Arrogance in medicine conveys ignorance, says Dr. Altman

I like to show absurdity by being absurd on this blog, although I do not make stuff up.  I simply use things that people say, or write, and I show how absurd they are.  I have actually found physicians who criticize other physicians.

Among them is Dr. Lawrence K. Altman, who wrote in chapter one, "The Public Perception of Asthma," in the book "Fatal Asthma" that the medical community in general tends to be ignorant when it comes to acknowledging the potential factors that may make asthma worse, such as thunderstorms.  In regards to this, he wrote: 

We (physicians) forget how much we don't know.  There is a certain arrogance -- or insecurity-- that inhibits the medical profession's ability to convey its ignorance to the public.

When it is documented evidence that statistics concerning a disease such as asthma are worsening, it behooves us not to be complacent about old beliefs.  We should take a fresh look in the light of new knowledge.  (1, page 6)

He is right.  Physicians should not continue to treat asthma the same way it was treated 20 years ago, especially considering there is better wisdom and better medicine today.  Physicians who fail to realize this do so to the detriment of their patients.

The same is true in other areas of healthcare.

Reference: 

1.  Altman, Lawrence K., "The Public Perception of Asthma," Chapter one of the book "Fatal Asthma," edited by Albert L. Sheffer, New York, Marcel Dekker, Inc, pages 3 and 11. 

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Low Information Doctors

The following is a guest post by our RRT friend Will Lessons.

Recently Obama received the Time Magazine "Man of the Year" award because he was, according to the magazine, "able to get the vote of the low information voters."  Playing on this theme, I would like to nominate for next year's prize the low information doctor.

Low Information Doctors don't know squat about respiratory therapy; it means they are not informed about Ventolin and Ventolators and BiPAP and Mucomyst and Atrovent.  Some low-information doctors don't care, to the extent that they care when they have a sick patient, but other than that, it's TMZ and the E! Entertainment channel.   You know, uninformed is not low informed.  Uninformed is not they don't care to be informed. The low informed doctor simply chooses to be informed about other things, like Claire Danes and what she did with Clinton after the Golden Globes.  Or Kim Kardashian's baby with Kanye.  I mean, they care more about that than they do the benefits of Ventolin or the truth about the hypoxic drive hoax.

Yes, you heard me right.  The low information doctor who may be the best doctor in the world, and yet he has no clue about respiratory therapy. Respiratory therapy is beyond the scope of their knowledge, yet they excel at making up theories about how ventolin ails every irritating lung sound.

Thanks. Will

Thoughts?

Note: The views of Will are not necessarily those of Rick Frea. 

The Hospitalist: Are they good or bad?

So we do not have hospitalists where I work.  Generally, we have one general practitioner and one internist on call every night and on weekends.  These doctors have to take care of all the patients during off hours.  Yet sometimes they complain due to being overwhelmed.  They get calls at all hours of the night, and it gets tiring.

I have heard many of these physicians recommend our hospital have a hospitalist, and I imagine that's coming soon in the future.

What is a hospitalist?  It's a doctor who is in house, and he takes care of the patients that are admitted.  They work in 12 hour shifts just like respiratory therapists and nurses, and ER doctors.  When you have a problem with a patient, that doctor is right there to help out.  It's nice because you don't have to worry about a doctor not being available when you need one.  

This past weekend we had a general practitioner rental doctor, and she decided to stay all night.  At first I thought this was going to be a good idea, but she kept ordering new breathing treatments all night.  She ordered breathing treatments even on patients who didn't need them.  She'd call me at 2 in the morning because she wanted to give a guy Xopenex instead of Albuterol, even though the guy just had an albuterol and was not short of breath.  And then she decided to give every one of her patients "now one time mucomyst treatment"  

By the end of the night I wanted to choke her.

