Breathing Treatments: The ideal way verses the real way

When I have a respiratory student I can't help but think of the two different worlds we live in side by side, at the same time, and these are the ideal world and the real world.  We as therapists try to live as though we are in the ideal world, although ultimately find shortcuts, we need shortcuts, to help us adjust to real life situations, and so we end up working in the real world.

For the purposes of discussion, allow me, once again, to define the two worlds we live in.

The ideal world:  The ideal world is the one concocted in a lab, it's the fake, world. It's euphoria. It's the place where everything is supposed to work as designed. It's where everything is perfect. In this world you walk into the room, identify the patient, and then leave the room to go to the pyxis to get the medicine. Then you go get the computer, log in, find the patient in the computer, click on the patient, and log into the emar. Then you grab the scanner and scan the patient. Then you scan the medicine. Then you assess the patient, and chart your assessment. Only now do you open up the medicine and start the treatment.  Then you ignore the patient (because in the ideal world the patient doesn't need you) and you chart. Then you look at the patient, maybe talk to him or her while you wait for the treatment to be done. And of course all this time no one else needs you, because in the ideal world you can pay 100% of your attention to just one patient at a time. Then the treatment is done.  You stop the treatment. You take the nebulizer to the bathroom where you take it apart and rinse it out in sterile water. Then you assess the patient again. Then you do your post treatment charting. Only now do you leave the room and move on to your next procedure. In the ideal world everything goes according to plan, and every solution is manufactured, as if in a factory.

The real world:  This is how things really work.  This is reality.  This is where things do not work as planned, because in the real world you never know what to expect.  In the real world there are outside forces placing pressure on you to take shortcuts so you can get done with this faster so you can move on to another task.  In the real world the patient wants to talk to you, or the patient may need you for some other reason, like walking to the bathroom or setting up a tray.  In the real world the patient matters.  In the real world you might need to talk to a nurse during the treatment.  In the real world all sorts of stuff happens that you cannot plan for in a factory, things that might pull you away from the patient and the computer.  It is the real world all the solutions manufactured in a factory (or in the case of medicine, in leather chairs in Washington D.C.) do not work.  In the real world you walk into the room, identify the patient , and start the treatment. Then you assess the patient. Then you log into the computer and scan the patient and the medicine. Then you chart the pre and post assessment and log out of the computer real fast.  Then you sit and pay attention to the needs of the patient.  You might have a discussion about how much the healthhcare profession is messed up.  Then you do you post treatment assessment and then stop the treatment, coil it up in a bag and set it on the windowsill.  Then you move on to your next procedure.  You jot down a few notes, maybe, and later (when you have time, if you get time) you log back into the computer and chart your post treatment assessment.  This shortcut, real world, way of doing a treatment is the only way that works in the real world, otherwise you would be so far behind you'd never get all your word done.

Of course, if they ask, you did it the ideal way.  You are, in this way, a trained politician; a trained liar.

You see, this is a perfect example of how everything in this world, including medicine, is politicized.  It's not based on science, it's based on politics. You have these people sitting in leather chairs, the so called experts, who think they can fix all the problems of healthcare with their pens and their papers, and then what they do is they create this ideal, fiction, euphoric world where everything fails to work as planned and chaos ensues. Their attempt is to increase safety and reduce costs, and what ends up happening is they make things less safe and more costly. This, my friends, is socialism at its best.  What we have in 2015 is a healthcare system based on socialism.  That is why it is failing. That is why nurses and doctors are so frustrated with it.

So, anyway, that is the difference between the ideal world of doling out breathing treatments and the real world way of doing it.  Surely, you want to do it the ideal way.  But in the real world, nothing ever works out as planned.  In the real world you play it by ear and use common sense, because nothing else works. If you sit and try to be ideal, you will fail to be a good respiratory therapist.  The trick is to find a way of being real and safe at the same time.  It is hard, and it takes effort.  And it can be done.  It would probably drive prices down too.  In fact, I know it would.  Because the only thing that has never been tried in healthcare is capitalism.

Further reading:

• Articulating Ideas: Idealism versus Realism
• RT Cave: Real World Versus Student World

Understanding stupid doctor orders, or SEE I TOLD YOU SO

Going all the way back to the ancient world doctors have written orders based on the following question: "Does it sound like a good idea?"

Unfortunately, even in the modern era where science rules the day, most medical theories are still based on this question.

It was based on asking this question that all pulmonary diseases have been treated as asthma since the beginning of civilization.  This was how the gods were thought to cause, prevent and cure all diseases in the primitive world: it sounds good.  This was how the hypoxic drive theory was postulated and became the golden rule of COPD, even though it was based on one fallacious study.  Despite it being disproved over a hundred times over the years, physicians still believe it to be true "because it sounds good."

Yet modern thinkers have challenged many of the old medical dogma's that have plagued the medical profession, and we can begin right here in the respiratory therapy profession.  I myself, for example, with the support of many of my peers, challenged the medical profession long ago on this blog by stating that albuterol does not enhance sputum production.  

We came to this conclusion by asking a better question: "Does it make sense?" Does it makes sense that oxygen knocks out the drive to breathe in COPD patients?  No, it does not.  Why? Because we oxygenate COPD patients all the time and they never stop breathing.  So we came to the conclusion that if they stop breathing, it's because they were going to anyway.  It is a proven fact that people need oxygen or they will die.  If they stop breathing, we use provide positive pressure breaths to improve ventilation.  

Does albuterol cure pneumonia? Does it sound like a good idea? Yes.  Does it make sense? No, it does not. Albuterol particles are the perfect size to attach to Beta 2 receptors in airways, but too large to even make it to the terminal air passages and alveoli, where the pneumonia is present.  Plus their are no beta receptors in the terminal airways anyway, so the albuterol wouldn't do any good anyway. Plus, albuterol is a bronchidilator, and pneumonia is inflammation.  

