The saga of the 99-year-old man: part 1

I gave treatment before I went home Thursday morning to an obtunded 99 year old patient who was wheeled into the emergency room with a non-rebreather plastered to his face. I was informed by the nurse the patient was from a local nursing home and was having trouble breathing.

"We are definitely going to need a breathing treatment on him, Rick," Julie, the patient's nurse told me, "he already had a Duoneb in route." They gave this guy a treatment enroute? Why?

Exhausted after perhaps one of the worst nights on recorded memory, one where I did 12 breathing treatments in the emergency room (two of which were indicated) and 12 EKGs in one four hour span while having a nursing student at the same time, I had long lost my ability to just keep my mouth shut and do what I was told.

So I let the nurse know what I thought about giving a treatment to this guy: "Looks more to me like he's in renal failure or is septic or something like that," I said. "More than likely he's probably wet."

I did an EKG, assessed the patient, and decided the patient did have no signs of bronchospasm. More than anything, he looked like a strong 99-year-old who had had a fulfilling life and was now ready to cross through the pearly gates to meet his maker.

So, after doing the EKG, I went upstairs. "Screw that nurse and her breathing stupid treatment," I thought to myself as I exited through the double doors and out of the emergency room. "I have patients upstairs who actually need treatments."

You guessed it, I as much as made it to the patient floors and was called back to do the treatment. What the, "I wanted to say hell here, but somehow managed to refrain myself as the doctor was standing right next to me, "the heck does he need a breathing treatment for," I grumbled. Honestly, though, I didn't mean to sound grumpy, but the exhaustion and burnout had raped me of my ability to control my cadence.

"Well," the all knowing nurse said, "He's short of breath."

You see, this is what's wrong with the medical field. Instead of actually assessing the patient, and knowing the indications for bronchodilators (for which all my blog readers know I am sure), some nurses think every patient who's short-of-breath needs a breathing treatment, including those patients, like this 99-year-old, who are in respiratory failure secondary to a metabolic problem.

I just want you guys to know that most of the time I an equanimitous guy who does what he's told and keeps his mouth shut and feigns a smile and grumbles to himself instead of verbally releasing into the atmosphere his frustration about an unnecessarily ordered procedure. For the most part, I have a mission to be happy and get along with everyone.

The nurse, who more than likely knew full well how miserable of a night I had (because her night was equally miserable) did not say anything back to me like, "This treatment is too indicated you stupid useless RT who thinks he knows everything." Nope, she did not say that.

And I'm glad she didn't, because I just wanted to go home, refuel and collapse. And, after I finished doing that breathing treatment, the nurse was preparing to insert a syringe into the patients newly inserted IV. I smiled and said, "Well, you don't have to give that," Julie.

"Why would that be?" She looked up at me and smiled. She knew what was coming.

"Because my Allbetterol mist just cured him of all his ailments."

She proceeded to smile and pushed her med.

I didn't tell her this, but also tossed into this mixture some Reserectolin to ease this patients transfer across the pearly gates, and some Waytoolateolin to ease the suffering of the nurse.

For more information on Waytoolateolin or Toolateolin check out this link. If you want to know more about Resurectolin, check out my list of 'olins at the bottom of this blog, of which I will update right now.

Oh, and I forgot to inform you guys that this patient was also a full code. Perhaps that will help you to understand my RT frustration a bit more.

(Note: I will continue the saga of the 99-year-old full code tomorrow.)

Albuterol a cure for annoying respiratory ailments

As part of my usual two week schedule I end up with 6 days off in a row every other week, and right now I'm on day three. To be honest, I'm still not recuperated.

It's not just the burning feet and eyes, but ridiculous doctor orders. It takes 2 days to recouperate from tired feet burnout, and 5 days to recouperate from doctor order's burnout.

I don't have a problem with doctors, but I wish they would actually assess patients rather than looking at them, determining they have no clue what to do, and deciding to annoy respiratory therapy by ordering a breathing un-needed breathing treatments.

I'm telling you guys, if you check out my post, "Physicians creed: how to take care of pesky RTs", you'll see that this is all planned out.

Just before I was called to intubate a patient I honestly didn't think needed to be intubated, I finished doing a second breathing treatment in ER on a 1 YO boy of whom the doctor stated "has obvious signs of RSV."

Upon finishing the treatment, I charted, "Patient happy and playful, no signs of respiratory distress, has audible rhonchi and congestion and runny nose, no observable difference with this treatment."

