The ER Doctor on tonight had a good point. He told me that gone are the days you can go to the emergency room with a headache, get a pill for your aches, and be sent home. Gone are the days when you can simply examine a patient, know what's wrong, and treat the patient.
He said, "Emergency Room patient assessments are basically useless now in a court of law. If you assess the patient, you have to have the test to back it up."
It's true. When my daughter is having trouble with her asthma I take her to the doctor's office, where she is given a breathing treatment, a few prescriptions, and sent home with me. Quite frankly, this is the ideal approach to medicine -- the common sense approach.
If I were to take her to the ER, even though the ER doctor is as smart as the pediatrician in the office and knows what's wrong with my daughter, he would also have to order a blood draw and x-ray at a minimum. My daughter might also end up with an I.V. or heplock for no reason.
So if you want to know why healthcare is so expensive, now you know. The cure for this is tort reform.
Showing posts with label er docs. Show all posts
Showing posts with label er docs. Show all posts
Saturday, October 3, 2009
Thursday, August 6, 2009
Sigh!!!
She sat in a chair next to her mother's bed. Her mom was a long time smoker/ old alcoholic with a boat load of problems, the least of which was her Hepatitis which caused her skin to turn yellow.
The daughter said: "This is a breathing treatment, mom. It's going to help get some of the fluid out of your lungs so you can breath better."
"No it's not," I said bluntly.
"Oh, well, it's going to make your heart pump better so you can breath better."
"No it's not," I said, bluntly.
"Oh, that's what the doctor said?" She looked at me blankly.
"Well," I said, "I guess the doctor was wrong then. This medicine is a bronchodilator that dilates the bronchioles if your mom is having bronchospasm."
"Oh... Oh, okay..."
The funny thing is, I don't doubt the doctor did tell her that. The unfunny thing is I get tired of explaining this every day.
The daughter said: "This is a breathing treatment, mom. It's going to help get some of the fluid out of your lungs so you can breath better."
"No it's not," I said bluntly.
"Oh, well, it's going to make your heart pump better so you can breath better."
"No it's not," I said, bluntly.
"Oh, that's what the doctor said?" She looked at me blankly.
"Well," I said, "I guess the doctor was wrong then. This medicine is a bronchodilator that dilates the bronchioles if your mom is having bronchospasm."
"Oh... Oh, okay..."
The funny thing is, I don't doubt the doctor did tell her that. The unfunny thing is I get tired of explaining this every day.
Friday, October 17, 2008
Dr. Q1
Jim Buterol is a fellow respiratory therapist who works at a famous hospital down south. I'm not going to reveal his real name to protect him. He told me that where he works there is a doctor that he refers to as Dr. Q1. Her real name is Dr. Krane, but that's not a real name either. She loves to order breathing treatments Q1 until discharge.
It gets old after a while, he said. While most doctors would at least assess the patient before ordering medicines, this doctor, once she learns a patient has shortness of breath, orders albuterol Q1 automatically.
I told my friend that I think this doctor is smart. He said, "Why?" I said, "Because she knows exactly when patients are going to be short of breath."
He laughed. But it really wasn't funny. It was actually horrible. In many cases this resulted in wasted medicine and resulted in a poor use of the respiratory therapists time.
In many cases, my friend said he would be in the emergency room tending to these patients who were, in many cases, no longer short of breath by the time the second, third, fourth, fifth and sixths treatments were being given. In many cases there were other patients he had to attend to but couldn't because he was in ER taking care of his Q1 treatments.
He said he complained to his bosses, but they said the job of the RT is to do whatever the doctor says. So, he decided, there was no point in further complaining. He said after a while he became burned out and apathetic.
We have similar stuff that goes on here at Shoreline. I talked to my boss this morning, and she said I did twice as many procedures last night as the other night shift worker the night before, and we both had the same number of patients.
I said, "That's because Dr. Q1 was working." She didn't understand what I was talking about, so she ignored me. I was fine with that. I didn't want to explain to her why I said that anyway.
When I gave report I said, "Dr. Q1 worked last night." My coworker understood immediately what I was referring to. It's sort of an inside joke, I guess. It's code language only RTs understand.
I wrote before that I think it's neat when a doctor is smart enough to know a patient will be short-of-breath and exactly when. How the heck does she know a patient is going to be short-of-breath every hour? We may never know.
Funny thing is, she's wrong most of the time. Most of the time, as I noted above, patients are not short of breath when they are ordered. But, who are we, as humble RTs, to argue with a doctor? Are there an Q1 doctors where you work? I have a sneaking suspicion that there are.
It gets old after a while, he said. While most doctors would at least assess the patient before ordering medicines, this doctor, once she learns a patient has shortness of breath, orders albuterol Q1 automatically.
I told my friend that I think this doctor is smart. He said, "Why?" I said, "Because she knows exactly when patients are going to be short of breath."
He laughed. But it really wasn't funny. It was actually horrible. In many cases this resulted in wasted medicine and resulted in a poor use of the respiratory therapists time.
In many cases, my friend said he would be in the emergency room tending to these patients who were, in many cases, no longer short of breath by the time the second, third, fourth, fifth and sixths treatments were being given. In many cases there were other patients he had to attend to but couldn't because he was in ER taking care of his Q1 treatments.
He said he complained to his bosses, but they said the job of the RT is to do whatever the doctor says. So, he decided, there was no point in further complaining. He said after a while he became burned out and apathetic.
We have similar stuff that goes on here at Shoreline. I talked to my boss this morning, and she said I did twice as many procedures last night as the other night shift worker the night before, and we both had the same number of patients.
I said, "That's because Dr. Q1 was working." She didn't understand what I was talking about, so she ignored me. I was fine with that. I didn't want to explain to her why I said that anyway.
When I gave report I said, "Dr. Q1 worked last night." My coworker understood immediately what I was referring to. It's sort of an inside joke, I guess. It's code language only RTs understand.
I wrote before that I think it's neat when a doctor is smart enough to know a patient will be short-of-breath and exactly when. How the heck does she know a patient is going to be short-of-breath every hour? We may never know.
Funny thing is, she's wrong most of the time. Most of the time, as I noted above, patients are not short of breath when they are ordered. But, who are we, as humble RTs, to argue with a doctor? Are there an Q1 doctors where you work? I have a sneaking suspicion that there are.
Sunday, July 27, 2008
There will always be physicians who hate RTs
While I don't know how it could be possible, but there are a few physicians who do not like respiratory therapists. One day, while the respiratory therapist was doing my job, or so he thought, by reviewing the chart of a patient he was taking care of in the emergency room, an angry doctor approached him.
The angry doctor said, "why are you looking at that chart?"
The RT said, "It's my job."
The angry doctor said, "No it's not."
"Well, yes it is."
"No, looking at the chart is my job."
"I have to know what's going on with the patient."
"No you don't. That's confidential."
"I was ordered to do a treatment, and I need to know about the patient."
"No you do not."
Hmmm. By this point the blood running through the RT's veins was starting to boil, and so so he marched out of the emergency room.
He reported the physician, but nothing was ever done. Over time he learned there were many therapists who had been cornered in such away by this doctor, and in all cases the incidence was reported, and in none of them was anything ever done.
That's just the way it is in the real world. To reprimand this one physician based on the word of said therapists would only rock the boat, and Lord knows it's easier to listen and do nothing.
Doctors like this, far and few between I must add, do come around from time to time, and we RTs simply have to grin and bear it. They think we RTs are mere ancillary staff, not trained with any medical skills that might benefit them and the patient. They do not, as a matter of chance, ever ask for advice from a lowly RT.
One day I was helping a coworker take care of a COPD patient in respiratory distress. My coworker knew the guy and was chumming with him. The doctor pulled him aside and said, "Please don't talk to the patient, he needs to concentrate on his breathing!"
However, the doctor's order was not complied with, because my coworker's bantering with this patient was well received by the patient. The doctor was wrong.
Justice was when the patient called for the supervisor to complain, not about the bantering therapist, but the physician.
One of my RT friends emailed me once and said she heard one doctor say: "Stupid RTs think they know everything."
It's true! It's rare. But it happens. There are pathways to solving such problems, but professionals learn how to cope with these kind of things.
The angry doctor said, "why are you looking at that chart?"
The RT said, "It's my job."
The angry doctor said, "No it's not."
"Well, yes it is."
"No, looking at the chart is my job."
"I have to know what's going on with the patient."
"No you don't. That's confidential."
"I was ordered to do a treatment, and I need to know about the patient."
"No you do not."
Hmmm. By this point the blood running through the RT's veins was starting to boil, and so so he marched out of the emergency room.
He reported the physician, but nothing was ever done. Over time he learned there were many therapists who had been cornered in such away by this doctor, and in all cases the incidence was reported, and in none of them was anything ever done.