So a doctor challenged me on this as a result of my article "A World of Bronchodilator Lies."  He said the fact that some studies show that albuterol does increase sputum production is evidence that I am wrong.  I stuck to my guns on the basis that his theory sounded good but made no sense.

But now I have been vindicated.  Now I get to say "See, I told you so."  The new AARC Clinical Practice Guidelines, as reported By RT Magazine, now state the following:

There is no high-level evidence related to the use of bronchodilators, mucolytics, mucokinetics, and novel therapy to promote airway clearance in the studied populations. 

So, does albuterol enhance sputum clearance?  Well, does it sound good? Yes, so doctors will order it. Does it make sense? No, so respiratory therapists will doubt it does any good.

Further reading:

• A world of bronchodilator lies
• RT Magazine: New CPG Questions Value of Aerosols for Airway Clearance
• Respiratory Care: AARC Clinical Practice Guideline: Effectiveness of Pharmacologic Airway Clearance Therapies in Hospitalized Patients

Stroking egos: The only way to succeed

Whether we admit it or not, we all have egos.  The most popular people around us, and the most successful, are those who excel at stroking egos.  

Look at just about any Chief Executive Officer, and the president is a perfect example here, and you will see someone who excels at stroking egos. They stroked egos all the way to the top.  

Les Giblon, in his book "How to Have Confidence and Power in Dealing with People," said that the central person in everyone is "YOU!"  When you feel good about yourself, it's because you have an ego.  You love it when someone makes you feel better.  Those who make you feel better are the people you want to hang around with.  You love it when someone strokes your ego. 

In other words, all people have an innate desire for acceptance.  The people who make us feel accepted are the people we want to be associated with. 

He said this works because the most important person in your life is YOU. And YOU have an ego whether you want to admit it or not. And YOU love it when someone strokes your ego. In other words, all we humans have an innate desire for acceptance.

So the best way to succeed in life is to become good at building up the egos -- stroking egos -- of those around you.  Nearly all great salespeople are those who excel at stroking egos.  

Some sales people may excel at speaking, although others do not.  So it is not the gift of speaking that determines success, it's what the salesperson says and does. Those who succeed say and do things that make other people feel good about themselves.  

Giblon said that if you want to succeed, you must understand some basic facts about people.  

1.  All people are all egoists

2.  All people are are more interested in themselves than anything else

3.  All people want to feel important and to 'amount to something'

4.  All people crave approval from others so they can approve of themselves

So whether you are loquacious, taciturn, or somewhere in between, you have the skills necessary to life egos and succeed, according to Giblon.  

Giblon provides us with an example.  

Say you walk into a hotel on the eveing of the 4th of July and you are in a hurry. You have just enough time to check into your room and get to the fireworks.  Yet the desk clerk says the hotel is full.

Now, easily you could become irritated here and start yelling obscenities at the clerk, but the expert ego stroking will have another technique.  He would say something like, "I know your hotel is full, but I bet if there is anyone in the world who can find me a room tonight it is you."

Some people succeed based on technical skills.  Some people succeed simply because of intelligence.  Yet even people with limited technical and intellectual skills make it to the top, and the reason is because they "have a way" with people.

He said:

There are millions of people today who are self-conscious, shy, timid, ill at ease in social situations, who feel inferior and never realize that their real problem is a human relations problem. It never seems to get across to them that their failure as a personality is really a failure in learning to deal successfully with other poeple."

Of course there are people on the other end of the spectrum too, those who are talkative, confident and "bossy."  No one wants to be around these people because they make people feel bad about themselves.  They do not boost egos other than their own.

Regardless of how hard they try, they cannot get people to listen to them, appreciate them, and cooperate with them.  In fact, these people usually have to force people to comply with their wishes.

Yet while they can force people to comply with their wishes, they cannot force people to like them.  They never really get what they want because they have never mastered the art of dealing with other people.

He said that when people have to force compliance it's because they have no confidence in their ability to deal with people.  Lack of confidence therefore results in a low self esteem, and a "low self esteem results in friction and trouble."

Thus, the best way of dealing with trouble makers is to help them like themselves better. They need to have their egos stroked, or they need to be fed ego.  So when you become the person to stroke their egos, you in turn become the person they like to be around.  They will treat you better than they treat anyone else.  

Give that person a reason to like you. Give him a personal reason to give you what you want. 

Bottom line:  Regardless of your personality, the way to succeed is to stroke egos. The way to stroke egos is to make other people feel better about themselves.  So get started!  Go stroke some egos today!

Fifth period of respiratory therapy: How will it end?

So at the present time our profession finds itself amid the fifth period of respiratory therapy, whereby many wonder if cost cutting measures will result in our profession being cut.  While we used to be a pay for service department, we are now mainly just a service department.  And while our services are essential to ideal patient care, there are those who believe our services have out lived their usefulness.

In many regards they are right.  For many years now our profession has sort of milked the system, as many of us find ourselves doing procedures that we know are pointless, but we don't say anything because we are being paid.

Hospital administrators don't say anything either, because they know, even though most of what we do is a waste of time, that many of the things we do are absolutely essential to good patient care. I mean, who gets called first when a patient is in respiratory distress?  It's the respiratory therapist.  In many cases, the therapist is called even before the doctor.

And even if the therapist isn't called first, the physician insists on the therapist being present. Ever watch one of those old movies when the doctor is doing all the work during a code in the ER and says, "Where the hell is respiratory?" While that's an inaccurate description of accuracy, it sort of portrays how the medical profession views our profession: they think we're a bunch of useless dummies, but in cases of emergency we are the first one called."  The point being: our services are needed, but they won't admit it.

The truth of the matter is, no one knows respiratory like the respiratory therapist.  I even had a hospitalist come up to me recently and admit this.  He said, "You respiratory therapists are our pulmonologists.  When we have a respiratory patient we call you and we heed your advice."

The fifth period of respiratory therapy exists in a time where the government is getting more and more involved in healthcare.  What this means is that many decisions regarding patient care have been removed from the physician, removed from hospital administrators, and given to government officials who sit in comfy leather chairs hundreds, if not thousands, of miles away from the patients they intend to help.

