Tips for the good RT Boss

The following is a guest post from Will Lessons, retired RRT

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I worked with Bob for 16 years.  He was a fun guy, and we would spend hours on slow days tossing EKG stickers at the clock or seeing how far our spit would drop from the stairwell. I mean, you have to be fun to do something like this.  Then we'd go out to the nurses station at 4 am and flirt with the female nurses.  On our days off we also had fun together.  

I also remember when it was really busy once Bob and I were taking care of a critical patient.  We so happened to rush into the supply room at the same time, and we realized there was no oxygen tubing.  Bob said, "Watch this!" as he ripped open a venturi mask and took out the oxygen tubing.  "Now we have oxygen tubing."

A few years later Bob became an RT boss and he completely forgot what it was like to be an RT.  It was like he completely morphed from a peasant to a dragon.  Instead of having fun with us he put a stop to all fun.  He was still nice, but he was meticulous at enforcing the rules set forth by the administrators.  He morphed from all fun to all no fun.  Everyone hated him.  He was great at managing the department, but his communication skills dropped off the southern end of the map.

So when he moved on and I became the RT Boss, I decided I wanted to be everything Bob was and everything Bob was not.  During my interview I said to the admins questioning me:  "Bob was a great boss.  He did many great things for this department.  I want to continue all he did.  Where Bob failed was he was a poor communicator.  He made decisions and forced them on us, or at least it appeared that way.  When someone approached him he did all the talking.  The result was a low morale.  I think we would all be better off if we all felt like we were a part of the process.  That's the best way to get the best results, at the best cost, and the lowest amount of waste."  

And then I added, "At least that's what I think.  And I understand you may not hire me because I'm being truthful here, but I think this is important in a boss.  This is from my observation."  

I was hired.  And I kept my door open at all times.  And I kept my voice off.  The sign on my door read:  "Come in and be heard."  That's my advice for prospective and current RT bosses.  Work among the staff, not above them.  

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Thanks once again Will.

Things RT bosses can do to keep you happy

Studies have overwhelmingly showed that the more satisfied workers are the more satisfied their customers will be.  This provides bosses with an added incentive to keep workers happy.

That in mind, here are some ways your boss may try to keep you happy:

• Parties
• Birthday cards
• Bonuses
• Good benefits
• Annual raises
• Involving you in tasks (writing protocols, teaching nurses, teaching BLS, writing policy, etc.)
• Involve you in departmental decision making
• Creating protocols
• Listening to you
• Giving praise

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Performance surveys: 90% is the new bad

So we had our monthly meeting this week. One of the things that comes up at each of them are various performance surveys. And the ironic thing is that no matter how good they are the bosses are never happy.

I know never is a generalization, but in this case it seems to be true. Shoreline contracts out a company to interview random patients to see what they thought of services provided, and the results showed for the caradiopulmonary department (or the RT Cave) were 95%.

"I know that sounds good," the RT boss said, "but that still means that 5% of the people are not happy with our services."

This is the kind of stuff we deal with at just about every meeting. Good is never good enough, as 95% is good. In essence, good is the new bad. To an idealist that might be a good thing. But to a realist like me it's simple insanity.

So at today's meeting I said, "You know what, Gary, that 5 percent are probably people who wouldn't be happy if you scratched their backs and picked their noses for them. We sit here and listen to you guys every month complain about really good performance reviews. Can we not find anything better to do?"

Of course then you get your political response, "It's always good to have a goal; to continue to strive for better."

"Yes, I know," I said, "and I think we all do that here. Everyone in this department gives 110 percent with every single patient. It's not just good, it's great to try to make things even better. I just think we can find better things to do with our time than deal with this stuff every month."

That was when my co-workers chimed in to back me up. Dale said, "Come on, Gary! Here we are doing stress tests, making people run on a treadmill until they're about to puke, and then we ask them, 'so what did you think of the stress test.' Well, some of them will simply say, 'it sucked.' Does that mean we provided a bad service. No! It means what we did wasn't any fun.

"We do ABGs," he continued. "We poke a patient where it ain't fun to be poked. And then we expect them to say, 'Excellent!' Come on! Let's get real here."

So the rest of the meeting played off this theme. Our intent was not to be negative or pessimistic, and I don't think we were. It was simply all of us RTs, who do all the work, who have to sit in these meetings every month, trying to make sense of why do we continue to do these performance surveys.