That's just the way it is in the real world. To reprimand this one physician based on the word of said therapists would only rock the boat, and Lord knows it's easier to listen and do nothing.
Doctors like this, far and few between I must add, do come around from time to time, and we RTs simply have to grin and bear it. They think we RTs are mere ancillary staff, not trained with any medical skills that might benefit them and the patient. They do not, as a matter of chance, ever ask for advice from a lowly RT.
One day I was helping a coworker take care of a COPD patient in respiratory distress. My coworker knew the guy and was chumming with him. The doctor pulled him aside and said, "Please don't talk to the patient, he needs to concentrate on his breathing!"
However, the doctor's order was not complied with, because my coworker's bantering with this patient was well received by the patient. The doctor was wrong.
Justice was when the patient called for the supervisor to complain, not about the bantering therapist, but the physician.
One of my RT friends emailed me once and said she heard one doctor say: "Stupid RTs think they know everything."
It's true! It's rare. But it happens. There are pathways to solving such problems, but professionals learn how to cope with these kind of things.
Saturday, July 19, 2008
More money wasted in the ER
Well, you get what you deserve. After I jinxed myself yesterday morning when I gloated about not getting paged once on my shift Thursday night, I ended up spending last night in ER until about 1:00.No, I didn't save any lives. In fact, I really didn't do much good at all. But, the doctor wanted those Q1 hour treatments on all her SOB patients. Who did the infamous Dr. Krane order Q1 hour treatments on last night?
- A lady with a history of pneumonia.
- A lady who was diagnosed with a pneumo
- An elderly gentleman with lung cancer (Left lower lobe removed) and Lymphoma. He never smoked a day in his life, so I would rule out COPD here.
- An elderly man who was scheduled to have a pleural effusion drained. He was diagnosed with sepsis and probable pneumonia.
- PE.
Sure, these all presented with symptoms similar to asthma, and the initial treatment did help on a few of these, but treatment # 3, #4 and #5 certainly weren't indicated.
Let's see. According to my new research, that is $88 * 5 = $440 worth of treatments when one and a good assessment would have been suffice.
ER treatments at our hospital are $88 a piece. Pharmacy probably charges even more for the medications used.
If Obama and McCain want to address something that would benefit the health care crisis, this is it. What a waste of resources.
Check out my 'olins at the bottom of the blog. I've finally updated them.
Sunday, June 8, 2008
Here is a case study for you guys
After Dr. Krook assessed the mild-SOB out-of-town smoker who so happened to be camping at one of Shorelines parks, he ordered 3 Q-20 minute treatments. How does he know that a second or even a third treatment will be indicated when I haven't even given the first and reported the results?
Later, before she or I even went into the patient's room, Dr. Krane ordered me to do Q1 hour breathing treatments. Upon assessment the patient was was a smoker, but her chief complaint was mild dyspnea and a cough and nasal drainage. What's wrong with this picture?
Later, before she or I even went into the patient's room, Dr. Krane ordered me to do Q1 hour breathing treatments. Upon assessment the patient was was a smoker, but her chief complaint was mild dyspnea and a cough and nasal drainage. What's wrong with this picture?
Tuesday, June 3, 2008
Dr. Krane and imaginary wheezes
I work with Dr. Krane (fake name of course) quite often during my night shifts here at Shoreline. I swear to God that she is the best when it comes to crisis situations, and she might even be among the best at fixing patients and sending them home.
And while at first I didn't like her personality, I have found that she is quite pleasant to work with. Yet even as I write this, I know most RTs in this department speak poorly of her, mainly for her unyielding desire to order breathing treatments .
CHF = breathing treatment
asthma = breathing treatment
cold = breathing treatment
runny nose = breathing treatment
cough = breathing treatment
You get the picture. Whether the patient has bronchospasms or not, she hears some sort of imaginary wheezes.
The worst part is that many times when she orders a treatment she orders them now and then every hour times three.
When questioned about this, she said, "I read somewhere that treatments should be given in groups of three."
Out of respect I didn't' say anything back to her. However, what she read was probably the standard frequency for asthma. However, no study I've ever read said the treatments should be given Q1 hour.
And, on a similar note, the recommendation of three treatments is a guideline, not a law. In my opinion, each patient should be assessed individually for a need for a treatment, and a guideline is just that, a guideline. In fact, GUIDE is right in the word guideline.
However, in reality, wouldn't it make more sense to do one treatment, and then if the treatment worked and the patient is now breathing fine, come back in about 30 minutes to re-assess for indication for another treatment, as opposed to just "assuming" they will need one every hour.
Do you see the awkwardness of ordering Q1 hour treatments? I have no problem re-assessing a patient, and I do so often, especially if I think the patient might actually need the treatment.
This is why I often joke that "Dr. Krane is so smart that she knows her first treatment will work, and that every hour the patient will be SOB again."
Again, note to Dr. Krane, you cannot schedule SOB. A good assessment is the best policy.
And you could say the same for most Q2, Q3 and Q4 hour treatments as well.
Regardless, I'll do as I'm told like a good RT.
And while at first I didn't like her personality, I have found that she is quite pleasant to work with. Yet even as I write this, I know most RTs in this department speak poorly of her, mainly for her unyielding desire to order breathing treatments .
CHF = breathing treatment
asthma = breathing treatment
cold = breathing treatment
runny nose = breathing treatment
cough = breathing treatment
You get the picture. Whether the patient has bronchospasms or not, she hears some sort of imaginary wheezes.
The worst part is that many times when she orders a treatment she orders them now and then every hour times three.
When questioned about this, she said, "I read somewhere that treatments should be given in groups of three."
Out of respect I didn't' say anything back to her. However, what she read was probably the standard frequency for asthma. However, no study I've ever read said the treatments should be given Q1 hour.
And, on a similar note, the recommendation of three treatments is a guideline, not a law. In my opinion, each patient should be assessed individually for a need for a treatment, and a guideline is just that, a guideline. In fact, GUIDE is right in the word guideline.
However, in reality, wouldn't it make more sense to do one treatment, and then if the treatment worked and the patient is now breathing fine, come back in about 30 minutes to re-assess for indication for another treatment, as opposed to just "assuming" they will need one every hour.
Do you see the awkwardness of ordering Q1 hour treatments? I have no problem re-assessing a patient, and I do so often, especially if I think the patient might actually need the treatment.
This is why I often joke that "Dr. Krane is so smart that she knows her first treatment will work, and that every hour the patient will be SOB again."
Again, note to Dr. Krane, you cannot schedule SOB. A good assessment is the best policy.
And you could say the same for most Q2, Q3 and Q4 hour treatments as well.
Regardless, I'll do as I'm told like a good RT.
Thursday, May 1, 2008
Another doctor sees things my way
When I started out as an RT, I was told when I did an EKG to take it directly to the doctor, even if you have to hunt the doctor down. That was when I was a student.
Then, after I was hired here at Shoreline, and I continued to hunt doctors down, I was lectured by one doctor about how I didn't need to do that. So, for the next five years I did the EKG and put it on the chart, unless it was one that needed to be seen right away.
Ultimately, however, we had a massive Dr. turnover in the ER, and now we have two doctors who require that we RTs hunt them down, Dr. Krane, of whom I work with most often, is one of them. So here I am after doing an EKG, running around like a little kid hunting the doctor down to show him an EKG I know is normal.
However, last week a new doctor (Dr. Click) and the nurses kept ordering EKGs, and I kept handing them to the doc. Then, as I was handing her the 6th EKG in an hour, I observed she had a whole stack of EKGs on the table next to her. And she said, "Rick, you don't need to hunt me down every time you do an EKG. I trust you to know when a person is having a heart attack."
Wow. I was so impressed I thought I could shout with joy. After ten years in this profession, and five years of hunting doctor Krane down, this doctor confirms that I am smart enough to know what an MI looks like.
I would like Dr. Click to have a word with Dr. Krane and knock some sense into her.
Then, after I was hired here at Shoreline, and I continued to hunt doctors down, I was lectured by one doctor about how I didn't need to do that. So, for the next five years I did the EKG and put it on the chart, unless it was one that needed to be seen right away.
Ultimately, however, we had a massive Dr. turnover in the ER, and now we have two doctors who require that we RTs hunt them down, Dr. Krane, of whom I work with most often, is one of them. So here I am after doing an EKG, running around like a little kid hunting the doctor down to show him an EKG I know is normal.
However, last week a new doctor (Dr. Click) and the nurses kept ordering EKGs, and I kept handing them to the doc. Then, as I was handing her the 6th EKG in an hour, I observed she had a whole stack of EKGs on the table next to her. And she said, "Rick, you don't need to hunt me down every time you do an EKG. I trust you to know when a person is having a heart attack."