So after dealing with this doctor all night, I've decided that I'm not sure I want a hospitalist.  One of the advantages of working nights is you don't have to deal with doctors and stupid doctor orders.  Well, this doctor sure put an end to that advantage.  

However, I think if you got a decent doctor to be a hospitalist, it would work.  Yet if it's this doctor, I don't think I'd be very happy with my job.  

Two ways to hire doctors: Part 2

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

---

Last week I wrote about the two ways of hiring doctors.  Basically you have large hospitals that have a large pool of doctors to choose from, and they get to pick the best of the crop.  Small town hospitals don't have a large crop, and they pretty much get the leftovers.

 Many small towns, therefore, tend to hire any doctor that is available, and this sometimes results in doctors that otherwise never would have been hired.  This often results in doctors who are power control doctors who want things done their way or the high way.  

They tend to frown upon respiratory therapists as ancillary staff who do what they are told.  This often results in RTs who have low morale and a bad working relationship with these physicians.  Now there are exceptions to the rule, yet for the most part this is my observation. 

Again, I must say that most doctors are awesome, yet the 10% of doctors who are generally your rejects tend to work for your small town hospitals.  That's just how it is.  And, again, this is my speculation.  

So that's the problem.  Now what can be done about it?  It's almost a no brainer here.  I think the best way to remedy this dilemma is for hospitals to hold doctors to the same standards as when hiring any of their other staff.  Doctors should take the same personality test.  Doctors should be asked the same questions.  Whomever is doing the hiring must make sure the doctors hired fit the personality of the hospital.  

A second thing I think would help is to involve other people in the hiring process.  If you're hiring a urologist, ask the other urologist to participate in the interview process.  If it's an ER doctor, ask your nurses or doctors or respiratory therapists their past experiences with this doctor.  Often you can get a feel for how a doctor will fit in by simply talking with the people who already work for you.

Surely there's no way to fool proof the hiring process.  You can have the best interview, and it may seem you're hiring the best person for the job, and still you you could hire a buffoon.  I've seen it happen by the best of interviewers.  When I was Supervisor for an RT department once I hired a couple people on the same day who looked to be very fine RTs, and they both flopped.  Yet on the other side, I hired one against my better judgment and on a recommendation from a fellow RT, and this person turned into an elite RTs.  

So perfection is not possible.  Yet still you could come up with a technique whereby you can pick out most of the weeds.  

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Thanks again Will.

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Doctors should treat patients, not insurance company

The doctor wanted to have the patient admitted for observation, yet the patient didn't meet criteria according to the insurance company. Still, the doctor didnt' feel comfortable sending the patient home.

So, what he did was write on the chart, "Recommended patient be kept for observation for best interest of patient."

That way, he said to me, the insurance company is liable if something happens to that patient and now the doctor. He also wrote on the chart, "Patient was sent home against my better judgement."

This is a perfect example of how cook book medicine does not work, and how doctors and nurses should be able to do what's best for the patient, and money should not be a factor.

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If it proves their own theories, the study is believed

Have you ever noticed that doctors pick and choose what study they want to believe in?

There was a study a few years back that showed that Ventolin, if used long term, may actually cause underlying bronchospasm, or otherwise known as paradoxical bronchospasm. Yet in the hospital setting this has never stopped a doctor from ordering Ventolin.

Yet there was another study that showed that Ventolin enhances sputum production, however minute, and so they order Ventolin for patients they want to spit up more, or when the patient has pneumonia (even though it doesn't get to the alveoli).

In fact, I debated a doctor about this here.

Xopenex was originally believed to be stronger than Ventolin, and to produce fewer side effects. Yet more recent studies show neither claim is true. Yet many doctors choose to believe the former and not the later studies.

So they choose to believe one study, while ignoring the other. If it proves their own theories, the study is believed. If the study contradicts their theories, it's ignored. Just a thought.

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.

Is your doctor out of date?

"Is your doctor out of date?" That's a valiant question, and the title of a Reader's Digest article from the November, 2009, issue.

