My advice to new RTs

Question: I graduate in two months. What advice do you have for those of us starting our first 'real' job?

My humble answer:

1. Punch in on time
2. Know that you are not ancillary staff, you are part of a professional team.
3. Give 110% all the time, but when it's slow don't be afraid to read a book and relax.
4. Get all your work done and then gossip or read a book or play on the Internet.
5. Start treatments a half hour early in case you get called STAT somewhere.
6. Get to know your patients and who really needs treatments, that way you know who to brush off should you be forced to prioritize therapies.
7. Get all your charting done as soon as you get a chance to sit down; do not wait until the end of the shift in case you get a rush at the end.
8. Get your oxygen rounds done and charted as early as possible. Don't wait to the end of shift to do them, as this make people think you are a slacker.
9. You are now a real RT. You can do more than one treatment at a time if you need to. But stay in the same general area. If you have a patient who takes treatments at home, there's no reason he can't be left alone in the hospital.
10. That said, the following patients should never leave a short of breath patient alone, nor one who has a really bad and sensitive heart.
11. If you have a vent alarm go off, look at the head first, vent second.
12. Don't let new vents scare you. They are all the same and easy, despite what you learned in RT School.
13. Never do a vent check without charting alarms, even if the slacker who worked before you didn't chart any
14. Make sure you take your time when charting and do it accurately. You can drag charting, but be sure not to drag over some else's comments, lung sounds and vitals.
15. At the end of your shift double check ALL your charting. Make sure you charted it and clicked on the right medicine.
16. Take criticism with a mighty, "Yes ma am or sir." I'm serious.
17. On the same note, do not back talk or make excuses -- own up.
18. Punch out on time. Don't be late checking out because you are charting

This is a growing list. Check back later for some more advice -- if you need it.

Good advice for hospital administrators

So, in watching the Today Show this morning, I learned that Fortune 500 has named it's top 100 employee friendly businesses in America.

This really was no big deal to me, except when the expert was asked the following question: "What is it that makes these companies so employee friendly?"

The answer: "Most companies put their customers first. All of these companies put their employees first. When your employees are happy, the customers will come."

Aha!!! I have been telling my RT bosses this for years. Finally this has been spoken about some of the most successful businesses. If it works for them, it could easily work for any business -- even a small town hospital.

So providing cheap health insurance, and not involving RNs and RTs in the decision making, has a tendency to frustrate employees. Thus, you create an environment for a revolving door (high turnover rate).

And the people who stay do so becaues they have no choice. A bitter, resentful environment of constant complaining is the result.

Hey, who ever would have thought that if you keep your employees happy, customers would come. Hmmmmm????? Right here at the RT Cave anyone!!

New strategy for change in the RT Cave

In my past few posts I emphasized the problem that has caused low morale in this RT Cave, in this post I will state the proposed solution to improving morale.

Actually, the best way of improving morale is to have happy employees. If you have happy employees, everything else simply falls into place.

Yesterday I told my supervisor I was going to quit. I was serious. In fact, as soon as I got home I downloaded an application to another hospital, filled it out, and then went to bed. However, by the time I woke up I had a more level head on. I was ready to tackle the problem head on. The time had come. I had nothing to lose.

At first I thought my bluff wasn't taken seriously. But, when morning came about, and the hour of 4:00 rolled by and I didn't hear from my supervisor, I knew something was amiss.

And, as I was just about to wrap things up for the day, the head RT boss approached me and wanted to see me in his office. Apparently, the supervisor had told him I wanted to quit, and he asked me what the problem was.

"The problem is simple", I told him, "that I have gone home miserable the past few days, and while I had planned on working another 22 years at this place, I refuse to be miserable for 22 years."

"Well," he said, "How can I make it better for you." Wow. Is that all I need to do to get some attention -- threaten to quit. I suppose the squeaky wheel gets the grease. I'm taking advantage of this.