Wow. I was so impressed I thought I could shout with joy. After ten years in this profession, and five years of hunting doctor Krane down, this doctor confirms that I am smart enough to know what an MI looks like.
I would like Dr. Click to have a word with Dr. Krane and knock some sense into her.
Tuesday, April 29, 2008
Finally a doctor who sees things my way
For years my RT co-workers and I have been trying to change the EKG policy in the ER so that EKGs are only ordered on people who need them, as opposed to every person who walks into the door with CP, stomach pain, back pain, toe pain, etc.
However, our boss doesn't like to rock the boat, and he didn't want to have to go out of his way to try to convince the ER RNs and doctors that they need to be more specific on who they order EKGs on. Or, better yet, it's all about money, and the more EKGs we do, the more money we make.
And our medical director did a review of the EKGs ordered in ER, and the reasons why they were ordered, and he agreed that there were many frivolous reasons for EKGs being ordered, however he was also reluctant to overrule the ER EKG policy where the nurses get to order the EKG on any patients they think one is needed on.
Yet today I went to ER to do an EKG on a 24-year-old female with CP. To me it sounded like she had a little chest cold or something, but considering I was overruled on my attempt to get rid of these frivolous EKGs, I had no choice but to complete the procedure.
Yet this time, as I handed the EKG to Dr. Honk, he said, "I don't think we need to do an EKG on every 24 year old with CP."
"I just do what I'm told," I said. "The nurses order the procedure, and I do the test."
"Well, Ill have to have a talk with them, because I wouldn't have ordered this EKG."
Awesome, I thought. Finally a doctor who's anti-useless therapies. And now that I think of it, he doesn't order breathing treatments on every patient who comes through the ER doors complaining of a common cold either.
Wow. If Dr. Krane, of whom usually works my nights, was working, not only would I be doing the EKG, but I'd be doing a breathing treatment "to ease that chest pressure." And I'd be coming up with a new name for a new 'olin for the bottom of this blog.
I'll have to have this Dr. Honk talk with Dr. Krane and have him knock some sense into her.
However, our boss doesn't like to rock the boat, and he didn't want to have to go out of his way to try to convince the ER RNs and doctors that they need to be more specific on who they order EKGs on. Or, better yet, it's all about money, and the more EKGs we do, the more money we make.
And our medical director did a review of the EKGs ordered in ER, and the reasons why they were ordered, and he agreed that there were many frivolous reasons for EKGs being ordered, however he was also reluctant to overrule the ER EKG policy where the nurses get to order the EKG on any patients they think one is needed on.
Yet today I went to ER to do an EKG on a 24-year-old female with CP. To me it sounded like she had a little chest cold or something, but considering I was overruled on my attempt to get rid of these frivolous EKGs, I had no choice but to complete the procedure.
Yet this time, as I handed the EKG to Dr. Honk, he said, "I don't think we need to do an EKG on every 24 year old with CP."
"I just do what I'm told," I said. "The nurses order the procedure, and I do the test."
"Well, Ill have to have a talk with them, because I wouldn't have ordered this EKG."
Awesome, I thought. Finally a doctor who's anti-useless therapies. And now that I think of it, he doesn't order breathing treatments on every patient who comes through the ER doors complaining of a common cold either.
Wow. If Dr. Krane, of whom usually works my nights, was working, not only would I be doing the EKG, but I'd be doing a breathing treatment "to ease that chest pressure." And I'd be coming up with a new name for a new 'olin for the bottom of this blog.
I'll have to have this Dr. Honk talk with Dr. Krane and have him knock some sense into her.
Sunday, April 27, 2008
Ventolin now productive mucus thinner
The infamous Dr. Krane has impressed me with her wisdom once again. If you guys remember, she is the one who discovered that Xoponex is more than just a bronchodilator, that it is also a humidifier of the airways.
She is also the same doctor who orders treatments in ER "Now, and again in one hour." She is so smart that she knows before the first treatment is given that it will work, and that the patient will be short of breath again in one hour. Awesome. Brilliant. All doctors and RTs ought to worship this lady as the Einstein of Respiratory Therapy. She is obviously a strong supporter of the real physician's creed.
Today, I must inform you (and I am very impressed I must add), that Dr. Krane (fake name mind you), ordered me to do a second treatment on a patient who has a cardiac history and renal failure, and who also had crackles in the left base, which is indicative of pneumonia and not bronchospasm.
As the treatment was going, I asked the patient, "Are you feeling short-of-breath."
"No, actually I feel better," the patient mused.
"I ordered the treatment," Dr. Krane intervened, "because her sats were in the mid 80s and I thought the treatment might help with that, and open her up." Then she added with a snarl: "I also think that she has thick sputum, and that treatment might loosen things up a bit."
So there!!!
I looked at her countenance to see if perhaps she might be smiling. I mean, she was joking right? Nope. No smile. She looked serious as usual.
I did smile, though.
She said, "What's so funny!"
I couldn't answer. Instead, I bit my cheek to prevent myself from laughing further. In my mind, I was laughing at the fact that she just reminded me a new 'olin compliments of the real physician's creed.
It used to be called Mucusolin, and then the name was changed to thinolin during the IPPB rush of the 1980s, but more recently it's called Mucobuterol. It's a revolutionary new medicine, included in ventolin somehow, that has the ability to thin secretions. It is far more effective than Mucomyst.
To see a full list of 'olins check here.
She is also the same doctor who orders treatments in ER "Now, and again in one hour." She is so smart that she knows before the first treatment is given that it will work, and that the patient will be short of breath again in one hour. Awesome. Brilliant. All doctors and RTs ought to worship this lady as the Einstein of Respiratory Therapy. She is obviously a strong supporter of the real physician's creed.
Today, I must inform you (and I am very impressed I must add), that Dr. Krane (fake name mind you), ordered me to do a second treatment on a patient who has a cardiac history and renal failure, and who also had crackles in the left base, which is indicative of pneumonia and not bronchospasm.
As the treatment was going, I asked the patient, "Are you feeling short-of-breath."
"No, actually I feel better," the patient mused.
"I ordered the treatment," Dr. Krane intervened, "because her sats were in the mid 80s and I thought the treatment might help with that, and open her up." Then she added with a snarl: "I also think that she has thick sputum, and that treatment might loosen things up a bit."
So there!!!
I looked at her countenance to see if perhaps she might be smiling. I mean, she was joking right? Nope. No smile. She looked serious as usual.
I did smile, though.
She said, "What's so funny!"
I couldn't answer. Instead, I bit my cheek to prevent myself from laughing further. In my mind, I was laughing at the fact that she just reminded me a new 'olin compliments of the real physician's creed.
It used to be called Mucusolin, and then the name was changed to thinolin during the IPPB rush of the 1980s, but more recently it's called Mucobuterol. It's a revolutionary new medicine, included in ventolin somehow, that has the ability to thin secretions. It is far more effective than Mucomyst.
To see a full list of 'olins check here.
Wednesday, February 20, 2008
An RTs worst nightmare
I certainly picked a good night to come back to work -- a full moon. Hopefully a full eclipse of the moon brings me some good luck as opposed to the usual bad luck normally associated with full moons.
I'm sure I'm not alone in dreading the first day back after a long vacation. But was especially dreading coming to work tonight considering the last six days I worked were pure hell, and the last hour of the last day before my vacation were the worst ever.
When I say the worst ever, I mean it. Think about this a minute: As an RT, what is your worst nightmare?
Mine is that I'll stare at a piece of equipment when a critical patient is depending on me, as are the nurses and doctor, and not have a clue what to do.
The EMTs informed us enroute the patient would need to be intubated as soon as he arrived in the ER, so we had all our stuff ready. And when he arrived he was blue, moderately labored, but I had seen people in worse condition not be intubated.
Whether or not the patient would be intubated was completely dependent on the doctor on duty. In my opinion, probably 90% of doctors would have intubated this guy right away. But, we weren't dealing with any normal doctor this night, we had doctor Krane, one of the best doctor's in critical situations.
Instead of panicking and intubating, she ordered me to set up BiPap. Considering how the patient looked, I rushed upstairs to grab the infamous Vision BiPap system instead of using the LTV 1200 that was setting next to the bed for such circumstances.
To be honest, the only reason I didn't use the LTV was because I forgot it was there. Up to this date, I had never had a problem using it as a BiPap, although I had read about problems other RTs at other institutions had had with it.
Once the Vision was set up, the patient's SpO2 jumped from 40% on a NRB to 98% with only 60% FiO2 dialed in. And, within a half hour, the patient noted that he was breathing fine.