A similar session happened before and we were called complainers and whiners. I didn't say this yet I wanted to, so since this is my blog I'm going to write it here and pretend I said it to my boss: "There's an old saying: The truth hurts, and then it makes you better."

How bosses and doctors deal with trouble

Bosses and doctors and probably even elected politicians go to the same class. To deal with problems they are taught to do one of the following:

1. ignore the problem
2. Piss off the person
3. Tell each person what they want to hear

Example of 1.

Jane has approached her boss several times about a new job posting. The boss sent an email, "I'll get back to you." Her boss never did get back to her. She doesn't want to fill the position, so she just ignores Jane.

Example of 2.

Let's take holter monitors in the ER as an example. I see no reason they need to be done in the emergency room. There is no reason I need to use up my valuable time to set one up. So, I approach my boss.

He says, "I will talk to Dr. Pepper to see if we can remedy this problem.

The nice thing about it is there were only 2 holter monitors in our department. So if none were available we could just say, "I'm sorry, but..." and be on your way..

When approached, Dr. Pepper says, "I think if a doctor wants to do a holter one should be available. So I think you should buy 10 more holter monitors.

So since we brought up the problem the RT bosses pissed us off and made it worse for us.

Another example of this is I approached Dr. Mark to let her know the patient had been on treatments for three weeks and I didn't think they were indicated anymore. She taught me a lesson and changed the order to Q2 and add IPPB plus added mucomyst and pulmicort every other treatment.

Of course we have one doctor who every nurse is afraid to call no matter how serious the problem. She's very rude and says things like, "Why'd you bother calling me with that?" Then the

The third method is basically politics as usual. You talk to your boss about a problem and your boss tells you what you want to hear. Then another person approaches the boss about the same issue, and the boss tells that person what that person wants to hear.

Sure there's some lying going on. Yet the peace is kept. No waves are made. That is until you and your coworker get together some day to learn you were both told a different thing.

And nothing got done. No peace was really made. Yet so long as you and your coworkers don't communicate, the waves are calmed until the problem is forgoten about. At least that's the intent.

Of course there's also a fourth method.

A better way to run a business is by this method. Yet sometimes politics is the better part of valor.

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Word of the day: Cacophonic: harsh discordance of sounds; a meaningless mixure of sounds

1. A cacophany of hoots, cackles and wails.
2. The cacophany of city traffic at rush hour.

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!!

RT bosses, admins think on different level as RTs

I can kind of understand why the administration here at Shoreline has been having conniption fits lately, and why they have been clamping down on on us lately, as I come to work today to learn there is an entire patient floor closed due to lack of patients.

As I wrote in a previous post, the size of this hospital is too small to be considered a large hospital, and too large to be considered a small hospital. As we are too small, we don't make enough money to be able to have extra staff on hand, which should explain to you why I have to work alone on nights regardless of whether I have eight patients on my board, or 22.

We are too large to receive government grants. Which is funny, because when I used to work at Death Line Medical Center, which is about 40 miles from Shorline Medical, I never could figure out how they could afford to have two therapists during the day. The RTs there never got called off, even if there was no work. When I worked there I was told, "If you are scheduled, why would the place call you off?"

Well, here at Shoreline, when it's slow, people get called off work. So how could these two hospitals so close together have such a different view on when to call workers off? I'll tell you the answer, Shoreline is located in such the perfect (or imperfect) location where we have just enough more patients than Death Line that we are over the line that would classify us as a small hospital. And, since we are over that line, we do not qualify for government grants.

So I suppose when the patient load is down, like it is today, workers get called off. The surgical floor and the step-down unit have both been closed, and, of course, all the staff that usually works over there are getting called off. While over at Death Line, even though their census is down too, well, they continue to make their paychecks.

That's just the way the medical field is. In September and October, if you remember from my posts, we were so slow for so long I wondered if it would ever pick up. Then from November through May we were so busy all the staff here was getting burned out. Now the cycle has come full circle, and we are excessively slow again.

So, I can see why the administration would make a big deal about a few miss charted treatments. If we were busy all the time like some big city hospitals, then I don't think the administration would have the time to worry about the minor things. If we were small, and the hospital received extra money from the government to cover its debt as is the case with Death Line, I don't think it would matter either.

