What is Disseminated Intravascular Coagulation (DIC)?

Classics of the RT Cave. This post was originally published March 18, 2008.

First off, I worked a bunch of years in the hospital setting before I had a clue what DIC was. I had observed the symptoms many times. I remember many patients, most of them on ventilators, who seemed to be seeping fluid from their pores. Yet I heeded this condition little attention, mainly because I was a newer RT who was intently focused on getting my own work done.

Then one day I remember one of our senior therapists told me in report she told the nurses to keep a particular close watch on this trauma patient because he was at high risk for DIC and ARDS. It later turned out she was right, and the patient developed both ARDS and DIC. So, it did not pass me by how this senior was correct in her prediction. I was curious to know what she knew.

So I asked her, and she said, "Do some research on DIC, and then get back to me. Do a Google search." She paused, then added, "I think that all therapists coming out of school should focus on doing their jobs and doing them well. However, there comes a time when you should take a look at the other aspects of the healthcare industry, and in this way become well rounded therapists. I say this because well rounded therapists are better team players. While nurses are busy looking in one direction, you can say, "Hey, look here!"

So, that said, here is what I learned about DIC. Here is how you can predict what patients might develop DIC.

First of all, DIC is an acronym for Disseminated Intravascular Coagulation. It is almost always a secondary disease, or a consequence of other diseases, disease conditions, or circumstances. In our patient, it was secondary to trauma.

DIC is a condition, more so than a disease. It is a process that occurs when the proteins in the bloodstream that normally cause clotting in an injured area overreact, form tiny clots all over the body. Then, clotting factors now exhausted, this causes the patient to bleed abnormally. Bleeding occurs from nearly every orifice, including skin pores, the anus, etc. It just leaks out. It's kind of gross. You better wear gloves when you touch such a person (well, you should always wear gloves, but int his case you'll definitely want to).

When you do an ABG, for example, you might hold the site for the recommended five minutes and the patient still doesn't stop bleeding. Usually, when this happens, the RN will have to wrap gauze around the puncture site and bind tape around the patients arm to act like a tourniquet. I've seen this done on many occasions.

Technically speaking, on these patients, a doctor will want to limit the number of blood draws (ABGs included), because of the complications of bleeding. Another thing for us therapists to remember is to be very careful when suctioning. Ideally (and I think this should be standard procedure anyway), the catheter should not be advanced all the way to the corina so as not to puncture it and cause it to bleed.

In severe cases, the patient will seep ooze right out of the pores on his skin. This can be quite disgusting. This is what I described above. But I've seen it quite a few times already. I will probably see it more times in the future. If you work in the critical care or emergency settings, you will see it too.

DIC can also cause sudden bruising, clotting, and, as I described, bleeding from multiple parts of the body, and can lead to severe bleeding, stroke, and lack of blood flow to arms, legs and organs. So, it's not good.

That said, how do you know who is at risk. Here is a list of who to watch.

1. Infection in blood (Sepsis)
2. Severe tissue injury, as in burns, trauma (particularly trauma to the head and brain)
3. Recent surgery or anesthesia
4. Reaction to transfusions
5. Labor and delivery problems
6. Liver disease

Trauma patients not only are at risk for getting DIC, but also ARDS and Sepsis. And sepsis in itself is primary cause of DIC in the hospital setting. And, if that wasn't enough, DIC may lead to acute renal failure and, ultimately, to multiple organ failure -- including the lungs.

It was about this time I started to understand the point my senior therapist was trying to make about being a well rounded therapist. This is why it's a good idea to go through and review the charts of all your patients, particularly the laboratory results. Yes, we can learn a lot from lab results. The following are some lab results that might show DIC:

1. PTT: Again, I'm no expert here. However, according to Medline Plus, this is a test to determine how long it takes for the blood to clot. If a patient is on a blood thinner like Coumadin, the PTT may be therapeutically high. A high PTT is anything greater than 33, and greater than 60 is considered critical, and may be indicative of DIC.
2. PT: Same as PTT, except for the high value is greater than 12.7 and greater than 40 is critical
3. D-Dimer: Greater than 500 may be indicative of acute bleed, but can also indicative of pulmonary embolism and DVT.
4. Platelets: A normal platelet count is 150,000 to 400,000. This is what is needed in order for normal clotting to occur. A low value will be 150,000, meaning abnormal bleeding may occur, and below 50,000 can mean a simple bump can cause bleeding. <80>
5. INR: Greater than 1.2 is considered high, but greater than 6 is critical. This is indicative of DIC or acute bleed.