"The answer to that is simple," I said, "Communication. I think that we all seek the same goal of improving the department, but you guys decided you were going to do something and didn't' tell us about it, and then all of a sudden you expect us to be perfect in our charting. That's simply poor business. Thus, I propose, simply that you better communicate."

I could have sat in his office complaining about how poor of a communicator he is, or how stupid the administration at this hospital is, which is what the RT Complainers may do anyway, but I didn't want to stoop to that level. I wanted this meeting to be productive.

"What do you mean by communicate?" he said.

"Exactly like you are doing right now. You are listening to me, and allowing me to speak. And, I am sure, you will explain to me why you are all of a sudden cracking down and expecting us to chart perfectly."

"That makes sense." And he proceeded to explain to me why the crackdown. He explained economic hard times. While the hospital might be really busy today, it has had many slow days. So, when random procedures don't get charted, that amounts to money that is not made for the hospital.

He said, "Okay, any other ideas."

By golly I did. I rattled off a list off the top of my head:

1. I would like a 12 hour leeway in which we can do our charting, or fix any errors in our charting.


2. At the end of the day, I want to be able to print off a sheet that lets us know what we charted, so if we didn't chart something, double charted, or didn't chart something at all we'd be able to see it right then so we could fix it. He thought we had this list already, and I explained we didn't. There, one communication problem fixed.


3. Another co-worker I talked with proposed that instead of leaving notes every day that we made a mistake, that we create a monitoring system where this data is recorded, and at our monthly meeting we can monitor progress or lack there of. If a certain person has more charting errors than the average RT, then he should be set aside and a plan should be worked out to determine how this might be improved. If the department as a whole is making the same errors, then perhaps a new strategy for charting should be implemented.

After I left his office, I coincidentally picked up a book I had in my basement and read it, considering it was only 174 pages long and pertained exactly to the situation at hand in our RT cave. The name of the book was The Effective Executive by Peter Drucker.

In this book he talks about a model for effective executive leadership. It shows a way to turn a failing model around into a successful model. And, considering the new policy in our department that attempted to make us RTs perfect on a dime, and that resulted in excessive complaining, animosity and low morale, this situation was on my mind as I read the book.

According to Newt Gingrich in his new book Real Change, Drucker's strategy goes something like this:

1. What do you VALUE?


2. What VISION of success do you have for achieving what you value?


3. What METRICS would tell you whether you are making progress toward your vision?


4. What STRATEGIES would enable you to achieve your vision?


5. What PROJECTS would enable you to implement your strategies successfully?


6. What TASKS have to be done well to complete each project?

Before I left his office I cracked a joke to lighten up the atmosphere, and then I told him I felt better now that we communicated, and I thought it would be a good idea to communicate like this with the rest of the staff as well. I was impressed when one of my co-workers called me to inform me she was to have a meeting with the boss later in the day, as has every other RT in the Cave.

"What the heck did you tell him," she said.

"Everything," I said, "What did I have to lose."

We value more communication and good morale in our department. We want back what was stolen from us when this new policy was enacted. Our vision of success is involving the entire department in the decision making.

Jane Sage is the one who thought of a strategy for metrics, and this is her idea was to create a monitoring system that showed us what we were doing wrong and whether it was the entire department or if some of us were more more prone to making mistakes than others, and what exactly were the mistakes.

Metrics is more than just the statistics that are pounded on us at each department meeting, statistics that show ups and downs in the monthly financial status, or how well the hospital is perceived within the community, or the RT department for that matter (as a side note, we are viewed as excellent on a regular basis).

While the statistics can show some trends, statistics cannot show morale. Likewise, statistics can become stale. Thus, having good metrics is a far better means of solving a problem.

By my meeting with the head RT boss I listed some of my ideas for improving the problem. And, as he plans on talking with other RTs, they will list some of their strategies, projects and tasks, and then we will get together in our next departmental meeting an analyze all the information accumulated and try to implement a plan.

Newt Gingrich, in his book Real Change writes that "Albert Einstein had a firm rule for thinking about new solutions. He asserted the following: thinking that doing more of the same will lead to a different outcome is a sign of insanity (Emphasis added).

