Ventolin now indicated for low heart rate

There are some things in healthcare that are too awkward to believe, but impossible to make up.  Such was the case when a patient was shown to have a heart rate of 50.

The doctor turned to the nurse and said, "Call respiratory for a stat albuterol treatment.  We need to get this guys heart rate up."

Fancy how such a thing can result in the ire of the respiratory therapist, who had better things to do.

Needless to say, after the treatment the RT sat down to chart.  His pre and post assessment was as follows:

Pt presented in no respiratory distress; hr = 50; rr = 20; ls clear with normal aeration... post treatment.... no difference observed upon assessment nor noted by patient; hr =48, rr = 21

Go figure.

Is the false hope worth $120 a pop?

Your question: #1: do no harm. I can't speak for all rts, but most of my pts improve with the therapy given. Some pts despite all efforts whether mythical or not do not. I've never killed anyone with an albuterol. Sure, some docs think it cures everything, but it can make people feel better even if its just in their head. Now lets talk nurses overmedicating and rts having to fix their mistakes. Thoughts?

My answer: Actually it is a fallacy that ventolin causes no harm. We must not for get the s-isomer, which has been proven to cause inert bronchspasm. The more you take the medicine, the more you need it. It's an endless cycle.

I do see your point though. Patients do get the psychological benefit of thinking we're doing something, and the company of an RT.

Yet this has been a problem that has plagued the entire history of medicine, is that most medicine has no benefit other than psychological. Ventolin, like charms, amulets, prayers, and incantations of the primitive world, provides nothing more than the best remedy of all time: HOPE.

In other words, there are times when Ventolin has a real scientific benefit to the patients who receive it. The other 90% of patients receive nothing more than mythical benefits.

Does this "mythical benefit" and "false hope" justify the $120 it costs insurance companies for every treatment given?

Think of it this way, you give a treatment that's not needed every four hours, that's $720 a day, and $5,040 in a week. Is that price worth hope? Of course then you add all the prn treatments given in between because the patient got dyspneic on exertion to the commode, or developed an annoying wheeze, and the price only goes up even more.

Also, taking up a respiratory therapist's time giving a treatment that's not needed takes away time from someone who does need attention. This is a principle concept discussed often in economics 101 courses. It reminds me of the Broken Window Theory.

In the Broken Window Theory you have a boy walk by a sweater shop, and he tosses a rock through the glass. Some economists say this is good for the economy, because it creates a job for the glass maker. What is not seen is the effect on the sweater maker.

During the time the window is broken, the sweater keeper is not allowed to sell any of his sweaters. He therefore is out of a job until the window is fixed. He makes zero sweaters.  If he sells zero sweaters, the sweater maker sells zero sweaters.  Various other unseen people are also affected, such as the delivery man, and the man who sells little gadgets to support his family.

But the people don't see this aspect of the economy, all they see is what is obvious: a broken window and it being repaired. They see that the repairman is making money.  They think this is good for the economy. It is, but what they don't see is that the sweater company being closed greatly effects the economy in an unseen way.

So, I guess I'm comparing useless ventolin therapy with the sweater salesman. While the patient and the physician see the breathing treatment, what they don't see is that it did no good. Regardless, studies show that 50% of patients who received a placebo also said they benefited from the patient. So this proves that the patient is unreliable.

Likewise, in a similar scenario, while the breathing treatment is being given, the patient is given lasix. While the lasix is forming pee, and thus removing fluid from the lungs, thus making it easier to breathe, it is not seen.

In this way, lasix is also like the sweater maker. Since the ventolin is seen, it is given credit. It is also like the primitive medicine man getting credit for saving the live of a patient, when the truth is that nature did the same. But since he did something, he is given credit.

Also, and I'd like to see a study on this, when an RT is burned out at the end of a day due to too many frivolous therapies, it diminishes his ability to make good decisions at the end of his shift. A burned out therapist is not always at the top of his game.

This, in my opinion, may work to the detriment of good patient care. A burned out RT who is grumbling and griping at yet another useless ventolin order is probably not good for public relations either. And it's not like you can fire this RT, especially, as I've observed, this is common among all RTs. So you can't fire them all.