Now, keep in mind these critical values will vary from hospital to hospital, but at least this gives you an idea of what critical is, and what the labs of a patient in DIC might look like.

Also, you should know that there is a lot more involved in the DIC process than what I describe here, but this is pretty much all that a well rounded respiratory therapist needs to know.  Now, see if you can put this wisdom to good use and impress someone the next time you find one of these patients.

Edited on July 5, 2016, by John Bottrell

Why is the RT program is so hard?

Today I would like to take the time to answer some questions about respiratory therapy that my readers have sent me.

Question: I know that you've commented before about how respiratory school is hard, but would you mind if I asked you some specifics? I, like most new Resp. students, am wondering exactly what I'm going to be getting into...

I used to work as a CNA/Monitor Tech at a large local hospital here and whenever I asked the Respiratory Therapists/Students how school was, they would say it's no big deal. I always got the, "don't worry, you'll be fine..." or "it's not that hard..." or "nursing school is much worse, don't worry..." But then other points of view I read online are, "It's HARD!" I'm curious what makes it hard? Is it the scheduling? Because you're in school everyday and you have labs and clinicals and you're just going, going, going, and you get tired. Or is it the actually coursework? Very complex and hard to understand? Is the work not so bad but it's the AMOUNT of work? There's so many different aspects to what makes something hard.

Any heads up or info would be appreciated.

My humble answer: I think RT school is extra hard because RT schools, and the AARC, want to make sure RTs are prepared and able to be excellent critical thinkers, along with having the basic skills of managing RT equipment. For that reason, RT students are inundated with as much information as possible, and forced to learn it in a short period of time. When I was in RT school, other prerequisites, balancing my time between studies, clinicals and home life very difficult. It was a very intense 2.5 year program.

I have many friends who went to RN school and all of them say the first year was intense like this, but the second year was pretty easy. And my friends who went to RN school and RT school all say the RT program was far more difficult. They say the main reason is that in RN school you learn the basics of a lot of stuff, but in RT school you have to go very in depth on on everything pertaining to just respiratory. When you have to know so much depth into one subject area, the classes are bound to be harder. Plus you have to learn all the equipment for adults, peds and neo.

Yes, the scheduling is hard but doable. The coursework is hard, but doable. It's just a lot is thrown at you all at once. Basically, when I was in RT School, my personal life took a standstill. All I had time to do was attend classes, study, eat, shower and study.

Quite frankly, I have never met an RT who said the program was easy. Even the people who got the best grades say the program was hard.

Still it is a challenge worthwhile, because when you get through it you will be among the elite brand of RRTs.

Question: Is there a difference between respiratory care and cardiopulmonary sciences. Are these two different programs?

My humble answer: I am under the impression they are one and the same. Some people, I think, believe cardiopulmonary sounds more professional. Or, as is the case where I work, cardiopulmonary covers both aspects of the RT department, which in our case consists of both the respiratory end that included breathing treatments and ventilator therapy, and the cardio end that included EKGs and stress testing. Many hospitals, including where I work, refer to the RT department as cardiopulmonary, or simply cardio for short. Some schools do too.

Question: What's the most annoying part of being an RT?

My humble answer: That would be doing breathing treatments not because they are indicated, but because insurance companies will reimburse for them. Likewise, many of the treatments I do are done not because they are needed, but because someone sitting in a chair in Washington D.C. decided they will not reimburse the hospital unless a treatment is given for such and such a disease. I would say about half of all the breathing treatments I do are for this reason, and the majority are unindicated. This, to me, is a perfect reason to keep government out of the healthcare business. But that's just my humble opinion.

Question: What is the most enjoyable part of being an RT?

My humble answer: The best part of the job is doing critical thinking on very challenging cases. I like it when an idea I come up with helps a doctor (or patient or nurse) make a decision. Likewise, I love spending time with my patients educating them on how they can better their lives. Likewise, I enjoy sharing my asthma experiences. I think it's neat that I get to know some patients at the end of their lives, and yet by their stories I know about their entire lives and experiences.