These government officials consider themselves the experts.  They know what's best for every patient in the United States even though the majority have no healthcare experience whatsoever.  This is where your protocols and order sets come from.  They say they are an attempt to improve patient care. But we know the true reason for them is an attempt to cut reimbursement costs to hospitals.

They say they are not being forced on hospitals.  But the truth is, if hospitals don't adapt them reimbursements will be cut.  So, in this way, hospitals are forced to adapt them whether they want to or not.  In the end, while the government saves money, hospitals have to eat the cost of implementing and enforcing these protocols and order sets that no one wants and that don't work.

In the midst of all this, sits the respiratory therapist in the RT Cave.  He grumbles and gripes under his breath when asked to do yet another breathing treatment on a patient who is not short of breath and probably doesn't need it.  Yet he keep his mouth shut for fear of alienating the very folks he relies upon.

Yet the time appears to have arisen whereby the word has gotten out, and certain members of Congress have established bills that would deregulate respiratory therapists in order to save costs. In other words, the process has begun whereby the powers that be will be looking at everything we do, and deciding if we are really needed.  There has even been talk of educating certain nurses to do what we do.  "After all," one nurse said to me, "All you guys do is turn knobs anyway, as most vents just work themselves."

You think that's true?  Most therapists know that we are more than just button pushers and neb jockeys: we are an essential part of the patient care team.  While most physicians, nurses, and hospital administrators understand this too, their hands might be forced to pull the rug out from under us for no other reason than to cut costs.

Will our profession survive?  Surely we will.  Yet the scope of our practice might result in us picking up duties we don't want to do, such as wiping butts and cleaning up puke.  Yet, if we play our cards right, it might evolve the other way too, where the scope of our practice allows us to remain an integral part of the patient care team.

Reason for being educator

One of the main reasons she took on a job as RT educator is not necessarily because she wanted the job per se, but because she didn't want anyone else to have the job.

She didn't want someone doing her annual check offs on all the equipment who knew less than she did.

She didn't want someone who was a complainer or someone who was a slacker teaching her.

She wanted to make sure whomever was doing the teaching was an expert in the area she was
teaching.

The only person she could trust with that job was herself. So, in that regard, she forced herself into being the educator.

And considering she and I were the ones in our department who dis all the research, she and I stay up on things.

Sure we found that quite often the other RTs know more than we do in a particular area, or regarding a particular piece of equipment, at which time we humbly listen and learn.

If all of our administrators had this skill, perhaps morale would be higher.

Now she is retired, and I have the job for the same reasons.

The dilemma of bronchodilator reform

For many doctors, treating all patients that are short of breath as though they have asthma and ordering breathing treatments is a culture and a dogma, just like conservatism and liberalism are.

Individual bronchodilator ordering doctors may think they've reached their conclusions through careful deliberation -- and no doubt many have -- but there is no escaping the undertow of history and culture. Ideas and ideology are transmitted in more ways than we can count, and ignorance about where our ideas come from doesn't mean they don't come from somewhere.

Now, of course, this doesn't mean that the past has an iron grip on the present. For example, I am a strong supporter of states' rights, but that doesn't mean I would have agreed with the Jim Crow rulings of old. Sure states' rights were used to justify this racist ruling, yet it's not something I would have supported.

The bronchodilators-treat-all-lung-ailments-and-all-annoying-lung-noise doctors are confident they've always been on the right side of history, just like George Clooney was confident he was on the right side of history when he said, "Yes, I'm a liberal, and I'm sick of it being a bad word. I don't know at what time in history liberals have stood on the wrong side of social issues."

Well, no human being believes in his own mind he's on the wrong side. That's one of the interesting things about life, is that we all think we are right. It's also the most challenging, because we know we aren't all right.

These doctors -- perhaps among the best in the business -- believe they are doing the right thing. They believe research and history supports their dogma. This is one of the main reasons I write about bronchodilator reform on my blog: to puncture the smug self-confidence that simply by virtue of being a bronchodilator loving doctor one is also virtuous, and in the right.

That simply ordering a breathing treatment so the family thinks you're doing something, you're in the right. That simply by covering your bases by ordering an $80 a pop treatment every four hours you're in the right.

Today's doctors aren't the authors of past generations' mistakes any more than George Bush is for the callousness of some conservatives who champion states' rights for the wrong reasons well before he was born.

No, the problems with these doctors (few they may be) today reside in the fallacies that were born with the advent of respiratory therapy. A perfect example is the hypoxic drive theory, which was born because a few RTs wanted to create work for themselves. Another example is breathing treatments today, where at a small hospital we need procedures to continue working, so we enable doctors to order frivolous, un-indicated breathing treatments.

Then there are those amongst us who champion for protocols, and many of us have protocols. Yet due to some of us being lazy, some doctors may be hesitant to give away a large chunk of responsibility and autonomy to the RT.

Yes, we RTs brought some of this unto ourselves.

The relevance to the past is that unlike the conservative who has wrestled with history to make sure he does not repeat it, bronchodilator doctors see no need to change their opinions of medicine. What they were taught in medical school is and will always be true until someone forces them to change.

Like we RTs here at Shoreline did when we put the mist tents in the basement and told the pediatricians we weren't allowed to use them anymore. Or until the pediatricians at the children's hospital we send our bad neonates to told our doctors they could no longer over-oxygenate children (although many still do due to dogmatic views).

And so, armed with complete confidence in their own good intentions, they happily go marching past boundaries we should stay well clear of. They reinvent ideological constructs we've seen before in earlier times, unaware of their pitfalls, blithely confident that the good guys could never say or do anything, or order any therapy, that was pointless because good intentions is by definition anything desirable or might have potential benefits that outweigh the risks.

Of course bronchodilators mostly come without risks, and therefore that makes ordering them for everything easy. It takes the "if" out of the equation for them anyway. Of course bronchodilator ordering abuse is nothing if not the organized pursuit of the desirable, just like liberalism is the desire for the ideal.