Of interest to learn is that while asthma used to be treated as an acute disease, whereas doctors would wait until an asthmatic had an attack and treated the symptoms, asthma experts now recommend using asthma controller medicines, preferably inhaled corticosteroids, to PREVENT asthma.

Yet, evidence shows that only 50% of the 9 million asthmatic kids are currently on inhaled corticosteroids, either because their doctors didn't prescribe them, or they weren't told to continue to use them when they were feeling well.

The old way of treating high blood pressure was to tell people to eat better and live better, although the new method is to make sure any person who has a blood pressure higher than 140/90 you need to be on one or more blood pressure medicine to bring it down to normal.

Past evidence showed that less than 10% of those with high blood pressure made the necessary changes to lower their blood pressure, which is why the "guidelines" for treating high blood pressure were changed.

It used to be that for those with back pain, an x-ray was taken, perhaps an MRI, and sometimes even invasive surgery was performed. Yet, evidence shows none of those ever did any good, and often resulted in unnecessary and painful procedures that did more harm than good.

New guidelines focus on encouraging exercise and heat pads to overcome the pain, and only going the next step if there is severe weakness, a history of cancer, or problems urinating.

While evidence show clot busting medicines like Asprin, angioplasty and other "proven steps" have been proven to make a big difference in outcomes of those having a heart attack, evidence shows fewer than 50% were getting clot busters, and 25% referred for other treatment.

Since then efforts have been made to get the word out.

All humans are creatures of habit, which makes all of us, in a way, set in our ways. This is why experts have come up with guidelines that are updated, and have made efforts to continually educated not just doctors, but patients and family members to.

As noted by the article, "when your doctor suggests a treatment, you should hear the word evidence in his or her explanation."

Yet, still, a guideline is still a guideline. There are times when common sense should prevail. A good example is the asthma guidelines, which state if you use your rescue medicine more often than 2-3 times in a week your asthma is not controlled.

But sometimes you have a hardluck asthmatic who does all the right things, yet still has trouble with his asthma. In this case, the asthmatic may have good control and still require to use his rescue medicine a few times a day.

So, is your doctor out of date? He might be, and therefore it's your job to know, to do your research, and to nudge him or her in the right direction if he or she is.

Click here to know if your doctor is doing a good job.
Click here to learn about maintaining a good relationship with your doctor

It's doctor to you

Whenever we approach someone of a higher rank it is appropriate, compassionate, to provide the proper salutation. In the case of us RTs and RNs, we refer to doctors as doctors. That's doctor Smith to you.

I write this because I have a couple friends of mine, people who used to be fellow RTs and RNs, who are now doctors. At first I wondered how I should greet them. Then I decided that they worked hard to earn the title of doctor, and they should get due respect.

Just by calling a doctor a doctor does not mean they are above you in any regard. They are fellow men, they are unprofitable servants of God just as you and I are, seeking to make the world a better place by the time they leave this world.

I have only one time in my career as an RT, in my 15 years working with doctors, had a doctor tell me to call him by his first name, and that was the only doctor I ever called by his first name. Other than that, the compassionate thing to do is for all of us to give due respect, and call Dr. Smith a doctor and not Sam.

Even doctors are prone to mis-diagnose

Here's an interesting post from Men's Health at MSNBC.com, "5 most common misdiagnoses for men." Several of us who are diagnosed with allergies, bronchitis and sinus headaches may actually have something else wrong with us.

The post notes that some men go to their doctors complaining of allergy-like symptoms of runny nose, watery eyes, and that downright miserable feeling and be diagnosed with allergies. When in actuality what they have is vasomotor rhinitis.

The article states it's rare to develop allergies in your 20s and 30s unless you change jobs or move to a new location. "Instead, your symptoms may be the result of vasomotor rhinitis, a condition triggered by non-allergen irritants, such as perfume, smog, and cigarette smoke, that inflame your nasal mucous membranes, says Patricia Wheeler, M.D., an associate professor of family medicine at the University of Louisville. The allergy medicines you're prescribed won't provide relief."