Oh, and my favorite part of the job is when I go into a room of two little old ladies to do a breathing treatment and, just after I exit the door and am still within earshot, one of the ladies says to the other, "Now, wasn't that a fine young man."

Hey, any further questions for me please email them at freadom1776@yahoo.com. Or, if you have criticism or a comment, or further information to add, please email or leave a comment below.

Coming up on the RT Cave

We haven't really written about anything educational in a while here at the RT Cave, and that is because Shoreline has been so busy lately. Now that things have settled down a bit (fingers crossed) we hope to learn a little and share some RT wisdom.

I wrote a while ago that I was going write more about COPD, and then I mentioned briefly that I was going to write about the hypoxic drive theory and how it's been disproven.

In fact, I had an RT student the other day tell me that her teacher told her that he was considering no longer teaching about the hypoxic drive theory.

Ah, but I will keep you in suspense. The great writers keep their readers in suspense mode so they keep reading. Kind of like the tabloid TV shows that hint about what's coming up, "Right after these messages," only to get to it 3 or 4 commercials later.

So, that in mind, I thought I'd give you a list of things I have on the edge of my brain that I'd like to blog about some day soon here on the RT Cave. If I had time I'd do it in a timely fashion, but being the family comes first, and patients come second, the RT Cave has to come somewhere down the priority line.

That in mind, these are some of the things I've been thinking about writing about when the opportunity presents itself. Things to look out for.

1. The nurse wants you to stand there looking at that sat. When should you quit this and actually call the doctor.


2. What the heck is ARDS anyway. Us small down RTs don't deal with it often enough to stay up to date.


3. I get asked this all the time: what oxygen device should be used and when. After explaining why nasal cannulas don't belong in the mouth, this is the most common thing I find myself educating RNs about.


4. I don't do PFTs, so I thought I'd do a little review for myself.


5. Why is it that doctors want to ventilate obese patients based on their weight? That in mind, how do we ventilate obese patients.


6. The hypoxic drive theory is the gold standard with doctors, but is proven folly time and again. Is it a fallacy or truth?


7. Why the heck do people breathe anyway?


8. Do we really need to learn the A-a gradient?


9. There's a lot of talk around here about PE precautions. So, who is at risk for PE, and how do you know if someone has it?


10. Many RTs stress out about the prospect of a baby going bad. That in mind, at what point do we intubate neonates, and how do we ventilate them? Since we don't get many bad babies here, this is something we constantly review.


11. You know normal adult ABGs, so what are normal neo ABGs?


12. The doctor tells you to select an ETT for a 4 YO girl. What size ETT do you select? Are you stressed yet, or are you prepared?


13. Remember bubble CPAP? It was outdated when I was in RT school, and now it's back.


14. Do you know your Ventilator graphics, or do you simply ignore them?


15. What about Capnography?


16. You do look at lab results, don't you? So do you know by looking at the labs if a patient has failing kidneys? liver? lungs?


17. We RTs are educated not to over oxygenate neonates. So why do RNs in OB still do it? Why is it still taught to keep that baby pink in STABLE classes?

We will get to these, right after these messages...

STAY TUNED!

The real RT world -vs- the RT student world

I have an RT student who follows me every Thursday. She is in her first clinical rotation, but she's such a good worker that I'm actually able to allow her to do several procedures on her own. She even does EKGs.

While I do let her do some procedures by herself at this stage, most of the time I'm with her, and sharing with her my opinion on this and on that. This way it is more of an educational experience for her, as opposed to just sending her out to do my work.

Yes, I do have to slow way down when she is with me, but I actually enjoy it. To be able to share the knowledge I've obtained is something I like to do. I don't know if I ever wrote this before on this blog, but I actually had my choices limited once to either being an RT or a teacher.

And the only reason I chose to be an RT was because I could start working right away, as opposed to waiting four years before I could teach. The bottom line in me choosing to be an RT was that I needed money right now.

Thus, when I get the opportunity to teach, I really enjoy it. But I told her that she needs to be careful what we teach her, because what goes on in the real RT world is not the same as what occurs in the teaching world. And, while it is our job to teach our RT students how to be an RT in the real world, it is your RT teachers job to teach them how to pass the exam.