But, since Shoreline is not small and not big, the administration spends that extra time looking at all the statistics. They get bored and instead of taking care of more important matters, they sit around double checking all our charting to make sure we dotted all the i's and crossed all the t's. The get nit-picky. And sometimes they make decisions that they see as for the better of the institution, yet they forget to involve us in the process.

And that, my friends, is why some RT departments might develop a low morale from time to time. The admins don't intend for morale to dip, but it just does. It does because the staff feels like the admins are making a big deal out of spilled milk. And, quite frankly, they are making a big deal out of spilled milk. But, as more and more smaller hospitals are merging, or closing their doors, Shoreline has managed to stay afloat -- alone. So, perhaps, this little nit-pickiness is a necessry component of independence.

Now, whether this battle to maintain as an independent hospital works to the advantage to us RTs or not I have no clue. Part of me thinks it would be bad. But, the other part of me thinks that if we merged with Aero Medical Center, that we would all get nice hefty raises so our staff would be paid as well as their staff. As, being a smaller hospital (not small enough, not big enough), the administration here will not even consider the idea of giving us all hefty raises.

But why would they give us raises? All the RTs in this department have been here so long we are all complacent. We have worked here so long, have so many friends here, love it here so much, are comfortable here, that we wouldn't go anywhere else to work. In a way, that's true. I am comfortable here. I love it here. I have many friends here. I'm complacent. And, while I could go somewhere else, I don't. It's far easier to stay here. Besides, if I decided to take another job, at Death Line for example, I'd have to drive. That's wear and tear on my car, and, hell, with gas prices at near $4.00 a gallon, I'm better off staying here, where my drive is only five minutes.

And, with 10 RTs here, and all of us in relatively the same boat as me, the administration can afford to push us a little bit. And this, what I write today, is some of the mentality behind the administration forcing our RT bosses to crack down on our charting, making a big deal of little errors, and make an attempt, as my fellow RTs and I like to put it, to make us perfect.

While I do have a bachelor's degree in business, and an associates in respiratory therapy, I still don't know as much about hospital administration as some of you guys. If I am ever to move up the ladder and become one of them, there is a lot I have to learn. However, I would imagine that my analysis here is not too far from reality.

Usually here at Shoreline the morale is high. Usually, all we little RTs and RT bosses and administrators get along. Some of us get along in close little friendship type relationships, and some of us in good little business relationships. Some of us, like me, have a combo of the two. But on occasion the administration pushes our buttons just because they can. And slowly but surely the morale will decline. The morale will decline until someone gets tired of it all and mossies on into the RT bosses headquarters for a little chit chat.

Then, once the RT bosses realize that they pushed us a little too far, they back off. Then morale starts to climb. Then things get back to normal for a year or so until someone in the administration gets another idea, and the RT bosses, or the administration itself, pushes us over that line again. They will wait just long enough so they think we forgot the last time they tried to cross the line. But we are smarter that: we don't forget.

I've worked here long enough now to know this is how it goes at a hospital that's too big to be small and too small to be big. That's just how it goes.

Tonight I came to work with a self diagnosed acute exacerbation of chronic laziness. I feel this way not just because I had too many days off, but because the patient census is so low again. Now, I'm not making a big deal about this, because I love it when its slow because I get paid to blog, as I'm doing now. And perhaps I blog too much, but you guys can be the judge of that. But the downside of a low census, as I've already explained, is that the admins get all stressed out. And when the admins get all stressed out, so too will the RT bosses. That's just how it goes.

This time around, it was my turn to let the RT bosses know they went too far. I had my little chit chat with the head RT boss. I had to tell him that morale was down. That it was so bad that even people in ER were asking me about the "tension" in the RT Cave.

"What?" he said. "I didn't know tension was that bad?"

Well, guess what? There ain't no tension anymore. While the RT bosses still want to improve our charting, improve the little things, they have backed off. It's like clockwork. I know these guys like the back of my hand.

Sometimes, as I sit here thinking about it, I think I could do that job and better than those guys. I think if I were the RT boss, there would be no lack of communication, particularly because I've worked here on nights for 10 years and I know what it's like to be on this end and I'd have empathy.

Then again, both RT bosses were RTs once upon a time. They are both dragons now.