While sinus headaches are often diagnosed when men come in complaining of facial pressure, they are diagnosed with sinus headache, yet sinus headache medicine doesn't work. What they really have is a migraine headache, which is treated a completely different way.

Bronchitis is often the diagnosis when men come in because they are "hacking up" a bad cold. Yet the culprit may be something "hidden," such as asthma.

There's actually quite a few times as I'm digging through charts that I suspect a diagnosis of "bronchitis" is actually asthma. Of course we know asthma is treated quite different than bronchitis, and asthma can be prevented if treated daily with asthma controller medicines.

Then again, quite often I see patient's diagnosed with pneumonia when there is no indication for this diagnosis: no pneumonia on x-ray, no elevated white blood count, etc. Yet this misdiagnosis is probably due to reimbursement criteria more so than ignorance.

So as you're perusing through charts, or dealing with your own health, just be aware that your doctor is, after all, only human. And Lord knows all humans are prone to error.

White Coat Fever

Doctor anxiety, otherwise known as White Coat Fever, is a collection of symptoms predominantly prevalent among people of all ages ages, races, creeds and sexes, which occurs when one is exposed to the presence of medical professionals or the anticipation thereof.

The term White Coat Fever is actually a misnomer, stemming from 19th century studies of English patients who mistakenly blamed their uncomfortable feelings when the doctor was in the house as the cause of their uncomfortable feelings. Likewise, people in the 19th century referred to any ailment as a fever.

In 1871 Dr. Al Buterol identified anxiety as the result of a phobia, or irrational fear of something or some situation that is generally considered to be harmless and, in the case of doctors, actually helpful. Accompanying that fear is a strong desire to avoid what you fear.

Yet the term White Coat Phobia never caught on, however, so we continue to use White Coat Fever as a generic term for what "doctors" more appropriately call Doctor Anxiety. Studies show, as you can see at HealthyCanada.com, that a phobia can also be linked to your parents, as if you saw your parents acting "irrationally" toward doctors, or a particular procedure, you might have adapted a similar behavior.

Fear can actually be a good thing, if you are in the face of real danger, such as if you are staring in the face of a loaded gun, or if you see a car coming at you in your lane. Yet, in the face of normal, healthy situations or people, fear is not normal, and can actually be a bad thing.

The major complication of this condition is a person not obtaining the medical care they need. In the case of undiagnosed ailments, this can actually complicate care, and worsen the "fever."

Causes of White Coat Fever might include:

• Traumatic experience, perhaps one you don't remember
• Fear of contagious diseases
• Fear you might get diagnosed with a disease
• Fear of the person taking care of you
• Fear you might get lectured
• Fear of needles
• Fear of blood
• Annoyance of procedures you might have to undergo
• Fear of medical instruments
• Discomfort by someone touching you
• Discomfort at anticipation of someone touching you
  

Symptoms most generally occur upon entry into the medical professions building, which can include, but not be limited to, a doctor's office, clinic or hospital. Despite common belief, the general hypothesis among researchers is that simple anticipation of physical contact or that the doctor might find something wrong, creates the anxiety and not so much the presence of the medical workers themselves.

Signs of doctor anxiety:

• Rapid heartbeat
• Biting of fingernails
• Sweaty palms
• Unusually quiet
• Tapping on the chair, bed or table
• Higher than normal blood pressure
• Feel warm inside or even hot
• Shivering
• Saying stupid things

Experts believe the best way of reducing doctor anxiety is by education. The more you know about your body, and the diseases you are diagnosed with, the less your anxiety will be. For example, if you are diagnosed with asthma, become an asthma expert by reading as much as you can about asthma.

Although even asthma the most renowned medical experts can show signs of white coat fever while sitting sitting back in a recliner while being prepped for surgery.

