My one concern about hospitalists

One of my initial observations about hospitalists is they don't seem overtly concerned with getting patients off ventilators.  I mean, if it weren't for we RTs pushing them, I think the average length of stay for ventilator patients would skyrocket at our institution. 

The number of ventilator patines has indeed risen, which is good because it allows us RTs, and those nurses over there, to keep up our skills.  Yet within the first week we had the current group working at Shoreline, one of my favorite CCU nurses said to me, "Rick, my biggest concern about these guys is they don't seem overly concerned about getting this patient off the vent.  A part of me wonders if it's because ventilator patines are their greatest challenges and joys."

She made sense; she made a lot of sense.  Since that day, I've paid attention to the length of stay of ventilator patinets, and it is indeed high.  Some patinets stay on vents several days after we RTs and RNs figured the patient could have been extubated.  We currently have 2 patients on ventilators, and both are so sedated and paralyzed they aren't even given a chance. 

When our old Internists were taking care of patients, they were mainly concerned with their family practice, and only saw inpatients for less than 30 mintues a day.  That was a concern.  however, they did understand the importance of thinking extubation as soon as a patient was intubated.  They created an extubation protocol for us to follow.  We gave ventilator patines sedation vacations daily to try to wean that patient; to at least give the patient a chance to fail.

Now, there's always the chance I could be wrong.  However, let us assume for a second that I am not wrong, and our current group of hospitalists are indeed keeping ventilator patients on vents too long.  Why would this be?

• Lack of experience:  this is possible, as some of our hospitalists are pretty young
• Lack of wisdom: Now, this is not so likely, although possible. 

I'm not going to go into it any further.  I just thought I'd bring this up and see if my readers had any comments on the matter.  Thoughts?

35 reasons we love Hospitalists

Here's 35 reasons we here at the RT Cave love hospitalists:

1. They are easy to approach, 
2. They tend to be open to suggestions, and
3. In a crisis they are readily available
4. The physician can see directly the patient's status, so
5. You don't always have to explain the patient's status over the phone.
6. They often enter their own orders, so
7. They make the unit secretaries job easier and less stressful
8. They stay in house, so
9. They don't get grumpy because the nurse interrupted a fishing trip.
10. They are held accountable for their actions, because
11. They are contracted by the hospital
12. They are adaptive to change and
13. Readily accept new wisdom.
14. Ventilator patients can be weaned at normal hours (as opposed to at 4 a.m).
15. Patients can be extubated at any time of the day, as opposed to around office hours.
16. They work shifts with nurses and therapists, and, therefore,
17. Are likely to become friends and not just acquaintances, therefore,
18. They tend to be kind to those with lesser degrees,
19. They participate in hospital social potlucks, and buy goodies (like donuts).
20. They are readily available for discussing patient care. 
21. They are readily available to receive test results.
22. The allow for more complicated cases to be admitted (as opposed to being shipped).  Therefore,
23. They are loved by the administration (which makes everyone happy). And,
24. Emergency room doctors love their accessibility.
25. They are loved by patients, because
26. They are easily available to patients, and
27. They are very kind to the patients, and
28. They explain complicated medical stuff in a pithy manor, and
29. They smile and say, "If there's anything you need, one of us is always available."
30. They are among the team, as opposed to above it
31. They are referred to by their title as opposed to by name, just like RTs (example, "Hey, where the heck is respiratory?"  "Please call the Hospitalist!"  
32. They develop apathy and burnout and develop dry senses of humor, just like respiratory therapists, 
33. So they develop blogs like the Happy Hospitalist, and
34. Create humorous blog entries like this.  Plus,
35. They get smarter by reading magazines like Today's Hospitalist.

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Hospitalists: Under and over oxygenating no more

I have done a tone of talking and writing about how wrong the hypoxic drive theory is a hoax based on an experiment with only 4 COPD patients back in the 1960s.  Regardless, I have witnessed many COPD patients suffer and die needlessly because a doctor refused to allow him the oxygen he required based on this popular myth.

By clicking on the link above, you will see that the myth has been disproved many times since that infamous experiment in the 1960s, but there continue to be an amalgamate of doctors who don't care; they continue to worship the myth as a primitive medicine man worships his favorite gods.

Physicians educated back in the 1980s either haven't seen the evidence, or refuse to accept it.  I asked one of our Interists once his thoughts on the myth, and he said, "It just sounds to good to be true."  Another Internist said, "I think it's a sound theory."  Another said, "I feel it's a valid theory."

There's this old theory:  Priests believe, lovers hope, and science knows.  Science is not an art.  In science, something either is or it is not.  The evidence has pointed for years to the hypoxic drive theory, that it is not true.  Yet based on the feelings of some physicians, it has lingered long in the medical profession, to the disadvantage of many poor COPD souls.

Then along came our hospitalists. These doctors even came with their own oxygen protocol: Maintain SpO2 of 90% or greater.  That's it.  There were no exceptions for anemia or COPD.  When someone is not oxygenating, we oxygenate.  When someone is over oxygenating, we turn down the oxygen.  It's that simple.

No more do we place oxygen on a patient just because they had anesthetics.  No more do we place oxygen on someone just because they are in critical care.  No more do we place oxygen on someone just because they have chest pain.

To the contrary, no more do we take oxygen off a patient just because they have COPD.  No more are we under oxygenating the very people who need oxygen the most.

Instead, we keep oxygen at a safe and comfortable level that is right for the individual patient:

1. COPD patients do quite well at 90-92% (some do well with less)
2. Anemia patients are saturated with oxygen, they simply have no seats on the train
3. Chest pain patients do not require supplemental oxygen when their SpO2 is > 92% (sorry, more O's will not increase the supply of O's to the heart when there is already an ample supply)
4. Post operative patients do not require supplemental oxygen when their SpO2 is > 92% 
5. Critical Care patients do not all automatically require oxygen

I would love to thank the hospitalists.  They have seen the evidence in real life and in the lab that the hypoxic drive theory is a hoax.  For that, we RT are greatly appreciative. 

Check out the Biggest Myths of Respiratory Therapy by clicking here. 

Hospitalists: A new breed of doctors

Hospitalists: A new breed of physicians.  They have been around quite a while now, but have just made it to Shoreline medical.  We waited for them eagerly, praying, hoping, that they would be what we dreamed they would be.  So far, they seem to be what we expected. 

Yes, folks, I'm happy about hospitalists.  Not only am I happy with what they have done for our hospital, and our patients, but I'm ecstatic that this new breed is market driven, and not government forced.  It's market driven, meaning that you and I and our patients are the reason it exists.  It is a wonderful profession, one that was long overdue. 

Over the years I have had one of one discussions with nearly every single one of our Internists and family practitioners of their thoughs on the change.  They all loved the idea.  No more would they have to balance their time in the office with the hospital.  I one every now and again walking down the hall with a brisk smile.  Yes, they are happy.  

In fact, one of our former Internists said, shortly before the change: "I'm looking forward to it.  I love working here.  However, taking care of inpatients is only 10% of my profit, and as much as 40% of my time.  I am eagerly awaiting the arrival of the new hospitalists. I think they are a great bunch, and I think you guys will love them."

The general consensus of all our physicians was the same.  Some were slow to adapt to the idea of change, but what's new.  Every single one of them eventually handed over their inpatients to the new group of hospitalists. 

Lord knows they aren't perfect.  After all, they attended the same dogmatic medical schools. Despite the flaws of the profession, I have found I enjoy working a bit more with these new docs.