For example, I showed her ABG results from the weekend before where I had a patient with a pH of 7.10 and she said, "The patient was vented, Right?" I said, "No. The patient was placed on BiPAP for 24 hours and now he's fine."

In the real world, I told her, you don't treat the number, you treat the patient individually. However, in the RT student world, the one where you have to prepare for "The Test," you have to intubate any person with a pH less than 7.30. At least that's what I was taught when I was preparing for the test.

Likewise, the theories they teach in school are not the same as theories in real life. For example, I told my student that I'm not sure I really believe in the hypoxic drive theory. I told her I wouldn't tell her why because I didn't want to confuse her.

"But tell me," she insisted.

"After you take your test I'll fill you in," I said.

I almost felt guilty bringing it up. And, the next week she told me her teacher said, "What kind of junk are they filling your head with."

I said, "I didn't tell you why I thought it was a myth, only that it was my opinion that it was. And," I added, "You can even look in that book of yours right there, the one with Egan's name on it, and it's in there that some people believe that the hypoxic drive theory is a myth. I know it's in there because I read it just last night."

"Really?"

"Yeah."

Again I felt guilty for having brought it up, except that it wasn't five minutes later, back in the RT cave, that we were having a hearty RT discussion with Jane Sage, and Jane coincidentally brought up the "hypoxic drive myth."

"If you follow it to a tee," she said, "like you would if you were taking the respiratory exam, you might kill some patients."

"Why is that?" the student asked.

"Well, let's give an example," Mrs. Sage said, "Say you have a patient who is a known COPD retainer, and that patient has an SpO2 of 40. What do you do?"

"You put him on a 40% venti mask or a nasal cannula at 3-4 LPM."

"According to your test, the answer would be yes," Jane said, "But in real life, you would want to give 100% oxygen. Think of it this way, your heart needs oxygen, and if it's oxygen deprived, it will poop out at some point. If you only give that person 100%, he might lose his drive to breath in 20 minutes. But, if you give him 40% FiO2, he might lose his drive to breath due to pure exhaustion and Oxygen depletion in ten minutes."

"Wow, you guys make some good points," the RT student said. "I never learned that in school."

"Well, it's just something to keep in mind that you can apply when you are doing clinicals, but when you are taking your tests you'll want to stick with what your teachers tell you. That's just the way it is in the medical field."

I'm sure we can think of many more examples of the differences between the real RT world and the RT student world.

Relearning what we learned and learning more

After I had worked in the hospital for about five years I realized I had forgotten many of the basic things I was taught in school. The old saying that if you don't use it you lose it rang true with me.

One day we had a new RT hired here right out of RT school and he was still studying for his exams. He asked me if I knew what the alveolar air equation was. Of course I knew what it was, but I couldn't think of the formula nor how to apply it for the life of me.

Then one day I was called to talk to the hospital's lawyer because a man who was diagnosed with pneumonia died of something else "coincidentally" and the hospital's lawyer wanted me to be a witness to testify that the patient had obvious signs of pneumonia.

The lawyer said, "How often do you take care of pneumonia patients?"

I said, "I would say that probably about half of all our patients have pneumonia. So we take care of pneumonia patient's quite a bit."

"So you should be an expert in identifying pneumonia."

"Yeah, I guess."

"Okay, to make the jury impressed with your knowledge, I want you to rattle off the signs of pneumonia as fast as you can, like they are second nature to you."

"Okay," I said.

"So rattle them off."

"Ummm, pain with deep inspiration, brown sputum, isolated crackles, ummm..." My mind went blank. I could think of no more, however I knew there were more.

"No problem," he said, "When I talked with your co-worker he rattled off a list. I want you to memorize them in case we go to court."

I looked at the list; studied it. I added a few more signs that my co-worker missed, and the lawyer wrote them down.

I went home, looked up signs of pneumonia in one of my RT books, and discovered that we had both missed a couple more signs.

That was the day I decided I was going to re-learn what I had forgotten that I learned in school. I think you lose it not just because you don't use it, but because you get so used to just doing whatever the doctor tells you to do.