Thus, even before any of us had read any book on the subject, we were on the right track to obtaining better communication and, perhaps, better morale.

Thus it only makes sense for the RT bosses to implement a new strategy to achieve their goal. This meeting I had with the boss was only the first step, I'll keep you guys updated on how things progress from here.

Here's my advice for hospital patients

Based on my own experience as an in-patient earlier this week, I've come up with a few bits of good advice for anyone going to the Emergency Room, or who might be a potential hospital in-patient.

1. Know your rights as a patient
2. Make sure you have someone with you.
3. If you think a therapy might be ridiculous, you may be right
4. Know you have a right to refuse therapy.

As you know from reading earlier posts on my blog, there are a lot of frivolous doctor orders pertaining to respiratory therapy. Knowing this, I ask nurses all the time if they get stupid orders, and usually they tell me they do, but can never think of anything off hand.

With no disrespect to doctors, I know they have a tendency to write orders out of habit and not necessarily because they are all necessary. Now that I've been that patient, I saw first hand what some of these frivolous orders are.

After I was told I was going to be admitted, and after I was stoned on phenergin, my ER nurse approached me carrying a foley kit. "The bad news is we don't have a male working who can put this in."

"I...don...crrrr..." slipped from my lips. I was trying to tell her that I didn't care who put the damn thing in, it wasn't going to happen.

Thank God I followed patient rule #1, because my wife was sitting right there and refused for me. She made sure the nurse was aware that we had a pact that the only time anyone would stick a foley in me is if I end up on a vent.

I like to call it a DNC order: DO NOT CATH.

"Why do you need to put a foley in him," my wife asked. "He can get up and pee."

"I don't know," the nurse said, and tossed it aside.

My wife added, "Just make sure you keep good track of your pee."

That was the end of that. In retrospect, I think this RN wanted me to refuse; that she knew it was a dumb order, but out of respect for the doctor she couldn't come right out and say it. I suppose this was not unlike me when I know a patient doesn't need a treatment.

Later that night, after I was admitted to the floor, a nurse woke me from a sound sleep. "I have to put these on you."

"What?" I said, groggily.

The RN said, "Sequential compression devices (SCS) to prevent you from getting clots."

"What do I need those for?" I know what they are for, but why do I need them?

"It's protocol to prevent clots." Clots? I can flip myself over no problem. And I didn't get clots when I slept in my own bed just last night.

"Okay," I said, "I'll try it." Why the hell am I agreeing to this? This is ridiculous.

Those damn things made my legs sweat, were excessively loud, and were extremely annoying. Not only that, but they made it nearly imposible for me to sleep on my side, which is how I like to sleep. These are coming off as soon as that nurse gets back in here.

"Why do I need these things again?" I said when she checked on me a half hour later with a syringe in her grasp. I proffered my arm.

"We have a standing protocol that all patients have to get these to prevent clots." She inserted the syringe into the IV.

"Every patient has to have these?"

"Yes."

"Well, that's ridiculous.

"I know." She's agreeing with me. That's it. She knows it's a stupid order.

"I thought it was just respiratory therapy that got stupid orders." Okay, shut up man; you're crossing into grumpy patient category.

She didn't say anything, finished her work on my IV. The machine beeped momentarily as she pressed a few buttons, and then she stood by the side of the bed.

What? Are you waiting for my order. "Then take these things off. I'm a young guy and I don't think I have a problem with clots."

"Okay," she said, and pulled the blankets from over my feet without hesitation. She's not argueing with me. That's reassurance enough. I heard the rip of the valcro as she stipped those things I couldn't remember the name of off.

I felt fresh air upon my ankles. Ah, that feels good. I rolled over and within a few moments was having pleasant dreams again.

"Do you think I need those things," I said to my wife when she arrived after breakfast the next morning.

"No," she said, "but I know sometimes doctors write orders just out of habit."

"I kind of figured that."

"You know you almost agreed to a foley last night? You were lucky I was here."

"Thank God for you."