---

Word of the Day:Corrigible: That which may be reformed or corrected; punishable

Bronchodilator abuse will some day be a corrigible offense.

Make a difference

The nice thing about America is that even stupid people get to vote. Even the stupid get to have an opinion or not have an opinion at all. In fact, even smart people can have an opinion or not have one at all. Yet, in the end, we all need to be careful what we do with our opinion.

One of my friends wore a McCain/Palin sticker to school during the last election cycle, and one student came up to her and said, "I'm voting for Obama."

"Why are you voting for Obama?" My friend said to the kid.

"Because my dad said he wanted to make a difference."

Of course some of you could turn this around and wear republican for President sticker on your coat, and you'd think the opposite. My point is the same.

I get tired of hearing people say "I want to make a difference."

I watched the Mrs. U.S.A. pageant once, and about half the women on stage said, "I want to make a difference."

Well, Hitler and Stalin both made a difference. They created fascist governments and social reform that many here in the U.S., even our own Presidents, were envious of until they learned what Hitler and Stalin were really up to.

FDR made a difference. Conservatives say that difference was to create a more socialistic America. Liberals say that difference was to create a more just society. Conservatives think the liberal view is stupid. Liberals think the Conservative view is stupid and should be shut up.

Many doctors believe in the hypoxic drive theory. I would say that 8 out of every 10 doctor who works at Shoreline Medical won't give a patient enough oxygen just based on that theory alone. Yet, I bet 8 of every 10 respiratory therapist have become aware, or will become aware, that the hypoxic drive theory is a hoax.

So are we RTs stupid, or are all those doctors stupid. Hitler had good intentions in that he wanted to create a more just society, and so did Stalin. FDR had the same good intentions, and so does Barack Obama when he decided to create his health care program. Although he probably thinks I'm stupid in that I call it stupid, yet that's beside the point.

George W. Bush had good intentions when he opted to call terrorists on their bid for war. Yet he was called stupid by many in the media and Washington, just like those who supported Bush called those who spoke out bad about the War were anti-American and, well, stupid.

So, what are good intentions then?. First of all, if you create a program or a policy or a belief based on good intentions, then you are assuming you have the right answers based on the facts. If you have the wrong answers, then you are doing something that will not benefit anyone. In this way, you are creating a stupid program or belief. Does that make you stupid?

Good intentions do not always create good results. As we saw with FDRs National Recovery Act and his high taxes (which were up to 80% on the upper class), which actually made the great depression last longer than any depression in the history of the U.S. He had good intentions just like Bush had good intentions when he took us to War with Iraq.

Doctors want to make a difference too, as did Dr. Marsha the other day. The patient was awake and alert and oriented and chomping at the bit to come off the ventilator. She passed her weaning screen with flying colors. Yet, because her heart rate spiked when the doctor came in to see her, the doctor decided to keep this poor patient on a vent for another day.

Too me this doctor's decision was stupid, because I believe the patient's heart rate spiked because she was pissed at the doctor and the nurse, and not because she was "failing the wean," as Dr. Marsha told me. Well, I actually KNOW the patient was pissed, because she told me so.

I begged the doctor to extubate the patient. The doctor said, "Rick! I am not extubating today!"

So am I stupid, or is she? One of us is.

My good intentions made me spend extra time with that patient to make her look good for the doctor so the doctor wouldn't make a "stupid" decision based on some "stupid" dogmatic protocol she has set in her head. Yet I failed the patient.

I wanted to get a job as an RT so that I could support myself and my family. I write because I want to make a difference. Although I don't just say, "I want to make a difference." I believe that making a difference is knowing that if you work hard and become good at what you do, making a difference will come naturally.

So when I hear a kid say, "I want to make a difference," I just think that if he keeps doing what he's doing he'll definitely make a difference. He might go home and throw a brick through a window and make a difference all right. Or he could become President some day and make a difference too, and if he's stupid it might not be good.

That's the neat thing about our country is you can vote for whomever you want, and you can believe in any theory, or you can do whatever you want. You do not need to have any measure of logic or intelligence or reasoning or goodness behind your decision either.

I come from the school of thought - or the hope -- that the best way to move forward as a nation or as an institution or whatever you're referring to, or to sustain the greatness, is a massively informed public. That is why I blog. And I bet I'm making a difference with one or two of you.

And, if we had a massively informed public, we would not have a nationalized health care program, and we wouldn't have all these entitlement programs that we can't afford, and that actually make health care more expensive, and add to unemployment.

If we had a massively informed public, people wouldn't do things just because "that's what my doctor said." Because they would reason.

I had a patient the other day who was going to a nursing home. I said, "Why are you going to the nursing home." She said, smiling, "Because my doctor said so."

You see, to me, that's not good reasoning. I get the same response when I ask the patient, "Why do you think you're getting a breathing treatment if you're not having trouble breathing?"

Do you ever twist reality in this way? Turn a question back on the patient. Make them think. Well, I did this, and my patient said, "Because my doctor says I need one."

To me that's not good reasoning. One of the reasons we have stupid doctor orders is because the public is not informed. One reason we have high health care prices is because the public is misinformed.

If we had a well informed public, politicians who ignore our Constitution and create laws telling you and I what we "have to do" for the better of society wouldn't have a chance. Also, misinformed doctors would be forced to better educate themselves, and politicians too.

As I wrote a while back, going to school does not make you smart. There are people in Washington who went to the best schools in the world, like Harvard or Yale, and they continue to create laws that are not the the benefit of you and me or America or our hospitals or whatever. So schools do not make smarts. What makes smarts is effort and logic and facts and the ability to listen, to read, and to understand facts.

Because for every one of you who are informed and enlightened and smart who "make a difference," remember: The ignorant can make a difference, too -- and when they do, it ain't good.

Medical wisdom continues to make life better

One of my favorite topics to write about is how much medical wisdom has improved just in my lifetime. Many of the ailments you and I suffer from today may not even be ailments in the future.