But, his X-Ray was whited out. According to Dr. Krane, the patient was in ARDS possibly secondary to bilateral pneumonia, but, she said, even that was difficult to diagnose at this juncture. And, secondary to being hypoxic so long, the patients cardiac enxymes were starting to rise, indicative to cardiac damage.
The patient needed to be shipped. No problem, right. As soon as the EMTs arrived the patient would be out of my hands, especially since the EMTs in our area now have their own ventilators.
When the EMT arrived pushing the LTV 1200, I felt completely confident this would be a quick and easy transfer, until Bill said, "Gosh, Rick, I've never set this up as a BiPap before."
"I have," I said confidently. "I'll set it up for you."
I pushed the button, and the damn thing would not go into BiPap. Bill and I felt equally stupid. Finally I gave in, and called my boss, hoping she would remember. What she told me was exactly what I had already been doing.
"Well, come down here anyway," I said to Boss, "We could use a fresh brain."
Bill and I laughed at that, considering he had been up for 24 hours at this point, and if it weren't for this transfer he'd probably be on his way home by now. And I was in the last half hour of my 12 hour shift. I was quite beat, as it was a swamped night. We were both burned out.
Just as Boss arrived in the ER I realized what hadn't before, and Bill and I removed the vision mask from the patient and set the LTV BiPap on the patient. According to the vent, everything was working fine. But the patient was panicking. "Take this off. This isn't working," he chimed.
The nurses were trying to fix the mask, but I knew the problem was with the machine, even though all indicators showed it was working. The patient was getting the dialed in VT, RR and pressure.
I felt especially stupid because I was the one who trained every one in my department and the EMTs how to use this vent as a BiPAP. I suppose my mistake is that I disregarded warnings that it didn't work well as a BiPAP more so because I had used it on other patients and it had worked just fine then.
I checked the internal settings. Everything was set appropriately. The machine was simply not working with this patient.
Then a lightbulb went on in my head:
Flow. It's not giving the patient enough flow. Isn't that the big complaint about using the LTV as BiPAP. This patient isn't getting enough flow
"It's not the mask, you guys," I said. "This isn't working. Take the mask off."
I set the Vision back up, and the patient was fine. "Ah, much better," he said.
It had occured to me then that we had never tranferred a patient before on BiPap. We had always just intubated patients. But, as Dr. Krane assured the RNs, "This patient is doing fine on BiPap, he doesn't need to be vented."
And she was right. He was awake, alert, orientated and breathing fine on the BiPap. So long as he didn't need to be suctioned, and so long as he wasn't a candidate to vomit, he would do just fine on the BiPap.
But, we needed to transfer him.
"Can we send him on the Vision?" Bill said. He lifted it right off the stand. "I think this will fit in the rig."
Sometimes in this job we have to jury rig.
I'm sure I'm not alone in dreading the first day back after a long vacation. But was especially dreading coming to work tonight considering the last six days I worked were pure hell, and the last hour of the last day before my vacation were the worst ever.
When I say the worst ever, I mean it. Think about this a minute: As an RT, what is your worst nightmare?
Mine is that I'll stare at a piece of equipment when a critical patient is depending on me, as are the nurses and doctor, and not have a clue what to do.
The EMTs informed us enroute the patient would need to be intubated as soon as he arrived in the ER, so we had all our stuff ready. And when he arrived he was blue, moderately labored, but I had seen people in worse condition not be intubated.
Whether or not the patient would be intubated was completely dependent on the doctor on duty. In my opinion, probably 90% of doctors would have intubated this guy right away. But, we weren't dealing with any normal doctor this night, we had doctor Krane, one of the best doctor's in critical situations.
Instead of panicking and intubating, she ordered me to set up BiPap. Considering how the patient looked, I rushed upstairs to grab the infamous Vision BiPap system instead of using the LTV 1200 that was setting next to the bed for such circumstances.
To be honest, the only reason I didn't use the LTV was because I forgot it was there. Up to this date, I had never had a problem using it as a BiPap, although I had read about problems other RTs at other institutions had had with it.
Once the Vision was set up, the patient's SpO2 jumped from 40% on a NRB to 98% with only 60% FiO2 dialed in. And, within a half hour, the patient noted that he was breathing fine.
But, his X-Ray was whited out. According to Dr. Krane, the patient was in ARDS possibly secondary to bilateral pneumonia, but, she said, even that was difficult to diagnose at this juncture. And, secondary to being hypoxic so long, the patients cardiac enxymes were starting to rise, indicative to cardiac damage.
The patient needed to be shipped. No problem, right. As soon as the EMTs arrived the patient would be out of my hands, especially since the EMTs in our area now have their own ventilators.
When the EMT arrived pushing the LTV 1200, I felt completely confident this would be a quick and easy transfer, until Bill said, "Gosh, Rick, I've never set this up as a BiPap before."
"I have," I said confidently. "I'll set it up for you."
I pushed the button, and the damn thing would not go into BiPap. Bill and I felt equally stupid. Finally I gave in, and called my boss, hoping she would remember. What she told me was exactly what I had already been doing.
"Well, come down here anyway," I said to Boss, "We could use a fresh brain."
Bill and I laughed at that, considering he had been up for 24 hours at this point, and if it weren't for this transfer he'd probably be on his way home by now. And I was in the last half hour of my 12 hour shift. I was quite beat, as it was a swamped night. We were both burned out.
Just as Boss arrived in the ER I realized what hadn't before, and Bill and I removed the vision mask from the patient and set the LTV BiPap on the patient. According to the vent, everything was working fine. But the patient was panicking. "Take this off. This isn't working," he chimed.
The nurses were trying to fix the mask, but I knew the problem was with the machine, even though all indicators showed it was working. The patient was getting the dialed in VT, RR and pressure.
I felt especially stupid because I was the one who trained every one in my department and the EMTs how to use this vent as a BiPAP. I suppose my mistake is that I disregarded warnings that it didn't work well as a BiPAP more so because I had used it on other patients and it had worked just fine then.
I checked the internal settings. Everything was set appropriately. The machine was simply not working with this patient.
Then a lightbulb went on in my head:
Flow. It's not giving the patient enough flow. Isn't that the big complaint about using the LTV as BiPAP. This patient isn't getting enough flow
"It's not the mask, you guys," I said. "This isn't working. Take the mask off."
I set the Vision back up, and the patient was fine. "Ah, much better," he said.
It had occured to me then that we had never tranferred a patient before on BiPap. We had always just intubated patients. But, as Dr. Krane assured the RNs, "This patient is doing fine on BiPap, he doesn't need to be vented."
And she was right. He was awake, alert, orientated and breathing fine on the BiPap. So long as he didn't need to be suctioned, and so long as he wasn't a candidate to vomit, he would do just fine on the BiPap.
But, we needed to transfer him.
"Can we send him on the Vision?" Bill said. He lifted it right off the stand. "I think this will fit in the rig."
Sometimes in this job we have to jury rig.
Friday, February 1, 2008
Working nights solo can be challenging at times
I came into work last night anticipating on working on my fantasy baseball rankings, and it ended up being reminiscent of how it used to be here at Shoreline every night: busy.
My co-worker normally stays until 9 p.m., but all I had were a bunch of 10 p.m. treatments I figured I'd knock off in no time. But, lo and behold, as soon as he left all hell broke lose. Every patient who could possible go bad did.
And, as what usually happens when you have ten treatments due and two patients in failure, the emergency room paged: "We need another now treatment on room 1," the pager read, "and then Q30 minutes after that."
"This is completely ridiculous," I grumbled under my breath, and then looked up at the middle-aged lady I was currently giving a treatment to and watched as her body jiggled up and down as she laboriously struggled to move air.
I didn't know what else to do, so I dropped the pager. This reaction prevented me from whipping it across the room. I looked at my patient, and watched as she closed her eyes and rested her head on the pillow. She was pooping out. I decided right then and there I was not going to leave her.
I grabbed the phone on the endtable and dialed ER. When the unit secretary answered, being political was the last thing on my mind.
I grumbled, "Dr. Krane really wants Q30 minute treatments on this lady?"
"That's what she ordered," Diane said very politely.
"You have got to be kidding me," I said. "I already gave two treatments to that lady,and neither of them were indicated. And now she wants this."
"Well," she said, "You'll have to take it up with the doctor."
"If you guys think she needs the treatments, then you guys are just going to have to do it, because I'm swamped up here."
And that was the truth. Not only was this lady failing, so to was her neigbor. And that's not to mention all my treatments were due, and so was my vent check, and someone on East kept paging me because the Vision BiPaP keeps beeping.
A half hour later ER paged again: "Duoneb needed in ER."
They know I can't get down there right now. Why are they paging me agian?
I grabbed the phone. The unit secretary answered, and I asked to speak with an RN.
Moments later a female nurse said, "Hello."
