I'm going to be written up -- I hope

I'm going to be written up, and I'm happy about it.

About seven hours into my shift I had a patient with a bad heart of whom the ER doc had already decided to ship. I had a bad feeling about this patient, so I decided to hang out in ER until the patient was secured into the ambulance, and the ambulance was gone.

Leaning against the wall, being cool, I casually looked down at the counter and saw that someone had written something on a note pad. This is what it said: "Respiratory did not respond to do an EKG after 2 pages."

I smiled, stood by coolly, and pretended I didn't see it. Most ER nurses understand that I am the only RT on duty, and that my other patients are just as important as ER patients, but this new nurse, her name is Mary, hasn't figured that out yet.

During my recent stay in the hospital, she was the only nurse who didn't treat me like royalty. In fact, when she was my ER nurse, that was the first time I had met her. Now I'm quite certain that not only is she a bitch from the patient POV, she is also a bitch from this side too. She is a rare and unfortunate scar on an otherwise awesome staff here at Shoreline.

Despite my opinion, which is subject to change once I get to know her, I continued to treat her with respect, and I continued to coolly smile at her each time I passed her. And, to my surprise, she was quite nice to me the rest of the night. She even smiled once.

As you guys know from a previous post, I have a proposal for ER EKGs that I have yet to take to the powers that be here at Shoreline. If I get written up here, I am going to use this as a prime opportunity to state my case for STAT reform.

Instead of paging me "EKG in ER" I think I should be paged "STAT EKG in ER" or "Just because EKG in ER" so that I can prioritize appropriately. However, I did tell this to a nurse once, and she paged me STAT for every EKG, because, as she said, "All ER EKGs are STAT."

"No they are not," I said.

"Everything ordered down here is STAT."

"That's not necessarily true." And I proceeded to give her many examples: Treatment for sputum induction, treatment on a not SOB patient, pre-op EKGs, etc.

I said, "If you start paging me STAT to all EKGs, then I'm going to get numb to the word STAT. It's not fair to my patients on the floor if I drop what I'm doing every time I get a STAT page, especially when the EKG in ER isn't needed."

When this nurse I do not like paged me the first time, and to my defense, I was with another patient. I did get the page. I was tied up in another room. And, since about 80% of ER EKGs are done just because, I figured I'd finish up what I was doing before going down to ER. And, lo and behold, I received a second page three minutes later, and still decided to finish up what I was doing.

I was swamped all night.

Okay, yes I could have called. I am at fault there. However, most of the time I call to say I'm going to be a while getting down there, I get down there 20 minutes later to find the EKG is still not done, so why bother calling.

Now, you might be thinking, "If they thought to page you a second time, didn't you think that perhaps they thought the EKG needed to be done urgent?"

No. The reason I didn't think that was because ER always pages me three minutes after the initial page, especially if I don't get down there right away. I get tired of it, especially when I drop what I'm doing and the patient has an EKG ordered for a hang nail or something stupid like that.

I'm the kind of RT who gets along with everybody for the most part. I never complain. In fact, just last night I walked into a room to do a STAT EKG on a patient who was being packed up to be shipped to the CCU, and I observed the patient's NC was hooked up to a tank.

"Is that tank even on," I said while hooking up my leads.

"Yeah, I'm sure of it," the young nurses aid reassured me.

I casually unplugged the tubing from the tank and hooked it to the flowmeter, and turned the flowmeter on. Then I checked the O2 tank. Yes, it was on to 2lpm, but there was something she didn't notice: the tank was empty.

Now, instead of jumping all over her and telling her she was a stupid ass like some people might do, I used this as a teaching opportunity. She probably thinks I'm going to write her up. I won't.

Why won't I write her up? Because I know that some day I'm going to do something stupid. We are a team. We need to stand up for one another.

This ER nurse however. I am very confident that once I get her trained I will get along with her just fine, so long as there is any humanity in her. In the meantime...

I hope she writes me up.

The six different types of respiratory therapists

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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


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


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


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


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

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

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

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

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

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

I couldn't have been more wrong.

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

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

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

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

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

Need STAT reform STAT

Aside from the need for bronchodilator reform, I've been thinking lately that we also need some major STAT reform. It's getting the the point that the word STAT has lost all credibility.

"RT STAT to ER," wailed overhead. I had a SOB patient in need of a treatment, but what was I to do? I rushed down to ER to find a kid in no respiratory distress. He didn't even need a treatment. I rushed back up to care for my SOB patient.

When I hear that word "STAT" that's what I think: drop what I'm doing and go (with a few exceptions.)

RT Rule #6: STAT means that you need to get to the patient's side right now. We are talking about a life and death situation.

I've been called to a room stat to do an EKG, only to find out the doctor wanted it done so he could go home. I consider that abuse of the STAT system.

I've been called to pre-op STAT to do an EKG prior to surgery on a scheduled surgery. Those EKGs should be completed way before the surgery so they can be inerpreted.