Then again, I think that once I cross over and become an RT boss, I will slowly but surely turn into one of them. I will slowly turn into a dragon. I will slowly forget about simple RT mindset, and start thinking in terms of money. For RT bosses, money is the bottom line. And money can do a lot of damage to ones mind. Hell, just look at Hollywood for some good examples of that. RT bosses aren't' far removed from that crowd. They get a little wacky sometimes. They don't think rationally. I'd like to think I'd be different if I were an RT boss, but would I?? Who knows.

Now, getting back to the size of this hospital. Death Line has remodeled all its rooms so that all patients now get a private room. They have remodeled all the OB rooms so there is a hot tub in all the rooms -- and they are all private too. And they have a brand new ER. I've decided they get to do all that because of the government grants, which they get because they are just a little less busy than us and are qualified by the Fed as a small hospital.

Here at Shoreline, well, we are stuck with an ER that is just too small, especially in the summer when all the visitors flush into the region, and an OB that is way too old for modern times, and patient rooms that are too small for all the modern equipment and two patients per room.

Yet, even while we have this old facility, the admins have managed to keep it looking pretty sharp. While we have an old ER, we have a damn good staff. While we have an old, rickety OB, we pride ourselves in knowing we have a far better staff than Death Line. We take care of our patients as good as the best big hospital, the best small hospital, and the best hospital that is too large to be small and too small to be large.

And, for the most part, except for a few bumps in the road, the morale is high here. We are all one big happy family. All the units work well together, and I know it's not like that at all hospitals, as I've worked for some where there was no click between departments. And since we all know oneanother on a personal basis, because this IS still a small town no matter how the Fed wants to define Shoreline.

So, while the admins at this too big to be small and too small to be big hospital can sometimes get a little anal about little things, things that would be totally ignored in other hospitals, they still do a pretty damn good at keeping this place together.

Hell, all they would have to do is go down into the basement and look at the main computer to see that I've been blogging here all night, and they could make a big deal about it -- but they won't. They won't because I hold this RT Cave up while they are away. I make this place look good (except for my little piddly mistakes).

And besides, because I'm complacent here, because I have kids in the local schools I'm trapped in a way in this small town of Shoreline. I come to work every day not just because I want to, not just because I'm a great RT, but because I have to. I have to because the alternative would mean moving my kids to a new school again, and I don't want to do that.

The admins know this. They know this because this is how it is for about 80% of the people who work here. Because of this, and because they know I love the aura here at Shoreline, an aura the admins helped to create in those many periods of high morale, they know they can get me for a cheap wage. The funny thing is I know this, and yet I'm still here. I know their game. I'm just smart enough to know their game.

So they won't say a word to me any more about this little game they have been playing about being perfect. Because, as I told the head RT boss the other day when I approached him in a civil manner, "I do not have to stay here. None of us have to work here. We work here because we love it here, but we do not have to stay here. So let's move on."

And we will. For the next two or three years the admins will not try to push us over that line. And they better not, because I could just as easily go over to Death Line and work for a better looking yet inferior institution.

Then again, they might call my bluff.

Reimbursement criteria going a bit overboard

I had to laugh as my co-worker today told me that he was approached by the lady in charge of double checking charts to make sure we are complying with quality management.

The basic purpose of her job is to make sure that charting is as such that we will be reimbursed for therapy. She also has to make sure that the patient meets criteria for payment.

"Hey Dale," she said, "What is it with all these Q4 breathing treatments being given 10 minutes late or 10 minutes early.

Dale told me he looked at her with a blank face. What was he to say? He told her that we are a busy department, and because this is a job with many interruptions, we have to have some leeway in doing our therapies.

"But," she said, "In order for our insurance to pay, Q4 treatments have to be done every four hours exactly."

Dale said, "At first I thought she was joking, then I realized she was being serious."

What is the medical world coming to. Not only are we incapable of deciding who really needs breathing treatments, we have to do them exactly when we are told.

However, that's not going to happen.

RT saves life and then gets no respect from RT boss

One of my day shift co-workers did an EKG on an out-patient and it was normal. Then the patient told him that she was fine when she was just sitting there, but got SOB and her heart felt funny every time he walked.

"Well, go run up and down the hall and come back and we'll do another EKG," my co-worker said.