In fact, while I suffered from uncontrolled asthma as a child as well as did many other asthmatics, new wisdom has it so that it's very rare for anyone to have uncontrolled asthma in 2010. In fact, as I will write about in an upcoming article, asthma deaths and hospitalizations have significantly dropped since 1996 alone.

I recently dropped over at a fellow asthmatic's blog, Kerry, over at Hold Your Breath to Breathe, and she posted (see here) her medical records from when she was born a premature baby. I hope she doesn't swat me for linking to them here, yet I think having access to such records is a great reminder of how well we have it today, or at least how much better our children will have it than we do.

If nothing else, it's neat to look back and know why things are the way they are. I have the discharge papers from my stay in a hospital in 1981 for asthma (somewhere on this page), and the doctor wrote about how important it was for me to quit using my inhaled corticosteroid as soon as I was feeling better. Of course that was good wisdom back then. Today we know that you should never stop using your inhaled corticosteroid, especially when you are feeling well.

I see from Kerry's first ABG that her PO2 was 370, which by 1991 standards was acceptable. By 2010 standards, we know that's way to much oxygen, especially for a premature baby, and can lead to more harm than good -- such as ROP (I write about this here). In a class I attended just a few days ago, it is now common wisdom to allow a PO2 to remain as low as 40, which is the PO2 that a neonate's organs were developing inside the uterus before birth. That to shock those organs with a higher PO2 can lead to other problems right away and later in life, such as retinopathy of prematurity, which is a disease of the eyes.

Another neat thing to note is that new wisdom actually greatly diminished the risk for diseases such as hyline membrane disease and neonatal sepsis. So while in 1980 most sick premature babies died, by 1990 most survived. And, while many of those kids in 1990 may have been forced to live with certain illnesses such as ROP, new wisdom has greatly improved even those risks.

I imagine that 10 years down the road new wisdom will make things even better. As asthma experts have learned that prematurity can lead to asthma, perhaps there will be something that can be done to limit this risk. And, while experts have learned that lack of exposure to certain germs can lead to asthma in term kids with the asthma gene, perhaps there will be a germ vaccine some day to prevent asthma altogether.

Ironically, through the suffering of our fathers things are better for us today. Because kids suffered from asthma years ago, beta adrenergic medicine was invented, and ultimately lead to the rescue inhaler that I got to use as a kid. And while asthmatics like me had to use the rescue inhaler often as a kid, most kids today with asthma barely know they have the disease.

The same can be said of other diseases. Modern wisdom is making life better for us all. This is why we must never forget the past, for what we learn by the past will only make the future a better place.

The plight of an artist and a writer

Why am I up so early in the morning you may be thinking? I doubt you care why? An idea struck me that I had to record, and now I can't remember what. Then as I was writing by the dim lights overhead I heard a loud, "Wah! Wah!" from the bedroom next to the living room.

Now my 11-month-old is happy and giddy on the couch next to me playing with the credit cards she stripped from my wallet. She took a few gulps from her bottle I warmed up, but at the present time that lies askew... oops, now it's time for another gulp... now it's cast aside nonchalantly... now she wants this dad...

Well, I started out writing gook. Sometimes I (we bloggers) write gook, but this blog post turned out to be pretty good. Yet sometimes when we writers look back on what we write we realize it deserves to be filed in cabinet #13, which in the blogosphere is equivalent to the delete button.

Sure most of what we write is normal blah, blah, blah. Yet, occasionally, one can't help but to write something worthy of immortality, yet one cannot judge his own creativity. I suppose that's
why Aunt Dike, who preferred to be called Leota when she turned 90, for some reason would toss her work in the trash and why grandma would pick it out of the trash for posterity purposes.

I suppose I should crop this post out and tape it to the backside of Aunt Leota's painting grandma gave me that grandma said she plucked from her sister's file cabinet #13 and I now have on my wall in my basement. My grandma said it was an awesome drawing and she appreciated it. Yet she said her sister decided long ago it was trash.

Obviously I appreciate it too. I wonder if Aunt Dike would be proud or if she would say "It's just gook like this post you're writing."

Actually, however she thought of her own art, she would never tell me mine was gook. And the only reason she'd file anything in file #13 is because there's an old saying regarding any one with artistic or creative talent: If you did it once you can do it again and better.

That's what I have to remind myself every time my blogger fails to save and I lose everything I've written over an hour, or my word processor fails, or if the power goes out. If you did it once, you can do it again and better. That's the best wisdom we can come up with for the day, gook or not.

I suppose the moral of this post is you yourself are your biggest critic. In fact, I've heard that about artists too, that they keep editing and editing and editing because they want to make it better, and then when they look at it again they feel the need to trim some more.

I think that's normal for we artists, whether we work with words or paint and pen or even chalk as my Aunt Leota did. The truth is, most of what we write is probably better than what we see in our heads as we read it. And, I suppose, that's why it's best to write and let it sit a month so we can view it as though it were someone else's creation.

And, sometimes as I'm reading my own creations, that's exactly how it feels: as thought I'm reading your writing and not my own. How does this stuff pour out anyway?

How would you like to die?

A lot of people I talk to say if they had a choice they'd like to just drop dead so they wouldn't have to suffer. Not me. I want to know I'm dying. I want to die a long, slow death. I don't want to suffer, but people don't suffer these days. There are good medicines -- thankfully-- to prevent pain and suffering. but I want to have time to say good byes, to smell the roses and the fresh air one more time, to snuggle with my wife, to hold my daughters (or granddaughters if I'm old). I want to play catch one more time, to share wisdom, and to drain the writing well dry.

I think a lot of people would choose the easy way, the painless way (again, I don't think there has to be pain with all the meds available) to end it all, and I respect that. I understand why someone would choose that (not that we have the choice anyway). But I would like to choose the less popular route because for no other reason than I'd like to share the ride to tell the story, to write about the adventures all the way to the bright light seen down the tunnel that leads to the pearly gates and the promised land. I love life, and I want to absorb, to share, as much of it as I can.