Not only that, but when you're a new RT, you are focused so much on just doing your job and doing it right, you tend to forget the most basic of RT knowledge.

When I was in school I took all the best notes. In some classes I wrote nearly word per word what the teacher said, and then went home and re-wrote all my notes into the computer and printed them off for studying.

But once I passed my registration test I put the boxes of RT class notes in the trash. Man that was dumb. So, instead of reviewing my great notes, I had to start from scratch. Thank God for the Internet.

Fast forward: I relearned what I learned once before and then I learned some more.

It's cool when a nurse calls you to assess the patient, and you know what is wrong right off the bat by your assessment. It's cool when you see signs not of bronchospasm, but of a pulmonary embolism. Or you see a reason to worry that this patient is at high risk for PE, or ARDS, or DIC.

Or, you look at the chart, and at the labs, and learn that the patient is probably a CHF patient as opposed to pneumonia based on the BNP of 30,000. And that the patient is in renal failure, confirmed by the high BUN and creatinin, and GFR of only 18.

Or you assess the patient and observe a high respiratory rate, high heart rate, normal BP, and learn the patient is on an antibiotic and you are the first to think sepsis. You talk with the nurse to see if she agrees with you, and when she does she calls the doctor, and a crisis is nipped in the bud.

In an ideal world you'd think anybody would be able to spot a sign of an illness and know right away what is wrong with the patient, but we all know it doesn't work that way in the real world. That's why we work as a team.

For that reason we at the RT Cave continue to do research on the Internet, to read the opinions of other RTs on the Internet, to listen intently when a doctor or nurse is patient enough to explain something we had no clue about that might come of some use at a later date. Who knows, we might be able to impress someone some day.

Being a small hospital, our bosses can't afford to send us to many RT seminars, or so they claim. But when we get the chance we go. When there is a free in service, and I'm not working, I'll be there with my pen and pencil -- especially if there's a free lunch.

While I'd like to think that this is the way all RNs and RTs think, I have had people tell me, "Why? You are an RT, so why do you need to know about sepsis? Why do you need to know about lab values other than ABGs? Why do you need to know about hemodynamics?

And sometimes I hear things like, "Well, I'm not getting paid anything extra, so I'm not going to learn anything new."

That's fine. I don't have a problem with people thinking that way. That's their choice.

That type of thinking isn't good enough for me though. I want to be more than just a body passing nebs, or doing some odd procedure.

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.

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 demographics of RTs will not change

Djanvk, in his blog Respiratory Therapy Driven, wrote on Friday his thoughts on why someone would choose respiratory. I thought recently about writing about this topic, but now I don't think I could word it better than he did. You can check it out here: http://respiratorytherapydriven.blogspot.com/

I have asthma, and my parents encouraged me to go into respiratory, but didn't think I could pass chemistry since I failed it in high school. A friend of mine told me she liked Ferris, and she provided me with an application. When I was filling it out I just happened to be sitting in my journalism class, so I selected "journalism."

The only thing I accomplished in those first 2 years of college was, as I tell my Friends now, joining the fraternity Tappa Kegga Brew. No that's not a real fraternity, but that pretty much sums it up.

While I did learn how to write, as you can see, I failed to make a career out of it. After I graduated I got a found a job, but after three months of stress I decided I couldn't do this the rest of my life. So I went on to get a BA in Advertising. After I graduated in 1993 I ended up spending the next year as front desk clerk for the Shoreline Days Inn while living with my parents. I decided I better go back to school to learn a trade.

As I think of the RT and Rt students I've met, I think Djanvk's list is accurate. I know several who tired of waiting to get into RN school, former construction workers, a former nurses, various moms, and a good share of asthmatics.

A friend of mine was invited to give a presentation about her career at her daughters school, and she asked me, "How am I going to explain what we do?"

"I don't know," I said. "How do you explain about suctioning, about ventilators, about being short of breath to 8 YO kids. I don't even think most adults, unless they have had use for an RT, would even know we exist."

She ended up showing the kids about BLS.

Unlike nursing, I think most quality hospitals are saturated with RTs. At least that's the case where I work. I've been next in line for a day job nearly 8 years now.

I suppose until the demand for RTs increases, the demographics of RTs will not change.