The patient did, and my co-worker did the second EKG, which turned out to be abnormal.

So said co-worker called the patient's doctor and the doctor said, "Excellent job of thinking off the cuff there." The patient is currently admitted in the critical care.

Said co-worker told the head RT boss about this situation, and RT boss said, "WHAT! YOU DID WHAT?"

"I had him run up and down the hall, and then I got this EKG." My co-worker showed the boss the abnormal one. "If I wouldn't have done that, the only EKG I would have got was this one, and it looks normal. Would you feel comfortable sending this patient home with this normal EKG on file, when every time he moves he gets this abnormal EKG?"

"Well, you better chart the hell out of this," the head RT boss said.

Here you go out of your way to save a patient's life, and not even that is good enough to please the RT bosses. This is another example of how they have lost touch with everyday RTing.

Doctors have more power than my boss

I was off work for five days already, just long enough to forget how burned out this place made me last week, when Jane Sage called me at home Tuesday evening. Shoot. What did I do wrong now.

It was nothing I did wrong, but what I did right that she wanted to talk to me about. You see, I had spent the last couple years making a cheat sheet of ventilator graphics for myself to use mainly, but when I finished it was so popular around here that now everyone has a copy of it.

Anyway, one policy we have here is that nothing can be posted, filed or even hung on a bulletin board unless it is approved by the forms committee. So, I placed this cheat sheet on my bosses' boss about four times now, and nothing ever happened. However popular it is among my co-workers, the RT think getting it approved would be too much work -- or something.

Once I corned my boss, and she said, bluntly, "The writing is too small and this is much too complicated. If you want to use this form, you can just carry it on your clipboard."

I dropped the idea, until Jane called. My wife answered the phone when I was picking my son up from school.

"Dr. Aerial saw your graphics sheet, and he loved it," she said. "He said he wants one. He wants to understand graphics so people don't have to keep explaining them to him. He wants one of those sheets on the vents."

"Holy cow," I said, "You mean a doctor is actually interested in something I did."

It was true: ego up one notch from zero to one.

It seems we are making progress here at Shoreline, slowly but surely. Or, doctors have more power than my boss.

A little tounge slippage due to pure exhaustion

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

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

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

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

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

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

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

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

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

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

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

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

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

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

That aside, what came next was a little slippage.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Dragons of the RT Cave

I feel bad for you that you have to come back to this place, because it's terribly busy.

Despite that omen from one of my co-workers, it has not been busy at all this weekend. In fact it's been wonderful. And, considering I was prepared for a miserable night, I'm enjoying it that much more.

I don't know if I ever mentioned this before, but the Dragons of the RT Cave wake up early to guard the cave. I usually grab my stuff and run when it starts to stir, and pray it doesn't use it's telekinetic powers to find where I'm hiding.

I have no clue why it wakes so early, but when it does I can smell it. Personally, believe it or not, I like our dragons. They're tough, but they hold down the fort rather well. Still, one of the perks of working night shift is you don't have to deal with dragons, as I write in one of my banner slogans, "the dragons are sleeping at night, if you know what I mean."

And keep in mind that not all dragons are bad. We actually have pretty tame dragons here at Shoreline, and they do a pretty good job of keeping us proles in line, and making sure we have all the best technology to work with. Still, a dragon is a dragon.

From Monday through Friday, however, our dragon hops is sniffing the grounds as early as 2 a.m.. So that means I have to pack up my bags and head to better Pasteur's. Well, I suppose I shouldn't say better Pasteur's as our dragon is quite friendly. It's just that a dragon is a dragon no matter how small, and dragons can get mad and rip your head off, or burn you good.

I used to hide out because it tried to eat my head off every time I got close to it, or so I thought anyway. Every time I forgot to dot an i or cross a t it was right there breathing it's fire hot breath over my head -- breathing fire. While some night shift RTs still fear it, not me anymore. Still, it's good to be wary.

Since those days of long ago, the RT dragon and I have helped each other out enough times now that we are on good terms. Still, having been away from the patient floors as long as it has, it's developed that business mentality -- forgot how it is on the floor per se. And, you guessed it, everything has a monetary bottom line. It has grown it's scales. Now it's a full grown dragon.