I had to leave to do an EKG in another ER room, and then, when finished with that, I just happened to walk by the room where the RSV boy was stationed. I overheard the doctor, "He's looking much better. I'll come by in a half hour to see if we need another treatment, and about getting set up for home nebs."

Home nebs? Since when does this child need home nebs. He's full of junk. He needs suctioning if anything. Home nebs? Where the bleep do we get these doctors from?

I rolled my eyes to no one but myself, and waited for the doctor to leave the room. When she did, I proceeded to assess the patient again. He sounded just as junky as the first time I listened to him.

He grabbed at my stethoscope and tried to put it into his mouth. I pulled it from him, and handed him the little blue corrugated tubing from the nebulizer, because I had already discovered he loved to play with it. He smiled at me and placed one end of the tubing into his slobbery wet mouth.

While he was so entertained, I placed my palm on his chest, and I could feel no retractions. With the blue tube, he smacked me on the back of the hand, and smiled at me.

I went to the nurses station, chose a seat in front of one of the computers, and pulled open a charting screen. I did this while two nurses stood behind me, and I made sure they watched what I charted.

"Re-assessed patient at this time. RT notices no signs of respiratory distress. Patient very happy and playful. No breathing treatment indicated."

I was tired, and I wasn't going to dink around. If the doctor is going to order therapy that isn't indicated, the insurance company can read about it via my charting.

Home nebs for this kid! How ridiculous! Why couldn't the doctor have asked me what I think. I've been taking nebs for 25 years; I've been an RT for ten. If I don't know who needs home nebs, nobody does.

Then again, I am bias. And, of course, I'm lazy. I'm lazy because I want to get out of doing work. I'm lazy if I tell the doctor a treatment isn't indicated. I'm lazy because doing the treatment involves actually doing something.

I would love to tell that doctor to look on the Albuterol insert, where no where does it say that irritating lung sounds is an indication for this medicine. But that would involve actually doing research. That would involve going into the room and actually assessing the patient for real signs of bronchospasm.

Then again, another doctor ordered a breathing treatment on the floor. The patient told me she was not short-of-breath and, upon assessment, her lung sounds were clear with good air movement.

She said, "Well, I did tell the doctor I had a little cold."

After doing this treatment I charted: "Patient denies SOB, NARDN, no signs of bronchospasm, no indication for therapy, no difference with therapy."

Read that, Dr. Astro. Read that insurance company, and think about why you have to put out $80 for this procedure.

I would love to tell that doctor to look on the Albuterol insert, where no where does it say that clear lung sounds is an indication for this medicine.

Later I had a patient in ER who was very short-of-breath. I noticed this while doing an ordered EKG, assessed the patient, and thought a treatment might benefit the patient. However, the doctor told me the patient didn't need one.

Whatever! I left the ER and went to my cave, where...

...five minutes later the phone rang. Oh, come on!

"Yeah, respiratory," I grumbled into the receiver.

"We need another treatment down here," the ER desk clerk said.

Okay, fine. So the doctor came to his senses on the patient I thought should have a treatment.

In ER I observed that there was not one order but two, and neither was for the guy I wanted to give a treatment to. Upon assessing the patients I learned that one was coughing too much, and the other was not coughing enough, and the doctor wanted a sputum.

Ah, I just want to go home.

It's amazing a world where the same medicine that can be used to make someone cough can make someone not cough. And the same medicine that can get rid of rhonchi can make clear-er clear lung sounds. And, yet, a patient that's really having bronchospasm has to wait.

You'd be proud to know I was a good boy and kept my mouth shut, but I charted "No treatment indicated," on all of them. Is this legal. I really don't care.

No wonder the cost of medicine is so high. I wish that doctors would look at my charting, at least then we could have a good debate about it. And, of course, I'd lose. I'd lose because these doctors are following the "Doctors Creed: how to take care of pesky RTs."

Doctors are not on a mission to annoy RTs. They are taught in med school that Albuterol nebs are a cure all for all annoying respiratory ailments. Understanding this should help us RTs who study research that shows bronchodilators are for bronchospams and bronchospasm only.

In other words, doctors don't think in terms of "does this patient have bronchospasm or does this patient not have bronchospasm." Heck no. That technique is simply too hard and would involve a full assessment and doing reasearch.

They don't think this way becasue bronchospasm is covered under "annoying respiratory ailment." There may be exceptions to this rule, but not very many.

This is why it's better to just keep RT mouth shut, however hard that might be to do sometimes, expecially when I'm burned.

For more information check out the list of 'olins at the bottom of this blog page. Even while docotrs order Albuterol, they have these 'olins in mind.