And I suppose that's why I write in the first place.

Thoughts of living long

When my 1-year-old girl is 40 I will be 80. And I think how fast my 40th birthday is approaching (I'll be 40 in January). That 80 years will be here in a heartbeat.

I think I want to be here to lend a hug and an ear to not just my daughters and son but my grandchildren. I imagine I'll have some by then. Perhaps that's the greatest incentive to eat well and exercise and live well.

Perhaps I ought to print this post and tape it to the fridge so I can be reminded of this incentive daily, because it sure isn't easy to eat right, exercise and live well.

I mentioned this to my dad who is 66. He said when he turns 80 his youngest daughter (my sister) will be 40. So, dad is in the same position in a way as me. The only thing is, when I turn 80 my dad will be 106.

I wonder if we'll be in the same nursing home by then. That wouldn't be so bad, because my dad's pretty cool. He seems to always know how to find fun. Perhaps his daughter and granddaughter can visit us regularly.

Appreciate!

It's good to take some time off to appreciate life. It's good to take time to squeeze your kids hard and appreciate them regardless of the nonsensical talk, talk, talk. It's good to enjoy the attention grabbing of your kids because sooner than you realize they will be all-growed-up. It's time to enjoy the company of your wife after your children are asleep, either sitting in front of the boob tube or on the front porch with a glass of wine and a beer. And even while you might not think you have the perfect job, it's great to appreciate the fact that you have a job at all. Even while politics at work and on a national basis seem to be quite frustrating, it's important to appreciate we have what we have and we were born where we were born. It's good to take a deep breath, relax, and appreciate what God has given us. It's good to take some time off to appreciate life, to feel the pleasant breeze blowing in from the West, to actually hear the wind rustling through the Oak trees, to watch the sun set, and to observe as the dew sets on the grass in the dusk. It's good to take some time off to appreciate life, even if it's a span of 30 minutes before you go to work.

Is it our duty to question stupid doctor orders?

I'm sure other RTs and even RNs have experienced the same thing, but there are a lot of times doctors order bronchodilator breathing treatments that are not indicated. I like to say that at least 80% or all bronchodilator treatments ordered are not indicated.

I don't like to pick fights. I don't like to complain. I'm not the kind of person to roll my eyes at a unit secretary when she gives me the order for yet another treatment order for a pneumonia, CHF, croupy kid, or whatever have you.

However, my coworker, Jane Sage, said to me tonight, "Have you ever thought to walk up to the doctor and say, 'Just what did you expect to happen when you ordered that 20th Xopenex treatment for croup after the first 19 did not work? Did you think to try race epi? Did you think to try nebulized Decadron?"

"Well," I said, "I think to say something like that every day. But, do you want to know the reason that I don't."

"You don't want to tick off the doctor?"

"Actually, that's not the reason."

"Well," she said.

"I don't because I know I'm not perfect, and there is a 1% chance I could be wrong."

"You could be wrong, but you're still pretty confident you are right."

"Yeah. I'm non confrontational."

"I'm like you," she said, "I don't like to cause controversy. Perhaps it's because most RTs are like us that no progress ever gets made at Shoreline Medical Center."

"True," I said.

"However," the sagacious Jane Sage said as her eyes lit up, the tel tale sign she was going to say something brilliant, "If a doctor were to order 200mg or Morphine, don't you think the nurse would say to the doctor, "Wait!"

"I see what you mean."

"Don't you think, like the nurse of that patient who was ordered to get 400mg of Morphine, that it is our duty as respectable members of society to question it when a bronchodilator is ordered and not needed?"

Anyway, that's something to think about.

I have a voice, and that's where my power stops

I was at an administrative meeting as a representative of the RT Cave. There were 11 admins and me. The admins wanted us RTs to do something that I thought was unnecessary.

One of the admins said, "We have to do something. Doing something is certainly better than doing nothing."

Your humble RT said, "I beg to differ. Doing something stupid is far worse than doing nothing."

How's that for some great philosophy.

The thing is, I don't have a problem with adding new procedures to the RT list of things to do. The problem is, they keep adding more things to our list and never even consider taking things off. I understand: it's business. I understand: profit is the bottom line.

They won't do protocols because we live in a small town and we have to please the doctors so they don't up and leave. They won't buy the new equipment we need because they don't have enough money (yet the CEO got a whopping bonus this year).

Yet when it comes to something they want, or something the doctors want, it's done in a heartbeat, regardless of what the people who actually are doing the real work think. And yet, in the end, we have no choice but to be submissive to the request (which really isn't a request so much as an order.

I think it's neat they let a peon like me sit in on their meetings. I think it's neat they allow me a voice. I only wish there was more of an incentive for them to listen to the voice they're hearing.

Three ways to deal with stupid policy, orders

In no institution -- hospitals included -- are things run perfectly. So, when management -- or RT bosses -- implement policies that are stupid, or refuse to implement requested changes, or doctors write stupid orders, there are three ways to deal with this:

1. Complain
2. Accept
3. Change

I can't think of any other options. I suppose, here at the RT Cave, we do a little of each. I suppose, in a sense, with my RT humor, I tend to complain in my own way here on this blog.

However, by keeping my mouth shut, I suppose, in a way, I'm accepting the status quo. I guess it's easier that way. Come in, do whatever work is required of you, and go home. Do it that way and there's no controversy, no confrontation.

I guess you can say, in this way, being an RT is no different than working in a factory. Only, instead of soldering two wires together, we are taking care of patient. And, instead of standing still, we are running around like chickens with our heads chopped off doing trivial therapies that suck more money from unaware businesses and government services.

And, then, on occasion we find the energy to implement change. Yet, the effort to do that, the setbacks, the rejections, the changes to the protocols you want, lead acceptance the easiest route.

Now I'm just making this up, but it makes sense to me. What do you think?

Habitual offenders of the superfluous therapy

So you ever wonder how many hospital therapies are ordered simply out of a doctor's habit.