I don't make many mistakes anymore, but occasionally I still get a note, or, if I happen to be working when it finds out I did something incorrectly, a telepathic call at. Mainly the goofus mistakes are minor things, but a mistake is a mistake no matter how small.

Recently I left a blood gas syringe by the ABG machine.Could the dragons let this one little slip pass without letting me know about it. No. The lab dragon sent a fireball with a message to the RT cave dragon, who snarled and waited for me to be working so it could call me at four in the morning to let me know about it.

But that was last week. Yesterday I'm sitting in the CCU with Scooter the RN, and my beeper goes off.

Just one morning, I think to myself, just one morning I'd like to go without getting a page from the RT dragon. Not that I don't like it, nor that I can't get along with the dragons, because I do, but it's 4:00 in the morning and I'm tired. Doesn't it get that? This is the time of the morning I just want to do my work or, if I have my work done, just sit around. I don't want to be quizzed.

Like a good boy, and wanting to stay on good terms with it, I picked up the receiver and dialed the extension to the RT cave.

"Hello," the dragon said.

"Yeah, this is Rick," I said into the receiver.

"Hey, Rick. No you didn't do anything wrong. But when you get a minute can you come talk to me."

"Sure, I'll be right there." I hung up the receiver.

"Was that your dragon," Scooter said.

"Yep."

"Well, you said it'd call you right at four. You have it pegged."

I laughed. "Yep, you're right." But I don't wanna go. I just wanna stay here and chill.

But, like a good peon, I left the unit and walked through the hospital to the RT cave. As I walked through med-surg I could swear I could smell that a dragon was here. I could feel it; sense it. It has telekinetic powers after all.

"So how was your night," it said as I approached the entryway to the cave.

"Oh, it wasn't too bad. Actually, it was very slow compared to the last several days I've worked. It was a great break."

"That's too bad," it growled, a puff of smoke billowing from its flared nares. "We need to make money, and we don't make money when you're not doing anything."

I had already been up 24 hours, so I had developed that 2 a.m. loose lipped mentality. I said, "Well, it's one thing being busy, but when we're busy doing a bunch of useless breathing treatments it makes me twice as burned out as if I were actually using my brain."

I followed the dragon around while it unchained the doors. It didn't snap around and throw a fireball at me, so I knew I was still in the good, even though I had more than likely crossed the line with my honesty. I never would have done that a few years ago, but, like I said, I was on good terms with it now.

"I think there are a lot of people here who no longer come to work because they love their jobs. They come here just to get a paycheck. When I used to do your job, I used to do it because I loved my job."

I was NOT going to touch that one. (However, my lack of comment here still haunts me today. This is one of those times where I thought of a good comeback after the conversation was over. I will write about this tomorrow). "I love my job, boss." Am I being political by saying that, or truthful, I think.

"I know you do," it said, "but I think that a lot of you guys are just too complacent lately," she said, "I think it gets slow, and then you guys forget how to work." It stopped and looked at me. "Not just you, but all you guys in general. Those treatments are how we make money. "

"Well, boss," I said, "I don't have a problem working, it's just that if we're going to be doing useless breathing treatment just to make money, I think they should be done during the day when there are two RTs on."

It turned around. I hit a button. Smoke was puffing from its little nares. "It's not just you, but all of you guys have been making a lot of little mistakes lately. Here, I'll show you."

I followed it into the dark cave through a corridor in the back. It was dark and horrifying back there, but I followed her anyway. In a way, being in here reminded me quite often of being in the principals office. I watched as it shuffled through papers on it's desk

"Here, see." it grabbed a stack of paper, flitted through them so I could see all the notes and who they were left for.

"I see that even Dale has made mistakes."

She flitted through the stack again. "Yeah, he's made several."

"Oh, I thought he was perfect."

"None of you guys are perfect."

"Well, it seems that's what you bosses are trying to make us out to be." Of course I won't call them dragons to their faces. That would be a violation of one of the RT cave rules. "Look, boss, we aren't' perfect, we are going to make mistakes."

"Well, you shouldn't."

"At no other hospital I've ever worked at did I ever receive one note, and I know I screwed up many times. I guess the feeling there was, if I make a mistake, and I have to go to court, then it's on my shoulders."

"Well, I guess we have higher standards here."