Experts surmise that good people skills also helps to reduce the amount of anxiety felt, although recent studies show this may not be the case. A recent study performed by a specialized anxiety group in Michigan studied 30,000 individuals who presented to various medical offices and emergency rooms across the country. Of those who participated, even those who noted good social skills noted at least some degree of doctor anxiety.

Another way of reducing such anxiety is by being compliant with the medicine regime your doctor prescribes, and never quit taking your medicine without the expressed permission of your doctor. By doing this, you will be doing your part in the process of staying healthy.

Included in the compliance department is avoiding situations that exacerbate your condition. For example, if you have asthma, you should work hard to avoid your asthma triggers. However, it is not advised that you avoid your doctor or other medical professional.

Hence, the worse cases of doctor anxiety usually occur in the following avoidable situations, which are well deserving of a lecture:

• Poor self care
• Ignorance (poor education)

However, as is mentioned above, sometimes doctor anxiety is not avoidable and simply just has to be dealt with in the best way imaginable that does not include skipping out on good medical care or advice.

Ways to reduce doctor anxiety:

• Educate yourself about your disease
• Be compliant with your prescribed medicine regime
• Be willing to make necessary lifestyle changes (i.e. quitting smoking, avoiding alcohol, avoiding allergens
• Be willing to avoid social situations that tempt you to do things you shouldn't.
• Visit your doctor regularly (at least once a year)
• Understand that doctors are not better than you
• Understand doctors are human beings not human doings
• Research doctors and find one who works well with you
• Be a team player with your doctor
• Use common sense
  

The awkward thing about doctor anxiety is that many individuals start to show signs hours, days and even weeks prior to such visits.

The neat thing about doctor anxiety is the symptoms tend to go away once the white coat contact is complete. Yet, while it may seem the anxiety is gone for good, renewed anticipation may progress as soon as one learns of a new upcoming contact with the white coat folks.

One myth is that the best treatment for other types of anxiety is to avoid whatever causes your anxiety, although when it comes to your self care, it appears the anxiety gets worse instead of better.

Thus, the best wisdom regarding the prevention of white coat fever is to remember the phrase: Action Cures Fear. The more active you are in your own self care, and the more often you visit your doctor and work with him instead of for him, and the more medical wise you become, the less your anxiety will be when exposure in imminent.

I think one of the biggest fallacies regarding medicine is some people find it easier to believe in old fallacies, such that second hand smoke is not dangerous, or that asthma will go away with age, or if I ignore my illness it will just go away.

What cures doctor anxiety is not inaction, it's action. So become a part of your own health care team, get educated, be compliant, and become a team player with your doctor instead of letting him have total control over you.

If you have what we define here as doctor anxiety, realize you are not alone, and that action cures fear.

A great description of blunt doctors

I was called to do a STAT EKG (which didn't need to be stat, but that's beside the point). Even though it needed to be done so quickly, I was unable to get to the patient because the doctor was playing with the man's groin.

I watched as the urologist played with the man's catheter, while the nurse tried to assist him. The doctor was blunt and not particularly nice to the nurse. And I got the feeling the doctor also forgot he was working on a real live patient, and not motor in an engine.

The doctor said things like, "Well, why isn't this in your kit here?", "Where's the tape?", "Why is the tape on the floor? Come on!", " We need to be better at this!", "I need some gauze here!", "Come on! Come on!"

Anyway, I watched this procedure for quite some time. The nurse left the room once to get something while the doctor waited impatiently, and she smiled at me as she walked past me, and rolled her eyes too. She knew I knew the doctor was being ridiculous.

The patient was calm through this whole thing, and he said to the doc, "Normally I'd be embarrassed with my thing all exposed with all these people in the room. But for some reason I don't care."

"Well, we'll be done soon," The doctor said. "We just gotta get this done."

"No problem," the patient said.