She told me she remembered a time when she was working in OB when the doctor ordered a cath on a lady. She approached the doctor. "Why does this patient need a foley?"

"Oh," the doctor said, "I just wrote it out of habit. I'll DC it."

Dr. Tree said nothing about me not having a foley when he checked on me that morning. I wondered if he even knew he ordered it.

The reality of small town hospitals

Shoreline Hospital is a relatively small hospital on the shore of a Great Lake in Michigan. I noticed the first time I walked into this place I was going to like it here. As one of the senior RTs described it to me at the time, "this place has a nice down homey feel to it."

There are the obvious goods and bads of working for a small place as this.

The good: We RTs have time to sit and get to know some of our patients. That's one of my favorite things about this job is learning about an elderly persons entire life in just a few short hours. Sometimes it reminds me of the movie Fried Green Tomatoes. If you haven't seen that movie you should.

When it's slow we talk, play cards or simply hang out. Sometimes, when a good ballgame is on, we turn on a TV and enjoy it, only to leave every ten minutes or so to check on our patients, or, in my case, to run down to ER occasionally. And, on nights like tonight, we have pot-lucks.

When it's really, really, really slow I sit here and do this. Earlier in the summer we wrote protocols for everything imaginable, we did research, we looked for new innovations to improve our hospital. That's what we do here. Or, that's what I do here when it's slow. I can't just sit around twiddling my thumbs or gossiping. I hate gossipping.

If I were busy I highly doubt I'd be making entries here every day. How many jobs can someone get paid to blog all night long? When it's like this, coming to work is like going on a vacation. I tell my kids this is what you get to do at work when you go to college.

The bad: When I first started working here Dave came up to me and said, "Rick, you should go to work in Grand Rapids. If you go there you will be able to use your skills all the time, instead of once in a while. If you stay here, you might lose your skills."

He told me he's been working here so long doing frivolous breathing treatments that he didn't have any real respiratory skills left, and that there was no hope for him ever getting them back.

Needless to say Dave is our complainer. He's a great therapist, but a complainer. You know what they say about complainers, that they say more about themselves than the people they are complaining about. Every hospital has them. I hate complainers. I avoid them to the best of my ability.

I also hate doing breathing treatments on people who don't need them. I hate going into a room at 5:00 in the morning to wake up a patient just because the doctor said. If the patient is not having bronchospasms, if he's sleeping, he doesn't need it. I hate waking these patients up. I feel stupid. I feel like any person out of college could do this part of my job. This is why I'm such an ardent supporter of protocols, to get rid of this junk.

We will get busy again soon, and more than likely it will happen all of a sudden, and involve 20 Q-forever breathing treatments for no reason, and ER will be swamped.

My ideal workload: I want to be busy doing real RT work. I want to be busy with critical patients, COPD patients, asthma patients, real chest pain patients, and the only breathing treatments I do are for bronchospasm.

Reality: We will have a mixture of all the above. I will not move to Grand Rapids or Ann Arbor and definitely not Detroit where I'd actually get to use my skills on a daily basis. I can't because I'm not switching my kids to a new school, and I hate moving as much as I hate complainers and gossipers.

So we make the best of it here at Shoreline Hospital. The complainers will continue complaining, the button pushers will continue pushing buttons, and us hard workers will continue researching, writing protocols, and thinking of new ways to make this the best small hospital respiratory therapy cave, even if it's just to appease ourselves.

But there's only so much of this we can do. So when we're slow as long as we've been it's easy to drift off into la la land. When you don't do work for a long time you get lazy.

And I guess that goes full circle to what Dale said. And, ironically, that was one of my biggest fears when I graduated with my RRT: do I go to the small Shoreline in my hometown and risk getting lazy, or challenging my skills in GR?

Anyway, my point is: Despite the bad, despite my newly formed laziness, despite the high school work, we still have a pretty good team here when it comes to solving real patient problems. I think this is a well respected, well experienced, well educated group of RRTs; and this is a pretty nice place to work. I suppose what it comes down to is: it is what you make of it.