Now, these are simply thoughts. Although in all the years I've communicated such thoughts, I have never had anyone come up with a counter argument. Not one person has ever come up with any facts to prove that ventolin is needed for CHF, pneumonia, cancer, pleural effusion, and other lung diseases that provide asthma like symptoms.

I have had many doctors say things like, "I think that ventolin helps with heart failure." I ask this doctor, "Do you have the evidence to support this claim, or is it just a feeling?" Never has a doctor proffered any evidence. Usually they get mad as I offer my proof. They get mad at me for being honest.

Getting back to the broken window theory, as I'm giving the breathing treatment that isn't needed, what is not seen is that two rooms down is a man in the early stages of heart failure.  He is the man I would be visiting if I wasn't stuck in this room. Later on he will be intubated, and and only because of that breathing treatment that was thought to do no harm.

The idea that ventolin therapy does no harm, in my opinion, is no better than treating diseases the primitive way with a medicine man dancing, rattling his shakers, beating his drums, and chanting incantations. Since this is what the sick person sees, when the patient gets better the patient will say, "The miracles of the medicine man cured my sickness."

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Stupid orders does not make a stupid doctor

And just to be politically correct, and perhaps I should say this more often on my blog: A stupid order doesn't necessarily make a doctor stupid.  It mans the doctor is ignorant in that area.  He could still be a good doctor overall.  He could still make a great doctor.

Plus, what I think of as a stupid doctor, that doctor thinks, obviously, is a good order.  So, in that regard, we need to be careful as to what we say.  In other words, the truth should not be spoken.  In other words, it's not a good idea to go up to a doctor and say, "That, my friend, is a stupid order."

A good example was the last time I went to the emergency room for asthma.  I already had enough ventolin in my system.  I did not need another breathing treatment.  I just took one before I went to the ER.  But, as expected, as soon as the doctor listened to me, he said, "Well, I think we better give you a breathing treatment."

I did not argue with him.  Because I went to the ER to get a shot of corticosteroids and prednisone, I put up with the stupid order.  I took my breathing treatment with a smile.  When my friend and fellow RT Jen came into the room, I knew that she knew why I was smiling.

Of course then the doctor ordered no blood taken from my body, and ordered no tests on my sputum, and yet she ordered an antibiotic.  "I think you should be on one," he said.

My initial thought was, "Why?" I have no signs of an infection.  I'm having symptoms only of bronchospasm.  But, being the good, politically correct boy that I am, I took the medicine and kept my mouth shut.

That is basically how I approach my own doctor.  I know that I know more than he does about asthma, yet here I sit on the patient's bed in his office and listen to his "theories" about why I'm sick.  He said, "I think you are dehydrated, and you probably have mucus plugging."  Fine, I can buy that.  But, where he caught me snickering was when he told me his remedy: "Add 3cc of normal saline to your treatments to make them last longer and to hydrate your lungs."

Yeah!  As he was explaining his theory, he stopped to say to me: "Why are you looking at me so funny? Are you not buying my theory?"

My politically correct response was, "I'm always open to suggestions."

So I think my doctor is brilliant.  I really like him because I know he keeps up on his research. I think most of the doctors I work with are smart too.  However, based on my own personal experience with asthma and bronchodilators, I have rarely met a doctor who understands either one of them.

There are, however exceptions.  There are doctors who truly understand asthma and bronchodilators. I know they exist because I hear about them from my asthma friends online. I have never met one in real life. .

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I've decided it's okay to cry during a treatment

No, I'm not talking about the respiratory therapist crying during a treatment, although that's okay, I guess, too.  What I'm referring to is a baby crying during a breathing treatment.

The fallacy among nurses and doctors, or many of them, is that if a patient is crying during a treatment he is taking deep breaths and will get the medicine deeper into the lungs.  Yet the truth is the opposite occurs.  During rapid inhalation, most of the medicine impacts in the upper airway, and hardly any medicine gets to the air passages.