"Listen," I said, "could you guys do me a real big favor and do that treatment for me. I'm really swamped up here."
"We would," she said, "but the doctor ordered Duoneb."
"How about if you just give Albuterol."
"Because the doctor ordered Duoneb." She was not going to give up.
"I'll be down there soon with some Duoneb for you." I was not in the mood for a debate, so I hung up.
If that's not the dumbest thing an RT ever heard. If a treatment is ordered because a patient is short-of-breath, why make them wait 20 minutes for an RT to give Duoneb when a vial of Albuterol is right there in the med cart just because the doctor ordered Duoneb.
My co-worker normally stays until 9 p.m., but all I had were a bunch of 10 p.m. treatments I figured I'd knock off in no time. But, lo and behold, as soon as he left all hell broke lose. Every patient who could possible go bad did.
And, as what usually happens when you have ten treatments due and two patients in failure, the emergency room paged: "We need another now treatment on room 1," the pager read, "and then Q30 minutes after that."
"This is completely ridiculous," I grumbled under my breath, and then looked up at the middle-aged lady I was currently giving a treatment to and watched as her body jiggled up and down as she laboriously struggled to move air.
I didn't know what else to do, so I dropped the pager. This reaction prevented me from whipping it across the room. I looked at my patient, and watched as she closed her eyes and rested her head on the pillow. She was pooping out. I decided right then and there I was not going to leave her.
I grabbed the phone on the endtable and dialed ER. When the unit secretary answered, being political was the last thing on my mind.
I grumbled, "Dr. Krane really wants Q30 minute treatments on this lady?"
"That's what she ordered," Diane said very politely.
"You have got to be kidding me," I said. "I already gave two treatments to that lady,and neither of them were indicated. And now she wants this."
"Well," she said, "You'll have to take it up with the doctor."
"If you guys think she needs the treatments, then you guys are just going to have to do it, because I'm swamped up here."
And that was the truth. Not only was this lady failing, so to was her neigbor. And that's not to mention all my treatments were due, and so was my vent check, and someone on East kept paging me because the Vision BiPaP keeps beeping.
A half hour later ER paged again: "Duoneb needed in ER."
They know I can't get down there right now. Why are they paging me agian?
I grabbed the phone. The unit secretary answered, and I asked to speak with an RN.
Moments later a female nurse said, "Hello."
"Listen," I said, "could you guys do me a real big favor and do that treatment for me. I'm really swamped up here."
"We would," she said, "but the doctor ordered Duoneb."
"How about if you just give Albuterol."
"Because the doctor ordered Duoneb." She was not going to give up.
"I'll be down there soon with some Duoneb for you." I was not in the mood for a debate, so I hung up.
If that's not the dumbest thing an RT ever heard. If a treatment is ordered because a patient is short-of-breath, why make them wait 20 minutes for an RT to give Duoneb when a vial of Albuterol is right there in the med cart just because the doctor ordered Duoneb.
However, I handled it. With excellent RN and RT care both my critical paitents averted a vent thanks to a wonderful drug called Lasix. I knocked off all the treatments, including ER. And, while doing all this, I was being paged various times for odd procedures like setting up suction, which you'd think RNs would know how to do.
And, just as I sat down in the RT Cave to eat my dinner, ER paged again: "EKG and ABG in ER."
So I trudged down there and find a 9 YO girl laboriously breathing. It's not often that we have to take care of a little kid here, and it's always a little bit of a shock to see such a little person lying there in my need, instead of an adult.
For the record, I never did an ABG on a kid before. In all my years doing this, I was never asked to. I took my time, kept my cool, succeeded, and walked the gas to lab. I expected it might be a little off, but here's what the results were: pH 6.90, CO2 17, HCO3 2.7, PO2 162 on 2lpm.
Gulp!
The RNs and I were tossing out possible diagnosis' from sepsis to cancer, but as soon as the doctor saw the gas she said, "We need to get a sugar."
That's when you think, "It was so obvious. Why didn't I think of that?"
The little girl's sugar was sky high.
There was nothing else for me to do with this patient, so I headed back to the cave thinking I'd put my aching feet up, when my beeper went off again.
That's how it was all night until about 4:00 when I finally made it to the cave to chart. And my boss just happened to be there. And, instead of asking me how I was doing, she provided me with some criticism about how we RTs have been making too many mistakes filing EKGs lately.
"Yes maam," I said. I really wanted to tell her to just leave me alone, but I didn't want to get into defense mode. I don't know about you guys, but 4:00 in the morning when I'm on my first day back to work, completely exhausted and swamped, is not the time I want to receive criticism from anybody.
"Wow," she said, smiling. "You are the only one who didn't blame someone else."
I looked at her stunned. I had expected many reactions from her, but this reaction caught me completely off guard. "Really," I said.
Instead of charting, which I didn't want to do anyway, I participated in a nice discussion with The Boss. And, as any of you night shift workers can attest to, when you are exhausted this late in a night shift, you tend not to hold anything back.
"You know," I said, "I never thought I'd say this, but I think that I've finally reached the point that I would like to go to days when a position comes open. I think I am just burned out from ER is what I'm saying."
She gave me a look I didn't know how to read. "I used to like ER when I worked nights."
"You know, boss, I really love taking care of vents and critical patients. That's why I love the CCU. And I love taking care of the critical patients in ER, it's just... I'm tired of the B.S. down there.
She gave me another look I could read. I don't want to say she rolled her eyes, but it was close to that. And then the subject conveniently changed. She was thinking this: "We make money on all those useless doctor orders."
It's neat how the mindset changes when you no longer have to actually do the stupid doctor orders.
And, just as my morning treatments were due, the the beeper went off.
Actually, this is how it used to be all the time here. While we are a small hospital, we have a large area we cover. I wonder if this is the start of a new trend, or an aberation.
Either way, working nights solo can be a challenge. But stupid doctor orders do not take precidence over critical patients.
Wednesday, January 23, 2008
Holter monitors not emergency room precedure
I was just sitting here when I was called STAT to ER to do a holter Monitor. Normally I wouldn't gripe about ER calling me no matter what the reason when I'm just sitting here, but it was a STAT holter Monitor, so it warranted a groan and a gripe.I don't know if all RT departments do holter monitors, but I know that most of the ones in this area do. However, we have other staff do them during the day shift, and RT just has to do them at night.
Which, one would think, would cover all holter orders, considering holter monitors are an outpatient procedure. But, lo and behold I get called to do at least one STAT holter monitor a week.
And, usually, it's during a time when I'm really busy.
When you are the only RT working, you learn to prioritize your therapies, and I can find very few things, aside from a STAT IS, that a holter set-up should be ahead of. Occasionally, I've been known to take over an hour just getting to the holter.
"This is the ER," one doctor told me once, "nothing in ER deserves to be put off for over an hour."
My short-of-breath patients on the floor are more important than this holter, that I shouldn't have to be doing in the ER in the first place, I thought. Yet I smiled and said, "Sorry."
If there are any readers of this blog out there who can think of one reason why a holter needs to be ordered in ER, please let this RT know. I can think of none.
Because the patient has chest pain?
Hardly. If he has that symptom he should be admitted.
What about if the patient had a fast heartbeat, but when she got here we didn't pick up anything on the rhythm strip or EKG?
If that patient is symptomatic, admit them. Otherwise, schedule them for an outpatient holter.
Another goofy thing we do after giving a patient a holter is give them this little log book for the patient to record any symptoms they might have such as chest pain, palpitations, etc.
If the patient is having these symptoms, they shouldn't be recording it in a log book, they should get themselves back to the ER.
Does a holter need to be ordered stat? Absolutely not in my humble opinion.
On the other hand, if the ER doctor called me and said, "Hey, if you guys have the time, and a holter monitor available, we would love it for you to put one on a patient so she doesn't have to come back in two days to get one."
If that happened I'd be ecstatic about doing the holter. In fact, it might cause me to have chest pain, and then I'd need a holter set up on me.
Saturday, January 12, 2008
Most Drs are patient, but some just intubate
To be fair to the nurses and the doctors in my last post who were eager to intubate the patient who tried to kill herself with a massive amount of a certain drug I can't remember the name of, I did leave one very important key point out. I was suffering from lack of sleep yesterday, and from massive burnout, so you have to cut me some slack here.
When the patient was first transferred to her new bed in CCU she had no gag reflex when I suctioned her airway to remove a massive amount of secretions that had accumulated there. Then she provided no response to the sternal rub. She was out. That, coupled with the fact she was agonal breathing, the nurse and the patient's physician decided the patient should be intubated to protect the airway.
Technically speaking, that was not a bad idea. However, I knew for a fact the patient was not like this an hour before, and that's why I thought maybe there was something else we were missing that might prevent her from needing to be intubated. So I did a blood gas while the nurses called the patient's physician.