Aa 35 YO patient was admitted to the ER. His chief complaint was drowsiness, malaise and lightheadedness, especially when he tried to walk. He said he vomited blood and had a bloody stool. He was still nauseous.

Upon assessment his heart rate was 110 and his standing BP was 90/50. His labs showed a hemoglobin of 9.8. The doctor ordered a drug to help with the nausea and then ordered "foley cath, watch i's and o's."

The RN cringed at the order, but entered the room. "Your doctor ordered a foley cath." The patient was an RT, so she didn't have to explain what that was.

"Oh, okay," the patient said through beady eyes. The nausea med was kicking in and he was obviously in no state to make decisions with his mind numbed so. "I don't care."

"Hold on there," the patients wife said. She was an RN who worked upstairs in this same institution. "My husband and I have a pact. We call it a DNC pact."

"What's a DNC pact," the ER nurse said.

"It's a Do Not Cath pact. We do not want caths unless they are necessary. My husband here can just as easily get up and go to the bathroom or pee in a urinal. There's no reason he needs a cath."

"Okay," the nurse said. Ah, no argument. She didn't try to defend the order, which meant she knew it was another frivolous doctor order.

"Dr. Bart is a great surgeon I have no doubt," the wife said, "but I'm sure he's just ordering that just by habit. I know in OB where I work a doctor ordered a foley on a patient once, and I asked the doc, 'Why did you order a foley on this patient?' The doctor said, 'Oh, I guess I just ordered it by habit.'"

So, the moral of my little story here is: Make sure when you are admitted to the hospital that you utilize your right to refuse therapy. If it doesn't make sense to you, chances are it isn't needed.

Or, at the very least, ask questions like, "Is this really needed?"

"Um, Rick, do I really need this breathing treatment?"

Well, no. I know for a fact doctor Utilipticolicupolisolinos orders treatments on all his post operative patients out of habit. I confronted him once, and he has no clue what a breathing treatment even is.

I kid you not. Someone told him once treatments help make post op patients recover faster. Hmmm. Well, that's fine. Show me the study. Show me your proof. That's all I ask.

Or, are you simply ordering it out of habit. Does this patient really need an invasive ABG? Does this patient really need to risk a urinary infection and possible sepsis by having a catheter inserted into his yahoo?

Doctors are great. Doctors can do things I could only dream of (well, in a nightmare anyway). Still, doctors are very, very busy people who have lawyers salivating as they watch their every move waiting for a slip. It is this environment that encourages useless and uneeded procedures.

Well, plus you have to add in the habit factor.

It is the job of the rest of the profession to watch out for the patient and question such frivolous orders. And it is the job of the hospital bosses to support the RTs and RNs who do question orders (however, money often wins out over common sense. Hey, we make a ton of money off un-needed and useless procedures.)

So, since RTs and RNs are often quashed at their insistence that some "habitual" policies should be eliminated, the buck stops at the patient. If he refuses, the superfluous procedure is not done and the bill the customer never sees does not grow.

The buck stop with the patient and the patent's family. Still, too many people have too much faith in their doctors to make all the right decisions. They forget that doctors are human too and prone to get caught up in the system.

The 35 YO patient with the GI bleed had his problem resolved with hardly any medicines given. He went home two days later. And, believe it or not, he survived without the breathing treatment and without the foley.

So, we must ask this question: how many procedures do we do that are not indicated? How many procedures do we do just to avoid a lawsuit? How many procedures do we have to do just because of a habit?

Rules must be enforced with common sense

Some people take things in stride & prefer to use their individual freedom to solve problems. Some people are tense and have so many rules that in order to keep them happy you have to follow all the rules.

I think some rules are important, but too many rules merely take away individual freedom. And, absent individual freedom, new innovations are stifled. In my humble opinion, this merely stifles creativity.

One of my co-workers took what I thought was a great idea and to the bosses, who promptly heralded it and then brushed it under the carpet. Five years later the promised changes have still not been made.

In essence, my co-workers, tired of being ignored eventually decided to keep their mouths shut and "grin and bear" the status quo. The result here is a bunch of happy workers with no one willing to stand up to fix problem areas. Hence, you either hear grumbling in the RT Cave or, in my case, facetious RT Cave humor.

I hear this a lot: "Why should I go out of my way to share my ideas to make the department better when all I get is ridicule or ignored?"

My co-workers, and myself included, and perhaps even you, are written up when we make serious errors. Of course even the gravest errors are learning experiences, assuming we don't repeat them. Those are acceptable write ups.

Major write-ups are rare. Yet pidly write-ups seem to be a common feature here in the RT Cave. And that, my friends, is one of the problems of working for a small town hospital. Most bigger hospitals have bigger fish to fry, so creating rules for paltry things is not a priority.

One of the best parts of working nights is the freedom of working by myself and prioritizing therapies. Still, the powers that be that set and enforce the rules can make life very stressful for you when they come in and tell you all the "minor" rules you broke, like forgetting to chart, "No treatment indicated" for a prn order.

I say this knowing my greatest priority is not giving treatments that aren't' needed, but saving lives. But, when it comes to the bosses of small town RT caves, they have little else to think about than the things that the larger hospitals WOULD brush under the carpet and not worry about.

That is exactly why large hospitals have protocols that allow us RTs to decide who needs our therapy and who doesn't. Smaller hospitals need the money from all those frivolous therapies to stay in business.

So, the whiny RT says, "Hey, boss, that treatment isn't needed. That patient has never had a bronchospasm in his life."

The boss says, "Whiney, if the doctor ordered it, it's needed."

Hence, whiny finds solace complaining about the "stupid rule," as opposed to making an effort to change it. Still, in my opinion, it's better to be humble. Take your lickin' and keep on tickin.

Whether you like the beast of politics or not, it shows its ugly head around every corner. So you might as well just grin and bear it. Even if it's rules that take away our individual freedoms.

So, I suppose you wonder what my point is. I simply think bosses should think about the rules they make, and have a little leeway in how they enforce the piddly ones like, "Did I dot all the i's and cross all the t's."