Finally the nurse came back with another nurse. The rest of the procedure was finally finished, and I started my EKG.

As I did this, the patient said, "You know, I really like that doctor. I really trust him and I think he does a great job."

"Yep," I said, "He is a great doctor."

"The problem is, he has poor bedside manners."

"True, yet I think that comes with the territory."

"You know what it is," he said, "it's that he is brilliant. He's brilliant at what he does. What he doesn't realize," he paused a moment, perhaps drawing the best words from his brain, "is that we aren't brilliant at what he does. And he has trouble comprehending that. And, for that reason, he has poor bedside manners."

"Wow!" I said. "You hit the nail right on the head. I couldn't explain it better than that."

Even after dealing with doctors like that all the time, it's never easy keeping your mouth shut and not telling the doctor he's an ass. Yet, I have never heard anyone confront a blunt doctor in this way, and I hope I never do.

How to deal with arrogant, all knowing doctors

My advice to physicians

Doctors are among the most respected profession on the planet, and rightfully so. Still, to continue to deserve that respect, doctors must earn it. There's nothing I hate more than when a doctor orders something that's not indicated, and yet a patient says something like, "Well, if the doctor ordered it, I must need it."

That's some pretty good respect. Literally, I've seen doctors order invasive procedures, and the patient just lets the doctor do it. I've seen suction ordered for a patient whose awake and alert, and the patient says, "Well, if the doctor ordered it."

I've seen BiPAP ordered on a patient with normal blood gases and no respiratory distress, and the patient said, "Well, if the doctor ordered it." Sure this is also a sign of ignorance among the patient community, but it may also be a sign that doctors, however well respected, must continue to better themselves.

That in mind, I've come up with a list of my humble advice to those among this greatly respected profession:

1. You ought to take a step beyond just assessing, diagnosing and prescribing.
2. By that, you ought to educate, educate, educate. Whether this is done by you or your staff, you ought to be sure that every patient understands fully their disease.
3. You ought to follow up with each patient to make sure they understand their disease and are following the treatment plan you prescribe.
4. If a patient is not being compliant, you ought to inquire of them as to what you can do as a physician to help them become more compliant. "What advice do you have for me?" Every doctor should ask that question of their patients.
5. You also must monitor prescription usage. If you see, for example, that an asthmatic is using three Albuterol inhalers a month, then you ought to be aware of this. If your patient has hardluck asthma, you need to know this. If your patient has poorly controlled asthma, you need to know this too.
6. You need to use common sense in your approach to medicine
7. You need to be open minded in your approach to medicine
8. You need to continue the education process yourself (for one thing, you need to read up on the real purpose of bronchodilators. You can learn about this by hanging around this blog, or clicking here).
9. You need to be proactive. Don't wait until a crisis hits to act.
10. You need to teach the people you rely on: such as RNs and RTs.
11. You need to learn to trust and rely on those who are with the patient: such as RNs & RTs
12. Other than that, continue doing what you're doing.

I understand that most doctors are the best at what they do. I respect most surgeons, because I know I'd never want that job. I respect Internists and family doctors, because I certainly wouldn't want to be bothered at 2 in the morning each night. Plus I wouldn't want the liability.

Still, I think all physicians, no matter how well you are at what you do, should take the next step at improving the patient/physician relationship.

Stupid doctors can keep us RTs very busy

With his briefcase in hand the pharmacist passed me in the hallway. It was 9:30 at night and I knew he was  scheduled to clock out at 8 p.m.

"Heading out finally?" I said.

"Yep," he said as we progressed to the staircase. "It's amazing how one patient can keep you so busy so long."

"Or one stupid doctor," I said ruefully.

He laughed. "That was a good joke."

"Oh, I'm not joking," I laughed. I really wasn't.

He was still laughing as he exited the building. It is amazing how one stupid doctor can keep you busy all night long, or one lazy doctor if you don't like me calling a doctor stupid.