When I noticed the gases were not exceptionally well, I called the patient's RN from the laboratory and informed her Dr. Krane should be notified with these ABG results since this was her patient in her, and I told the nurse I'd rush down to ER and show her myself. Then, en route, I decided I would just go up to the CCU to be with the patient, and, lo and behold, when I got up there Dr. Krane was standing alongside the patients bed.
"Holy cow," I said, "How in the world did you know we needed you? And how did you get up here so fast?"
"I was just concerned about the patient," Dr. Krane said, "And I wanted to make sure she was okay for you guys."
"Well, I'm very impressed."
Then she stunned me with this: "Give a breathing treatment."
Oh, come on. Here the patient is crashing and you want to give a breathing treatment? Like a good boy, I set up the treatment and fitted the mask on the patient's face. This ought to cure her of all her ailments.
Then Dr. Krane provided us with some information we did not receive in report. "I just talked to the husband, and he informed us that she (the patient) uses her rescue inhaler 5-8 times per day."
Aha, well, that makes more sense. "Well," I said, "In that case she probably uses it 10-16 times per day, because it's usually double what they say."
"True," she said.
Dr. Krane and I watched over the patient, literally, for the next 30 minutes, and I kept watching the clock and the entry way to the CCU for any signs of the doctor who said he would be here any minute. I prayed he was really late.
As she watched over the patient, eyed the numbers on the monitor which showed a heart rate of 126 but otherwise normal vitals, I wondered if she thought she had overlooked something in ER. Was she sleeping the last 6 hours the patient was down there and too lazy to check in on the patient and the nurses didn't pick up on the fact the patient was failing?
"You saw this patient in ER," she said, "Did you notice she was labored?" Perhaps I'm right.
"No," I said, "She wasn't labored at all. What do you think?"
"Well, I think she's going to be fine with the breathing treatments. I think that she hasn't had her bronchodilator in well over 12 hours, and her body responded to the transfer to the floor by having an excacerbation of asthma." She continued to look at the patient, and only occasionally looked up at me. "I think if we just be patient here we won't need to intubate."
"I really like that idea," I reassured her, as though it mattered what I said.
"What do you think of this doctor," she said. I figured she was referring to Dr. Seamon.
"I don't know Dr. Seamon very well," I said, "But I think he'll want to intubate as soon as he gets here regardless, and he'll want a massive tidal volume like 1000 or something stupid like that." Dr. Krane laughed.
Seriously, while I think she does order some stupid treatments, she is really nice. I didn't always think that way though. I've learned to keep an open mind about people I meet while working, and not take anything they say personally. Many people I talk to can't stand her because she is such a control freak.
"I think she will be fine," she said.
"Well, did she have a gag reflex in ER?" I asked.
"Yes, we tried to put in an oral airway, and she definitely responded."
I hesitated a second, as I didn't want to ask a stupid question, then I decided the heck with it. "Why do you think she's has no gag reflex all of a sudden?"
"I think the (drug she took) has peeked. In ER she was just lying there almost obtunded, but she was comfortably breathing. She was in a deep drug induced sleep."
"How long is that drug supposed to last?"
"I know she does cocaine and other stuff too, but poison control said about 24 hours. We can't know for sure how long it will last, but if we monitor her very closely we should be able to avoid intubation. However, that's my opinion, and I won't have jurisdiction over this patient as soon as Dr, what's his name? gets here."
"Dr. Seamon."
"I thought you guys said he would be here any minute." She smiled.
"That's what he said.
Now, fast forward over what I wrote yesterday to the intubation. As soon as we turned the patient on her back she started fighting. When the anesthesiologist started to insert the tube, the patient fought vigorously and even sat up -- twice.
She was obviously no longer under the deep, dark influence of the drug. And she had an obvious gag reflex. That, coupled with the good repeat ABGs, made me wonder if the patient didn't need to be intubated after all. But Dr. Krane was no longer in control, and I had transferred my beeper to my relief.
While watching all this, and assisting in holding the patient down so she didn't whack some nurse or my fellow RT in the head, I watched as the anesthesiologist drew up a white medication via syringe. These doctor's are very intense on intubating this patient. Are they forgetting to look at the big picture?
I audaciously tossed out an idea, "Um, you guys might want to disagree with me here, but I just wanted to toss this idea out. Since she appears to be responding to your efforts here, do you think we still need to intubate?"
"Oh definitely," Dr. Seamon said without hesitation, "We need to protect the airway."
My coworker, while holding cricoid pressure with one hand and bagging with the other, looked at me with a funny grin and rolled his eyes. We RTs, you know, have no control. And it's not that we don't want to take care of another vent patient, it's more that we wonder if sometimes, just sometimes, hospital staff get over aggressive with some patients.
After a lot of tinkering, finally the patient was intubated, and the airway secure. Dr. Seamon said, "Let's see, I think a tidal volume of 750 should be good, a respiratory rate of 14 and, oh, how about 50% oxygen."
My coworker looked at me, cocked his head and rolled his eyes. I knew exactly what he was thinking. "I calculate a tidal volume of 600 for this patient, and definitely no more."
"Well," Dr. Seamon said, "I learned to go by weight, and this patient weighs 230 pounds."
"No!," my coworker chimed, "We go by size..size definitely. How tall is this lady."
"I was told she's 5 feet 3 inches," I said, "and I calculate 350 to 600 is the tidal volume range based upon our ventilator protocol of 6 to 10 millimeters per kilogram of ideal body weight." There, that should help you out Dave.
"Okay, well, start out at 700 tidal volume then," Dr. Seamon ordered.
Dave rolled his eyes again, and made no effort to hide it from Dr. Seamon.
I laughed audibly. I'm sorry, but I was very tired, as I had been at work 13 hours at this time. Nobody but Dave noticed I was laughing, though. I looked at each person in the room, and they were all intense with their respective tasks.
I couldn't hold it in any longer. I wished Dr. Krane was still here, because she had a clue.
Later, as I was finally giving Dale report, he said, "What the hell tidal volume do you figure for this patient."
"Max 600, but with her asthma I'd go lower."
"Good, because the vent was set at 500, and that's what I used."
"I thought it was cool you showed frustration to Dr. Seamon," I said, "but I had that discussion earlier with him and I didn't care what he said, because he doesn't have vent privileges here, and we have our protocol. I was just doing to set it at what I wanted, and hope the Internist agrees with me when he gets here.
"Right on," he said, and smiled. "I just give up."
We have to keep in mind here, however, that the medical field is an art that is based on science. And there is often more than one right answer. Thus, while I disagreed with this intubation, I could still be wrong.
When the patient was first transferred to her new bed in CCU she had no gag reflex when I suctioned her airway to remove a massive amount of secretions that had accumulated there. Then she provided no response to the sternal rub. She was out. That, coupled with the fact she was agonal breathing, the nurse and the patient's physician decided the patient should be intubated to protect the airway.
Technically speaking, that was not a bad idea. However, I knew for a fact the patient was not like this an hour before, and that's why I thought maybe there was something else we were missing that might prevent her from needing to be intubated. So I did a blood gas while the nurses called the patient's physician.
When I noticed the gases were not exceptionally well, I called the patient's RN from the laboratory and informed her Dr. Krane should be notified with these ABG results since this was her patient in her, and I told the nurse I'd rush down to ER and show her myself. Then, en route, I decided I would just go up to the CCU to be with the patient, and, lo and behold, when I got up there Dr. Krane was standing alongside the patients bed.
"Holy cow," I said, "How in the world did you know we needed you? And how did you get up here so fast?"
"I was just concerned about the patient," Dr. Krane said, "And I wanted to make sure she was okay for you guys."
"Well, I'm very impressed."
Then she stunned me with this: "Give a breathing treatment."
Oh, come on. Here the patient is crashing and you want to give a breathing treatment? Like a good boy, I set up the treatment and fitted the mask on the patient's face. This ought to cure her of all her ailments.
Then Dr. Krane provided us with some information we did not receive in report. "I just talked to the husband, and he informed us that she (the patient) uses her rescue inhaler 5-8 times per day."
Aha, well, that makes more sense. "Well," I said, "In that case she probably uses it 10-16 times per day, because it's usually double what they say."
"True," she said.
Dr. Krane and I watched over the patient, literally, for the next 30 minutes, and I kept watching the clock and the entry way to the CCU for any signs of the doctor who said he would be here any minute. I prayed he was really late.
As she watched over the patient, eyed the numbers on the monitor which showed a heart rate of 126 but otherwise normal vitals, I wondered if she thought she had overlooked something in ER. Was she sleeping the last 6 hours the patient was down there and too lazy to check in on the patient and the nurses didn't pick up on the fact the patient was failing?