"I know. We do. And I think it's good. But I think sometimes you guys go overboard. Look, you guys got Paul and Steve up on the edge. They're to the point they hate you. I mean, I know it's not you, you're just doing what you're told, but since you're the one leaving all the notes, you're the one they are going to hate."

"My boss," she said, "makes me do this. He wants me to keep track of every note I write, and if I write six notes then I have to write you guys up for now on. That's why I called you here. I want you to be more careful."

"Boss, if you do that, then you'll have to fire us all. We aren't perfect. You're just opening up a can of worms."

"Hmm, worms, that sounds delicious," said the dragon. Just kidding. She said, "I just do what my bosses tell me."

"Well, if you write us up for every notes, then that means we'll get a verbal warning, and then, the third time, we get fired. By the end of the year you'll have a 100% turnover rate of RTs. We'd all be fired."

"Why is it you have to argue with everything I say." She beamed at me. I jumped back. There was no fire, but I could see it was close to exploding.

"I don't mean to, but we have a right to disagree with you. There's more than just one opinion in this department, and I think we are having a good discussion. There's no way you can make progress, in my opinion, without discussing. Don't you think?"

"You have a good point."

Whew. "Well, I think your bosses should come down here and work like we do, and they'd see how not easy it is to be perfect. They are so far removed from the real work, it's easy for them to make such frivolous policy for you. If they had your job, they wouldn't do what they make you do. "

"That's very true. They wouldn't. And, when Gary had my job, he didn't do any of this. He has me going over every chart, every day, writing down every little mistake I find. It's very exhausting, especially when I have to hear it from... well, not you, but Steve and Paul."

"Gary only has you doing all this stuff because you act as a shield. When us RTs get mad at you, you get the brunt of the spears. Your bosses feel no pain."

"Wow," she said, and smiled. "You hit the nail on the head."

The RT Dragons: They are abounding.

The winners and pinheads of hospital life

Some people are really great, and they make life easier for all of us. They are the winners. However, some people make life worse for all of us, and they are the pinheads. Here is a pithy list.

Winners: Dennis Quaid for not suing the nurse and hospital who overdosed their Twins with Heparin. Yes the nurse screwed up, but the Quaids weren't out to destroy them, nor to seek their money. To me that's a classy act.

Pinheads: Baxter Health care Corp for failure to change the labeling on similar looking bottles but different doses of Heparin, even after three kids died from receiving the wrong dose for this reason.

Winners: The few politicians who seek to to put an end to frivolous medical lawsuits.

Pinheads: Politicians who are more intersted in getting re-elected than doing what's right.

Winners: Prescription drug companies for continuously gambling millions of dollars researching for new medicines for today's many illnesses.

Pinheads: Any politician who's out to punish prescription companies for making a profit when they do succeed. They do this sometimes by proposing price controls. This may give the poor cheaper drugs right now, but it would stymie the incentive to risk further money on new drugs, especially considering the cost of a new drug reaching commercialization are 6000 to 1, & costs 10-20 years of research and $15-20 billion.

Winners: Medical workers who keep up on their research.

Pinheads: Medical workers who don't keep up on their research.

Winners: The people who do medical research.

Pinheads: Doctors who believe every study out there, especially the ones done by pharmaceutical companies on their own new drugs. Xopenex rings a bell here. Does it really have fewer side effects as Albuterol. Some new studies say no.

Winners: The makers of Xopenex. Hey, it's a new option, and options are good.

Pinheads: The makers of Xoponex for getting us foolish RTs and DRs to buy their product by way of our stomachs and fancy restaurants.

Winners: Hospitals who give Christmas bonuses.

Pinheads: Hospitals that are cheap at Christmas time.

Winners: RTs who volunteer to work overtime to make life easier for everyone else.

Pinheads: RTs who only help out when it's convenient for themselves.

Winners: People who do the scheduling and put up with all the whiners.

Pinheads: Bosses that require mandatory overtime. I refuse to work for them.

Winners: Volunteers

Pinheads: Greedy bosses

Winners: Fun to work with people.

Pinheads: Complainers.

Winners: Dr's for writing Doctor's orders. You guys are awesome.

Pinheads: Dr's for writing doctors orders. Some of these orders are just plain quacky.

The six different types of respiratory therapists

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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


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


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


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


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

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

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

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

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

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

I couldn't have been more wrong.

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

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

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

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

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