I've been called STAT to induce a sputum. Once I was called to STAT NT suction patient for this.

After I very reluctantly performed this not indicated and traumatic procedure, the nurse cornered me. He said, "I called that STAT because of the pneumonia protocol, and we had to give the antibiotic within four hours."

"That's a silly reason to call me STAT," I said. And you're lucky I didn't have anything else to do, or I wouldn't have come down right away either. I'm not letting my SOB patients suffer for this.

I was even called to do a STAT Halter Monitor once, but that ended up being the ER staff fooling around with me because they knew I hated doing Halters in ER. I suppose I deserved that one.

The first thing you learn as an RT is that a page to ER is considered a STAT page. I was told that I should be down in ER in about 5 minutes.

When I first started working here I was told by the ER staff how impressed they were at how quickly I got down there to do EKGs and treatments. "You get down here almost twice as fast as any other RT."

I was perplexed. I thought we were supposed to be in ER within 5 minutes. I thought we were supposed to drop whatever we were doing and get down there.

Then I caught on. I realized that I was quitting in the middle of a breathing treatment, rushing down to ER, and doing an EKG on a patient who had leg pain, or abdominal pain, or bad fingernails or something stupid like that. Or I'd get called down there to do a treatment on a kid with a cold.

Either that or I'd get down there and the nurses were putting in a catheter and tell me I had to wait. After a few months of waiting 10-15 minutes each time this happened, I decided I could better utilize my time.

I tried to go to my boss, but they had more pressing issues to deal with. That was a dead end. I learned that other RTs had done the same thing when they first started as RTs. Now we are all slow. According to some ER RNs, we are slow getting to ER because we are lazy.

That's fine, call me lazy, but you guys need to learn how to use the word STAT. I would like a reform of the ER paging system. When I think of STAT I think of running. I think that if I don't get there right away the patinet might die or have prolonged suffering.

One day an ER nurse was blunt with me. "What took you so long to get down here?"

"I'm sorry, I'm swamped," I said. It was true.

"You should at least call so we could do it."

"I was at a code."

Twenty-minutes later I received another page to ER for an EKG, and this time I really was busy and called. An hour later I made it down to ER and the EKG was still not done.

To be fair, most ER staff at Shorline are very understanding that sometimes RT is busy, and that we have to prioritize. And, as it turned out in this case, the nurse that did complain was a rental nurse not familiar with our hospital.

And, even while ER procedures are considered STAT, the people who order them are simply following the current protocol and, thus, doing there jobs.

To correct this problem, we at the RT Cave wrote the following letter. It was signed by all my fellow RTs:

To whom it may concern:

To speed up time from door to EKG for critical patients in the ED, and to allow the respiratory therapy staff leeway in prioritizing EKGs with important therapies on the patient floors, we propose the following paging protocol be instituted for all EKGs ordered in the Emergency Department (ED).

1.EKG Priority One: This page will be sent out for all EKGs ordered on highly critical patients such as obvious MI’s, life threatening arrhythmias, failing patients, etc. Upon receiving this page, the RT will drop what he is doing and run as fast as he can to the ED. If RT is unable to complete the EKG within 5 minutes, the ED will be called and the ED staff will complete the EKG.

2. EKG Priority Two: This page will be sent out for all EKGs that fit under the ACLS protocol where the EKG must be completed within 10 minutes of the patient’s arrival in the ED. Upon receiving this page, the RT should be in the ED within 10 minutes to complete the procedure. If RT is unable meet this time frame, the ED will be called and the ED staff will complete the EKG.

3. EKG Priority Three: This page will be sent out for all EKGs that do not fit under the ACLS protocol, the patient is stable, and a time frame from door to EKG is not essential. Upon receiving this page, the RT will have leeway to complete other
essential procedures prior to arrival in the ED. This page will also be utilized for all pre-op patients, and any patient currently unavailable due to use of commode, bathroom, gone for x-ray,CT, etc.

Ideally, priority three EKGs should be completed within 20 minutes from time of page. If RT is unable to meet this timeframe, the ED will be called with an estimated time of arrival. In some cases,the ED staff may decide to complete the EKG and, if this occurs, RT will be notified the procedure has been completed so they don't have to rush down when they finish the task at hand.

If the ER staff is called to do an EKG, and the EKG is not completed in a timely manner, the RN will have to order pizza for all the RTs on duty. If this is not possible, the total sum of $50 will be extracted from the RNs paycheck and set aside for an end of year RT party.

We believe the implementation of this protocol is essential to improving staff time management, and, more important, improving patient care.

Sincerely, The RT Staff

We understand it's a hell of a lot easier to be called lazy (we're used to that) than to try to change policies and procedures that make no sense. But we had to try with this letter.

If this works, we will tackle STAT ER treatments ordered on patients not having bronchospasm next.