wasn't indicated.

While most times I keep my mouth shut and just do the treatment, sometimes I like to take the time to educate the nurses. While most times they want to learn, sometimes they take it as a complaint. And, if I'm burned out, I probably come across as I'm complaining. So, I've learned it's best just to keep my mouth shut even in these situation.

5. Non-constructive complaint:

Using the above example, we know that educating is not complaining. However, when you have to do this on a daily basis, particularly over and over to the same nurse, it can become frustrating and can lead to non-constructive complaining. Most nurses, however, want to learn and will listen.

If the nurse is really busy, she might not want to hear it. This can get frustrating in itself. More than likely in this case, she just want you to make sure you take care of the patient, regardless of whether the treatment is needed or not. And, many times, RNs and doctors determine that giving a treatment is better than doing nothing, even when it's not needed.

In cases like this, I've learned to keep my mouth shut as, I'd presume, most RTs have.

6. Non-constructive complaining:

I will use all the above examples here. While RT complainers excel at this, all other RTs will complain about just about anything from time to time. It can't be helped and it's a fact of life. (If a content does this, you know you're in trouble.)

7. Constructive complaining:

I always tell my friends that I'm not complaining, I'm simply stating a fact. And, when I show people my list of 'olins (listed at bottom of blog), or I tell them some of my RT humor (plastered all over my blog), I think this is the best way to complain. Just by thinking of all this stuff we have to be learning something. So long as we don't go overboard, I think this is the best way to let off steam.

Well, at least I think so.

I can probably think of more types of complaining, but my mind is strapped at this time.

Overall, the greatest complain is regarding non-indicated breathing treatments. If you are a true professional, you would understand explaining them away like this:

When doctors and nurses call me for therapies I feel are not indicated, I like to think they simply want an RT to be assessing the patient QID or Q4 just to be on the safe side. That's not such a bad thing, is it? (It is if it leads to burnout.)

If you're still not content with non-indicated therapies, I suppose Taylor on Kid Nation says it best: "Deal with it."

The best way of dealing with the grumbling and griping is to continue to work toward impressing doctors and nurses by generating respect with them by always staying on the cutting edge of knowledge.

Likewise, if we do not have protocols already, we must study the protocols of other hospitals, continue the education process (as we do on these blogs), and work, slowly and patiently if needed, to get them implemented. Will this get rid of all non-indicated therapies, probably not.

By continuously working to better ourselves, we strain away our desire to complain. Most important, we know that by our complaining we only cause other professionals (Drs, nurses) to stray further away from us. They hate complainers. This is the best way to not make progress, as you can read about at Snotjockey's Revisited.

And you will be reminded many times that "the grass is not always greener on the other side of the fence."

You will find complainers everywhere you work. I was a journalist once, and they were there; 80% of them. I was a hotel desk clerk once, and they were there; 80% of them. I worked in the fast food business once, and they were there; 80% of them. It never ends.

Still, if you've set foot in any RT Cave, you know that RT complainers are not interested in making the RT Cave a better place, because deep down they are simply content to keep things the way they are. For reasons I listed above, they know they will be trapped in the RT Cave for the rest of their working lives.

To make themselves feel better, they gripe and groan. The rest of us are forced to take the brunt of it.

However, if you can stand to listen to a complainer, they are very intelligent people. As you know, they complain mostly because they are overqualified for the job. I really think that's true. I've obtained tons of material for this site by listening to complainers. They are up on their knowledge.

It's just too bad they don't use all that energy and focus it in on progress.

Here's a thought before I end for the day: "If it weren't for complainers, nothing would ever get accomplished in this world." I'm sure you've heard the old saying, "The squeaky wheel always gets the grease."

The six different types of respiratory therapists

There is much resistance to change inside the RT Cave. After much thought on the matter, I have figured out why. It has everything to do with the six different types of Respiratory Therapists (RTs).

Many RT Caves do not have protocols. I've heard every complaint

Very, very slowly I think doctors are becoming more and more receptive to the benefits of adding respiratory therapy patient driven protocols. In real time seems tortuously slow, but I think in ten or twenty years we might be talking about some major changes in the rolls of RTs.

While this is true, there are still many RTs themselves who don't seem to be receptive to change. This became ever more so apparent to me after reading an excellent column over at Snotjockeys Revisited, "Clinician Resistance to Adopting New Practices".

I agree with her, and have my own experience to add to the mix.

A fellow RT, Dale, is very fun to work with. He's intelligent, a great RT; but he is a constant complainer. He complains in a fun way, but nevertheless he is still a complainer.

"I circled all the indicated treatments on the board," he said the other day in report.

"Um," I said, looking over the list of patients, "there are none circled."

"That's my point," he said, and chuckled.

One day he handed me a list. I looked at it thinking it was serious at first, then I started to laugh. On it was a list of 'olins that he made up. (You can view parts that list at the bottom of this blog)

He said, "I bet that 60% of what we do here is absolutely not indicated."

I'm a firm believer that if you're not having fun with your job what's the point. So we make fun of our job. We make fun of doctors, we make fun of nurses, we joke around during a code. I think that's medical humor, and we do it to maintain our sanity.

I check doctor blogs and nurses blogs, and I see their humor all the time.

But humor is one thing, complaining is another. And complaining with Dale is fun, but most complaining in the RT Cave is simply annoying. I avoid it every chance I get. If I have no choice but to give report to a complainer, I give a quick report and scram.