Tonight we had a good example of this, as the patient was extremely labored when admitted to ER. After several bronchodilators and BiPAP she was finally feeling much relief. She was even feeling well enough to joke about getting up and walking out.

And, ironically, she was off the BiPAP for 20 minutes during and after the transport to her room, and she was satting well and doing just fine. Not only that, she had gone six hours without a breathing treatment and she's still feeling fine.

Yet, I look at the chart and find out that the order says to continue the BiPAP and give breathing treatments every 2 hours.

This is one case I wish the patient would simply refuse therapy, but she's nice and she won't. So, because the doctor was too lazy to come in and assess the patient and order stuff she really needs than stuff out of habit, I'm going to be really busy tonight.

Yep, one patient can keep us busy. Yet, one stupid doctor can keep us even busier. I'm sure the admins will smile, however, when they see all the procedures I do tonight, whether those procedures are needed or not.

Is it our duty to question stupid doctor orders?

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

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

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

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

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

"Actually, that's not the reason."

"Well," she said.

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

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

"Yeah. I'm non confrontational."

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

"True," I said.

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

"I see what you mean."

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

Anyway, that's something to think about.

To call the Dr. or not to call, that is the dilemma

Here's something you will come across from time to time if you work nights. Of course as all RTs may have noticed by now, there often seems to be no rhyme or reason to "some" doctor orders, nor consistency to how a doctor will respond to a request to change the order.

Consider the following example:

The patient is a 75 YO non-COPD post operative patient with a registered SpO2 of 88% at 3-o-clock in the morning. Mind you, I did say three a.m. The patient is in no respiratory distress, and has no respiratory history. Otherwise, his vitals are normal. The order is for 2lpm. What do you do?

1. Call the doctor and wake him up
2. Increase the oxygen to 3lpm and have the RN call the doctor in the morning
3. Ignore the spo2 and pretend you didn't see it as the patients SpO2 probably always drops while he is sleeping
4. Since the SpO2 has an accuracy of plus/minus two, assume actual reading is 90%

Okay, what's your guess?

Day #1: This night the RT decides to use his common decides "b" is the best solution. The patient is stable and no harm done. If the patient's SpO2 was at a critical level, then a call to the doctor would be warranted, but not in this case.

The next day when the RT arrived at work he was lectured by said doctor who said, "Why do I write orders if you're not going to follow them?"

Day #2: Different patient but same information; different doctor, but this doctor is the spouse of the doctor in the scenario above. What does he do now?

Using the same choices above, since the RT now knows option #2 is not good, he decides to go with option #1 and wake up the doctor. The doctor says, "Why the hell are you waking me up at 3 in the morning to tell me this?"

"Um," says the RT, "Because yesterday, same scenario, your husband told me that I have to call before I increase oxygen to get an order."

"Oh," she says, "Well, then increase it to 3lpm and leave it at that."

"Well, then can we..."

Click. The doctor was no longer available.

"...get an order for protocol just in case... oh, what the heck.

So, what is the best thing to do in a scenario like this? Well, based on my experience, you're damned if you do and damned if you don't, so you might as well wake the doctor up and let her lecture you about how idiotic you are.

Thus, RN Cave Rule #72:

If you think you better call the doctor you better call him. If you think the doctor might yell at your and tell you you are an idiot because he doesn't want to be irritated in the middle of the night, call him anyway.

The smartest doctors in the world: part 4

Darn it! I did it again! I busted myself thinking again. When am I gonna learn. They always say old habits die hard.

Let's see. This time I was giving a treatment to a 7 YO asthmatic, and during the treatment he went on a coughing jag. His heart rate was 150 when I started the treatment, but after the jag it shot up to 200.

So I stopped the treatment. I didn't do this because I was thinking, because if I was thinking I would have finished the treatment. I did not think it was the Albuterol that shot the heart rate up. But, I knew who I was working with: a doctor with a 200 IQ.