Or, said another way: they should encourage a little common sense.

I say this because I'm certainly not going to rush upstairs to do the seven treatments that are due on people who have never had a bronchospasm in their lives, when I have a patient who really does need me in the ER.

But that's common sense.

It is true that absent rules people are lazy. Yet rules must be enforced with some common sense. And that, my friends, is the thought of the day.

Note: The leading hospitals in the world did not get where they are today by stifling creativity.

No human is worthy of god status

One of the things about this job, is it is absolutely not predictable. When I left work Sunday we were finally down to to seven patients, and things were starting to look really good.

Sometimes I wish I had the power to predict a good night, but only God has that power.

I take two days off, and come back to work with 16 patients on breathing treatments. I'm not sure how many of these patients actually need these treatments, but that's beside the point.

The doctor thinks the treatments are needed, and that's really all that matters. Our RT bosses are more than happy to absorb the extra money they will generate. RT bosses aside, I want to take a moment to talk about doctors.

I know on this blog I spend a great deal of time writing about humor I find in stupid doctor orders. I know that there are people out there who think everything a doctor says or does is gold, but the truth is doctors are humans just like you and me. They are not gods.

On a similar note, I am not a god either. I read somewhere that kids think of their parents as gods. We are everything to them. They worship us. My kids worship me. It's true. My nine year old thinks I can't do wrong. He learned to love baseball because he wanted to impress his god -- me.

Truth be told, however, I am no god. I am not worthy. Just as a doctor is not worthy of god status. No disrespect here, it's just the truth.

However, like a god, I am feared by my kids. When you fear someone, it's because you respect that person. When you know there are consequences to disrespect, you have a tendency to spend a lot of time trying to be good, especially around the people you respect.

And, like the One God, if I do a good job of raising my kids, they will continue to make decisions not so much out of respect for me, but out of respect for themselves once I am not there for them, or once I am but a voice in the back of my child's mind acting as a conscious.

This voice saying: "Don't do that," or "I wouldn't do that if I were you."

So, while I am not a god, I am like a god to my kids. And, while doctors are not gods, they are like gods in the medical community. They are revered and honored in ways others are not.

When a doctor comes to the nurses station, I usually get up and offer him or her my seat. This used to be standard practice back when nurses used to have to wear those cool white caps, but it's a practice reserved for respectable people like myself.

Doctors are gods in a way that they are able to save lives. They are gods in that they have the ability to overrule any medical thought I have. I can have this idea that this treatment is completely useless, but if the doctor ordered it, I must do it (within certain limits).

In that sense, doctors are like gods.

Occasionally my fellow RTs or I approach the RT Bosses to see if we can do something to get doctors to stop writing orders we think are stupid. The RT Bosses treat doctors as gods, and therefore they don't want to do anything to over rule them.

I think it's funny how the medical staff has to stay awake for an entire 12 hour shift no matter how busy it is, but if it's slow a doctor has a bed that he can sleep in. If it gets busy, we just wake him up. This, in essense, is on par with god status.

We RTs can ask for something 100 times, but if a doctor asks for something once, it's as good as done. As least that's the take I have on most hospital administrations.

Despite my RT humor, I want my readers to know that I truly do respect doctors. I couldn't do HALF of what they do. I certainly wouldn't want to take the responsibility they have, and have to purchase the liability insurance that goes with that responsibility either.

Still, as with us dads, as with all people, doctors make mistakes. Doctors are prone to be stubborn. Doctors hold on to old fallacies that have been disproven since they left college. Doctors do order things based on habit, rather than based on science. Doctors order things that are not indicated. Doctors misdiagnose. Doctors screw up sometimes. Doctors have bad handwriting.

Sometimes they even have bad attitudes. And, of course, these fallacies go along with all the good that they do, which is why they EARN respect. It is true that any HUMAN -- not a god -- has to EARN R-E-S-P-E-C-T.

Therefore, doctors are flawed just as all of us are flawed. They are not gods. Which is probably a good thing, because there is a lot of responsibility, I surmise, for a god. I'm sure a doctor wouldn't want THAT responsibility.

Which is why I have to cringe when I hear a nurse say: "The doctor ordered it, so it is needed." And I cringe when I listen to a patient telling me he knows nothing about his illness, and "I just rely on the doctor to tell me what to do."

Ummm, that would be just fine if doctors were, in fact, gods. But, the truth is, doctors are not gods. And, as we've decided by deduction, that is a good thing.

From an RT perspective, we go to school for 2.5 gruelling years learning the body as it pertains to the respiratory system and respiratory therapies inside and out. Not only that, but we have, in my case, ten years of respiratory experience, and even more experience for those of us of whom have respiratory illnesses.

My point is, we are the respiratory experts. While the doctor spends less than 10 minutes with each of his in-house patients per day, we RTs are there to give EVERY breathing treatment. We are right there to assess the patient before and after EVERY treatment -- and many times in between.

It doesn't take long to know when a treatment is needed or not. Therefore, it is a flaw for doctors (of whom we truly respect) to not utilize the respiratory knowledge and assessment skills of RTs to determine what RT therapies are indicated.

It's called using the resources available to you for the best interest of the patient, the RT, the nurses, and the doctor himself. It also benefits the economy, as frivolous therapies that are not indicated are not given.

So, while we can't call up a doctor and tell him how flawed we think he is -- we usually do the opposite out of respect, we here at the RT Cave like to find humor in this. Thus the humor link to the right.

In review: We RTs really do respect doctors, but we know they are not gods.

So, what got me on this tangent was the following quote from a member of COPD International regarding my blog:

"I loved this guy's blogs on 'Cave Rules'...especially about asthmatics and COPDers using fans and Albuterol not being a treatment for pneumonia. He and his fellow RTs certainly don't think of doctors as Gods!"

She is right, we don't think of doctors as gods, as well as we shouldn't. And no patient should either, lest he or she wants to gamble on one man's opinion.