I used to work with Dale a lot. In fact, I'm glad I had that opportunity to work with him because I learned much and he helped me develop my RT humor. However, I was never going to get anywhere via complaining. Complainers rarely get anything accomplished. But they are abounding in the department.

What's that old saying? "Complainers say more about themselves than the person they're complaining about."

I realized this, and I switched weekends. Now all the complainers work with Dale on the other weekend. The RTs who work on my shift are Jane Sage, a very optimistic, intelligent and fun to work with person. And we have Dee, who happens to be a complacent RT (see list below).

Jane had an epiphany one day, and decided the laid back RTs on our weekend are awesome, and she started referring to us at the "A" team. We called the RTs on the other weekend the "B" team. Once the "B" team got wind of this they decided that they were the New "A" team.

"That's fine," Jane said, "We won't tell them that "A" now stands for Anal and "B" now stands for Better than Anal."

Despite the complainers, we have enough "balance" of different personalities to make things work in our department. You need the complainers so we know of our faults, we need the anal people to make sure we get all our work done, we need the content people to boss around, the laid-back people to ease tensions, and the clowns to make us laugh.

I'd even go as far to say we have a great department. I suppose that means we have good balance. I'm sure the members of this RT Cave are no different than any other.

With this in mind, I created the following list. Based on my experience working with many RTs in the past 10 years, these are the six different types of RTs:

1. The stepping stones: These are the RTs who use the career of RT as a stepping stone to a more illustrious medical profession. In my humble opinion, this is the way to go. What better way to learn about medicine than through the eyes of an RT. I'm serious here.


2. The quitters: These are the RTs who don't like to work. Some "Quitters" take a job of RT because they think it will be an easy job and they won't have to do anything. As soon as they learn what RTs really do, they either quit or are forced out the door.


3. The contents: They are the happy-go-lucky RTs who never complain. They are the RTs you love to give report to because they are always happy. They rarely make any effort at learning new information other than what is required. They usually prefer not to work with critical patients, and when they do they never question doctors and they prefer to be button pushers. Usually, you will see these RTs happily knocking off treatments on the floors.


4. The complainers: This composes probably about 60% of all RTs. These are usually very intelligent people who love the career of respiratory therapy in theory, but hate the reality of it. They are usually well up on all the new technologies, and are very quick to question doctors or offer suggestions. However, while they are not happy, they do nothing to better their career field. After working for a while, they become frustrated and content and they give up. One of the reasons they are so frustrated is that they have decided that they are too old to get another job, or have families which makes changing jobs difficult. Yet, while they complain, they do not support change.


5. The optimists (or learners): These are the RTs who write blogs. They may or may not be more intelligent than complainers, but they love to learn. These are the RTs that consistently do research on the Internet and read magazines. These are the RTs that attend every seminar possible. These are the RTs who write the protocols and make recommendations for new equipment, and then write the policy and procedures for this new equipment. These are the RTs who learn about things like Graphics and educate the rest on how to use them. These are the RTs who make the best of their career even though they know there are a lot of forces working against them. Most important, these are the RTs every one in the department loves to talk to because they are good listeners (they listen because they love to learn). More often than not, they work with the leaders to solve these problems as they occur. They often let other RTs take credit for the work they do. They do this to keep morale in the department high. In essence, the optimists are the strings that keep the department together. A department without optimists does not run very well.


6. The leaders: These RTs, while far and few, take charge and lead. They make changes to the RT Cave and they are resented for it. They make sure everything is stocked. They make sure all the i's are dotted and the t's crossed. They are usually opposed to protocols because they don't want to "rock the boat", but they won't say so openly. They listen to the rants of other RTs, but they usually side with the administration on issues. They question RTs who question the status quo. You might hear them at an RT meeting saying something like, "Don't you think protocols might actually create more work for you guys." When they say things like this, they are catering to the complainers, who will work with them to stymie any change. The leaders do no like change because it goes against their philosophy of "do not rock the boat." It is also important to note that while most leaders are good people with normal home lives, they are often hated and revered at work. Complainers often do not get along with them, and optimists are often seen working with them "for the better of the department."

I can give examples galore, but I'll give just one more.

Even though she had several protocols shot down years earlier, Jane wrote a new and updated ventilator set-up and weaning protocol. The complainers in our department all said it would never be approved by the doctors.

Jane trudged on nonetheless. She had the support of me, another optimist, and Dee, the easy going content on our weekend. Finally, with a bit of luck, the protocol was approved.

With our confidence on high after, Jane and I wrote a breathing treatment protocol we thought might work. We were very proud of our efforts. We thought we'd show it to our co-workers and get their support.

I showed it to Dale first. Surely he'd approve of it since he was the most outspoken RT about useless and not-indicated breathing treatments.

I couldn't have been more wrong.

"So what do you think?" I said after he stared at it for several long minutes, grunting and sighing often.

"Well," he paused while staring off, then spoke slowly, "The biggest offenders will still abuse the system. If it does anything it will just create more work."

"Okay," I said. I made no effort to change his mind. I walked away. No point in beating a dead horse.

Jane brought up the protocol at a department meeting. Gary, the department head and quintessential RT leader, said: "It is possible you might just be creating more work for yourselves by doing this."

He may be right; he may be wrong. Either way, Jane and I keep moving forward. And that's easier to do now that we know about the six different types of RTs.