Less than five minutes after the treatment the heart rate was back down to 145. I also concluded via my assessment -- or simply just watching the patient huff and puff -- that my little patient NEEDED another treatment.

After the treatment I'm standing behind the nurses station, and the doctor asks me for an update on the patient. The nurse interjects, and tells the doctor I had to stop the treatment because the Albuterol made the heart rate go up.

"We better wait awhile before giving another treatment," the doctor said.

I said, "I don't' think it was the Ventolin that caused the heart rate to spike."

The nurse said, "It was definitely the treatment. The heart rate was fine before you started it."

The doctor said, "Yeah. We'll wait a while before giving another treatment."

"I really don't think it was Albuterol," I said, hoping to convince the doctor that another treatment would be safe for the patient. "If it was the Ventolin that caused the Heart Rate to spike, it would still be up. Since it came right back down after the coughing jag, we should conclude the spike was due to exertional dyspnea."

The doctor looked at me dumbfounded. Then he said, "I'll call you when his heart rate goes down and we're ready for another treatment."

"Sounds good," I said.

Yep. I should know better than to ever question the brilliance of a doctor with a 200 IQ. Challenging such a doctor is highly unacceptable and should never be done, as every RT should know that any spike in heart rate during a treatment is definitely caused by the Ventolin. End of discussion.

I have to stop thinking. I have to do it. I need therapy.

The smartest doctors in the world: part 3

I was busted thinking again.

There has been more than once on this blog I've mentioned how I think holter monitors are not an ER procedure. I think that if a patient is so "questionable" that monitoring needs to be done, the patient should be admitted and placed on overnight telemetry.

If the patient is stable, then he can come back during the day time to have a holter hooked up by the people who are hired to do it.

I said to my boss that it's not that I don't want to do holters, nor that I do not like doing them in the ER, it's that I don't have time to do them.

"But the doctor ordered them?" she said to me.

"But..." I grumbled, "Just because a doctor orders something doesn't mean it's indicated."

Needless to say I was put in my place. I was lectured like a 1st grader who said his first swear word.

You see, I was rightfully so put in my place. I was wrong. And I realize that now that I have been informed the IQs of any doctor hired here at Shoreline is 200 (click here for part1 & 2).

Now I know my folly. Now I know never to question the brilliance of these doctors. Now I know that I shouldn't think, but rely on the brilliance of the doctors.

To punish me for thinking, the RT boss purchased nine more holter monitors. She did this so that I could never say again to the ER doc, "I'm sorry, but we are out of holters tonight."

No more excuses. One should learn never to question a doctor. After all, they did go through medical school and you did not.

The smartest doctors in the world: part 2

Going along with what I wrote yesterday about the doctors here at Shoreline Medical being among the smartest in the world. I was written up in February because I placed a patient on 2lpm nasal cannula, and her sat was 94% on that 2lpm.

Now, if you're like me you might be doing a double take as you read over that, and doctors who work for inferior institutions like Butterworth in Grand Rapids or the so-called elite institution up in Ann Arbor might do the same, but the doctors here at Shoreline Medical KNOW better.

Yep, you heard right. While I thought I was doing the right thing by making sure the patient only had as much oxygen as she needed -- which was 2lpm - I was WRONG.

That doctor who was taking care of that patient that night wrote an order for 4lpm -- not 2lpm. She was smart enough to know that that 2lpm was not going to be enough oxygen.

Of course nothing bad happened to that patient in the 8 hours she was on 2lpm during my shift, but that was only because I was lucky. Thankfully that doctor came in right after my shift ended and spotted my medical error and turned that flow up right away.

Man, my heart was just a fluttering as I realized my error. If that patient wouldn't have been turned up to 4lpm when she was, something awful might have happened. So it was only justified that she make the day shift RN write me up for thinking.

On the variance I was forced to write: "I am sorry. I will never think again."