"You saw this patient in ER," she said, "Did you notice she was labored?" Perhaps I'm right.
"No," I said, "She wasn't labored at all. What do you think?"
"Well, I think she's going to be fine with the breathing treatments. I think that she hasn't had her bronchodilator in well over 12 hours, and her body responded to the transfer to the floor by having an excacerbation of asthma." She continued to look at the patient, and only occasionally looked up at me. "I think if we just be patient here we won't need to intubate."
"I really like that idea," I reassured her, as though it mattered what I said.
"What do you think of this doctor," she said. I figured she was referring to Dr. Seamon.
"I don't know Dr. Seamon very well," I said, "But I think he'll want to intubate as soon as he gets here regardless, and he'll want a massive tidal volume like 1000 or something stupid like that." Dr. Krane laughed.
Seriously, while I think she does order some stupid treatments, she is really nice. I didn't always think that way though. I've learned to keep an open mind about people I meet while working, and not take anything they say personally. Many people I talk to can't stand her because she is such a control freak.
"I think she will be fine," she said.
"Well, did she have a gag reflex in ER?" I asked.
"Yes, we tried to put in an oral airway, and she definitely responded."
I hesitated a second, as I didn't want to ask a stupid question, then I decided the heck with it. "Why do you think she's has no gag reflex all of a sudden?"
"I think the (drug she took) has peeked. In ER she was just lying there almost obtunded, but she was comfortably breathing. She was in a deep drug induced sleep."
"How long is that drug supposed to last?"
"I know she does cocaine and other stuff too, but poison control said about 24 hours. We can't know for sure how long it will last, but if we monitor her very closely we should be able to avoid intubation. However, that's my opinion, and I won't have jurisdiction over this patient as soon as Dr, what's his name? gets here."
"Dr. Seamon."
"I thought you guys said he would be here any minute." She smiled.
"That's what he said.
Now, fast forward over what I wrote yesterday to the intubation. As soon as we turned the patient on her back she started fighting. When the anesthesiologist started to insert the tube, the patient fought vigorously and even sat up -- twice.
She was obviously no longer under the deep, dark influence of the drug. And she had an obvious gag reflex. That, coupled with the good repeat ABGs, made me wonder if the patient didn't need to be intubated after all. But Dr. Krane was no longer in control, and I had transferred my beeper to my relief.
While watching all this, and assisting in holding the patient down so she didn't whack some nurse or my fellow RT in the head, I watched as the anesthesiologist drew up a white medication via syringe. These doctor's are very intense on intubating this patient. Are they forgetting to look at the big picture?
I audaciously tossed out an idea, "Um, you guys might want to disagree with me here, but I just wanted to toss this idea out. Since she appears to be responding to your efforts here, do you think we still need to intubate?"
"Oh definitely," Dr. Seamon said without hesitation, "We need to protect the airway."
My coworker, while holding cricoid pressure with one hand and bagging with the other, looked at me with a funny grin and rolled his eyes. We RTs, you know, have no control. And it's not that we don't want to take care of another vent patient, it's more that we wonder if sometimes, just sometimes, hospital staff get over aggressive with some patients.
After a lot of tinkering, finally the patient was intubated, and the airway secure. Dr. Seamon said, "Let's see, I think a tidal volume of 750 should be good, a respiratory rate of 14 and, oh, how about 50% oxygen."
My coworker looked at me, cocked his head and rolled his eyes. I knew exactly what he was thinking. "I calculate a tidal volume of 600 for this patient, and definitely no more."
"Well," Dr. Seamon said, "I learned to go by weight, and this patient weighs 230 pounds."
"No!," my coworker chimed, "We go by size..size definitely. How tall is this lady."
"I was told she's 5 feet 3 inches," I said, "and I calculate 350 to 600 is the tidal volume range based upon our ventilator protocol of 6 to 10 millimeters per kilogram of ideal body weight." There, that should help you out Dave.
"Okay, well, start out at 700 tidal volume then," Dr. Seamon ordered.
Dave rolled his eyes again, and made no effort to hide it from Dr. Seamon.
I laughed audibly. I'm sorry, but I was very tired, as I had been at work 13 hours at this time. Nobody but Dave noticed I was laughing, though. I looked at each person in the room, and they were all intense with their respective tasks.
I couldn't hold it in any longer. I wished Dr. Krane was still here, because she had a clue.
Later, as I was finally giving Dale report, he said, "What the hell tidal volume do you figure for this patient."
"Max 600, but with her asthma I'd go lower."
"Good, because the vent was set at 500, and that's what I used."
"I thought it was cool you showed frustration to Dr. Seamon," I said, "but I had that discussion earlier with him and I didn't care what he said, because he doesn't have vent privileges here, and we have our protocol. I was just doing to set it at what I wanted, and hope the Internist agrees with me when he gets here.
"Right on," he said, and smiled. "I just give up."
We have to keep in mind here, however, that the medical field is an art that is based on science. And there is often more than one right answer. Thus, while I disagreed with this intubation, I could still be wrong.
Friday, January 11, 2008
We RTs appreciate good doctors
We here at the RT Cave often find humor by things that might otherwise frustrate us. I suppose this is our natural way of maintaining our sanity over things we know we have little control.
You can look at the list of 'olins at the bottom of this blog to get a perfect example of what I'm referring to, or you can check out what I wrote about Doctor Krane two months ago to the day.
We are also fair here at the RT Cave, and we are more than willing to give credit where credit is due.
When a nurse calls for the rapid response team on a patient we determine to be perfectly fine, we reassure that RN that she did the right thing. And when she calls the team and we prevent a patient crashing, we give her full credit for saving the patient. After all, it was her vigilance that made us aware there was a problem.
When we have a patient in crisis, and we all perform our specialized tasks in an effort to save the patient, we all thank each other for a job well done, regardless of the outcome. We are a team. We work together to give the patient the best chance possible
As I had predicted I was busy last night because I was burned out. And just when I finished my morning treatments and found a comfortable seat, I was called to the critical care to assess an overdose patient who had just been brought up from ER.
The nurses wanted to intubate this patient, and based on gases I drew, the family physician, Dr. Morgan, gave a phone order to have the anesthesiologist intubate the patient. I was informed that Dr. Morgan was on his way in.
The gases he based his decision on were this: pH 7.28, CO2 52, PO2 111 on 5lpm.
"Call Dr. Krane," I said. "We need a doctor now, not in a few minutes. We need need this patient to be assessed by a doctor right now."
I knew Dr. Krane had the patient in ER the past 12 hours, and, despite how many frivolous breathing treatments she orders, she is excellent in these types of situations. She doesn't do overkill.
Dr. Krane came up, assessed the patient, and impressed me with this statement: "I'd be more than happy to intubate this patient, but I think she will be fine if we just be patient. I mean, I don't know how aggressive Dr. Morgan likes to be, but I don't think we need to be aggressive in this case."
"I'm very impressed," I found myself saying, "I absolutely agree with everything you said."
It was totally unlike me to say this, but I couldn't let this opportunity pass. She was modest about what I said, but I could see the glee in her eyes.
Unfortunately, the patient's family physician wanted the patient to be intubated, and when he arrived an hour later, and Dr. Krane returned to her cave, that's exactly what happened, even though repeat ABGs showed the patient was improving: pH 7.35, CO2 48, PO2 52 on 30% venti mast. (The oxygen here was low, but that could be resolved with more oxygen.)
However, I'd like to take this opportunity to thank Dr. Krane for her brilliance in critical situations, even though she has no clue I'm writing this blog, and I'm using a fake name for her.
I absolutely appreciate doctors who look at the whole picture rather than just a number.
You can look at the list of 'olins at the bottom of this blog to get a perfect example of what I'm referring to, or you can check out what I wrote about Doctor Krane two months ago to the day.
We are also fair here at the RT Cave, and we are more than willing to give credit where credit is due.
When a nurse calls for the rapid response team on a patient we determine to be perfectly fine, we reassure that RN that she did the right thing. And when she calls the team and we prevent a patient crashing, we give her full credit for saving the patient. After all, it was her vigilance that made us aware there was a problem.
When we have a patient in crisis, and we all perform our specialized tasks in an effort to save the patient, we all thank each other for a job well done, regardless of the outcome. We are a team. We work together to give the patient the best chance possible
As I had predicted I was busy last night because I was burned out. And just when I finished my morning treatments and found a comfortable seat, I was called to the critical care to assess an overdose patient who had just been brought up from ER.
The nurses wanted to intubate this patient, and based on gases I drew, the family physician, Dr. Morgan, gave a phone order to have the anesthesiologist intubate the patient. I was informed that Dr. Morgan was on his way in.
The gases he based his decision on were this: pH 7.28, CO2 52, PO2 111 on 5lpm.
"Call Dr. Krane," I said. "We need a doctor now, not in a few minutes. We need need this patient to be assessed by a doctor right now."
I knew Dr. Krane had the patient in ER the past 12 hours, and, despite how many frivolous breathing treatments she orders, she is excellent in these types of situations. She doesn't do overkill.
Dr. Krane came up, assessed the patient, and impressed me with this statement: "I'd be more than happy to intubate this patient, but I think she will be fine if we just be patient. I mean, I don't know how aggressive Dr. Morgan likes to be, but I don't think we need to be aggressive in this case."
"I'm very impressed," I found myself saying, "I absolutely agree with everything you said."
It was totally unlike me to say this, but I couldn't let this opportunity pass. She was modest about what I said, but I could see the glee in her eyes.
Unfortunately, the patient's family physician wanted the patient to be intubated, and when he arrived an hour later, and Dr. Krane returned to her cave, that's exactly what happened, even though repeat ABGs showed the patient was improving: pH 7.35, CO2 48, PO2 52 on 30% venti mast. (The oxygen here was low, but that could be resolved with more oxygen.)
However, I'd like to take this opportunity to thank Dr. Krane for her brilliance in critical situations, even though she has no clue I'm writing this blog, and I'm using a fake name for her.
I absolutely appreciate doctors who look at the whole picture rather than just a number.
Thursday, January 10, 2008
One more night to go...
I'm burned out today, as this is my 8th day in the past 12 that I've worked. I have to admit I haven't been necessarily busy, but nonetheless I feel the usual burn. Usually when I feel this way the powers that be find a way to keep me busy, and that seems to be the case so far tonight.I have a lot that I want to write about, but the right words just don't seem to want to display themselves on this screen. And then when I do get into a groove ER pages me and I have to drop my train of thought and rush down there. I certainly don't want to make them wait because I'm blogging -- God forbid.
I'm sitting here writing about nothing and I still can't get words out. We here in the RT cave have a nice view of the parking lot, and I'm sitting here watching the snow pour down on my car. I'd say there's at least a six inch blanket of snow covering it now. In the morning I'm going to have to go out there and freeze.
However, I'd rather be out there and on my way home to snuggle under my warm blankets than in here right now. The clock seems to go slow when I'm burned out. I find that to be true no matter how busy I am.
Tomorrow, Friday, is my first day off of six in a row, and that's something to look forward to. Carrie has to work the next three days in OB, but that will give me quality time to spend with the kids. Rather, I'm going to play Zelda on my son's Nintendo DS, and the kids can entertain themselves.
I kind of lost interest in games the past 10 years or so. Rather, I suppose I grew up. But now that my son is old enough to be interested in the same games I used to like, I've found myself playing them on occasion again. I think JJ thinks it's cool. Of course, I am a cool dad. I hope he understands than when I ground him from his Nintendo DS so I can play it.
He's way ahead of me in the game, so that means I'll have to stay up all night tomorrow night until I catch up with him. If that's not enough, I'm going to have to make him read for two hours on Saturday, and when he's done with that he can clean his room. That will give me plenty of time to catch up, or maybe even get ahead of him.
My daughter? Well, she can watch movies all day. That's the best baby sitter I've ever known. I don't know how dad's got by without that baby sitter all these years. Then again, prior to me most dads probably didn't have jobs that allowed them to spend so much quality time with their kids.
Well, it's still snowing. And, by golly, ER hasn't called me in... 30 minutes now. Wow. I thought Dr. Krane would have called me for a fourth treatment on that man with a cold in room A. Oh well, if she calls me I'm going to smile while I'm giving it, because I know in seven hours I'm going to have a nice stretch off.
Have a good day (night).
Sunday, November 11, 2007
New Study: Xoponex now a humidifier
Okay, this is about crazy, but Dr. Krane called me back down to ER to do another treatment on a baby with a cold. The order read: Xoponex low dose. Okay, so I'm making this up, there is no Doctor Krane. She is a figment of my imagination. She is a composition doctor I made up. But if you're an RT of any duration, you probably have met her.Like many of you guys, I grumbled to myself of how little medicine gets to a baby during a blowby treatment to begin with, let alone when using a low dose of albuterol. But I kept my mouth shut and gave the treatment.
The baby hated me. She wailed and kicked and screamed until I gave up and gave the neb to the dad. The kid smiled. I was stupid to even try to give it on my own, I should have had dad do it from the start. My bad. To my credit, however, most kids take treatments great. Sometimes, however, we RTs have to get creative.
Unable to assess the baby, I watched it's breathing. There were no signs of respiratory distress. I was essentially giving this treatment to satisfy the physician, and to make the patient's parent's think we were doing something. I understand, however, that this time of placebo is common in medicine. In fact, studies even show that the placebo effect amazingly cures ailments, including parental stress, in about 50 percent of cases that it's tried.
After the treatment I approached Dr. Krane. I said: "So, what kind of assessment did you get on this child, because she didn't like me too much."
"Oh," Dr. K said, "she was really clear down below, but up in her throat I heard a little croupy sound."
She thought a second, then continued, "Basically I just wanted her to have the humidity for her throat."
Humidity for her throat? Did she actually say that?
"Thank you." I said. "I just wanted to be able to chart something."
HUMIDITY FOR THE THROAT?
I thought I was up to date on all the latest research.
Upon doing furher research, I found the following from my anonymous source, which actually made Dr. K. look pretty good.
New medical study shows a low dose of ventolin, once it enters the throat, enlarges to 10 microns and turns into steam. The medicine then coats the cells within the throat and soothes them. Persistent croup is not an indicator of ineffectiveness.This new version of Xoponex is called Humidonex. To see more frivolous ventolin therapies click here.
I violated RT Cave Rule #3 and now I must pay
RT Cave Rule #3: If you are trying to get a protocol passed, you have to keep your mouth shut about treatments not being indicated. You must be diplomatic.
I think I got Dr. Krane our ER doctor mad at me tonight. And I suppose that's not good news considering she's the main obstacle to us getting an ER protocol
Dr. Krane was back in her cubby behind the ER desk, and one of the ER nurses said, "So, other than us nobody is bothering you tonight, hey."
"Pretty much you're it," I said, "Except for this one professional COPD patient who calls me every 3 or 4 hours for a treatment."
"Oh, that's pretty good then."
"Yep, He's a pro. I don't even really need to check in on him, he just calls me when he's ready for one."
"That's cool."
"Yep," I said, "And those are the kind of patients that I really like to give treatments to. You know, patients that are really having bronchospasms and need them, as opposed to... just because."
Dr. Krane walked out of her cubby and past me without as much as a look my way. She went to ER Room 1 where I was currently giving the 10th treatment to a patient who came in with a cough and was never short-of-breath.
I followed her into the room, "So, you think you got her cured yet."
Dr. Krane gave me a smile. I'm not sure if that smile was her acknowledging my humor, or her annoyance at my comments. Or if I was just imagining things, because maybe she never heard me in the first place.
However frivolous I think some of the therapies we do are, like this current series of treatments, I rarely say anything to the nurses or doctors about it. I save comment for this blog and make humor of it. I think that'a far better therapy than complaining.
When I'm tired, or have too much time on my hands like tonight, my tounge sometimes slips,
and they give me this look like, "Um, you're trying to get out of work. You're just saying that because you're lazy."
I'm serious. It happens every time I mention something like one of my 'olins, or if I tell them my true opinion of a treatment I'm doing.
The first treatment on this patient was Duoneb X2 and then again in an hour.
"Are you short of breath?"
"No."
"Do you have asthma?"
"No."
"Have you ever gotten short of breath?"
"Only when I go into a coughing jag, of which I've had many tonight."
"But you're not short of breath now."
"No."
The patient appears to be in no respiratory distress, and before and after every treatment she has denied short of breath, even after several Duoneb treatments and one Xoponex the wonder drug.
I think DR. Krane is privy to knowledge esoteric to even the other doctors here, because she not only orders Atrovent with every treatment, she will know that someone will be short of breath an hour later.
To me, it would make more sense to have me come back and assess for the need. Then again, if that were the case, I probably would have done maybe one, and the nurses would complain that I was just being lazy.
Okay, so there goes our ER protocol.
I need to be more political. I need to be more diplomatic. I need to keep my mouth shut.
I know there is new research on Atrovent. I'm going to try and tackle this in the next few days. I might even talk to Dr. Krane about it; that is, if she still likes me.
If she follows RT Cave Rule #2 we'll be just fine, although, as we RTs so well learn, Drs don't always follow the rules.
RT Cave Rule #4: Hospital workers, especially one's that work nights, do not hold grudges.You can't hold coworkers accountable for what they say under stress, pressure or lack of sleep -- especially lack of sleep.
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