Plus during crying most of the time is spent during exhalation.  So, if you're giving said treatment as a blowby, you can guess that about 0.99234234234234234234234234234 percent of the medicine is getting to the airway.  The treatment is useless.

So you have a kid who is crying vehemently, and the patient is also in respiratory distress.  The doctor and nurse are all panicked and insisting you give the blowby treatment.  So you do to no effect.

Finally you tell the nurse and doctor the treatment has no effect, so they order you to give ten more.  And you are pissed because you know this isn't doing any good anyway.  You know the patient does not have bronchospasm, because that audible stridor is not a sign of bronchospasm.

So, this irritation has made me a lazy RT.  I find that it is easier just to do the blowby treatment on the crying kid and go back to the RT Cave and blog.

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MCAT question #55

I cannot reveal my source, but I once again am privy to esoteric wisdom. The following is a question I have obtained from the Medical College Admission Exam (MCAT):

#55.  What makes sense about the following:  

Assessment:  

• No respiratory distress
• Speaks in full sentences
• No acessory muscle use
• Lungs clear
• Normal breath sounds
• No respiratory history
• No asthma
• No CHF
• No pneuonia

Diagnosis:  Intractable pain and seizures

Plan: Breathing treatments of Albuterol Q6 and Pulmicort BID

Of the above, which of the following are true: 

• a.  Nothing makes sense about the above orders, as if a person is not short of breath and has no respiratory history, he should not require breathing treatments
• b.  Preventolin will assure a speedy recovery
• c.  Breathing treatments are indicated to assure patient meets criteria for reimbursement
• d.  Seizurebuterol sooths and relaxes the myelen sheths in the cerebral cortex to minimize spasms of the head and shoulders.  May be alternated with headandshouldersuterol.  The medicine should be given at a frequency of QID.  Pulmicort should be given BID to lubricate the albuterol particles to help crossage of the blood-brain barrier.  

What are the advantages of BiPAP?

I had a doctor today order BiPAP on a patient who was suffering from heart failure.  I walked into the patient's room and saw that the blood pressure was 65/20.  Based on my knowledge of BiPAP, I felt that it was contraindicated for this patient. 

So I sat down with the doctor.  I said, "The patient has a low blood pressure. Do you still want to use BiPAP." 

He said, "Yes!  He's a very calm patient, and if you irritate him with that mask it may help get his blood pressure up." 

After taking a couple deep breaths, I said, "Can you explain to me what BiPAP does for CHF patients?"

He said, "Yes.  It increases the pressure in the lungs so that it forces fluid out.  It helps decrease the pulmonary edema."

I said, "What I learned about BiPAP is that it decreases preload to the heart, thereby decreasing cardiac output, and thereby decreasing blood pressure.  In this way, it helps to decrease the patients work of heart.  That is how it helps with heart failure.  It does not force fluid out of the lungs."

"Well, put it on him anyway," he said, and stormed out of the room.

That occurred in the emergency room.  Up on the floor, a doctor ordered BiPAP on a patient who was septic, suffering from kidney failure, and in metabolic acidosis.  The patient likewise had a low blood pressure, but it was being somewhat controlled by dopamine. 

I asked the doctor why he was ordering BiPAP.  He said, "Because it will decrease the work of heart.  The patient is a DNR and I understand she's going to crash at some point anyway, but this will help delay the inevitable."

I asked, "So, how do you think the BiPAP will decrease work of heart?"

He answered me:  "Becaues it will force fluid out of the lungs and make it so the heart doesn't have to work as hard to breathe."

I took a deep breath, and said, "BiPAP will decrease the work of heart, but it does it by decreasing preload. This in turn decreases after load, and therefore decreases cardiac output.  This is what decreases work of heart.  Since blood pressure is an indicator of cardiac output, I'm concerned BiPAP will comlicate your efforts to control her blood pressure."
"So what do you suggest?" he asked. 

Impressed that he asked me, I said, "She's breathing normal.  So how about we don't use BiPAP."

"Welp!" he said.  He hymned and hawed a few minutes, then he said, "EEEEEEeeeeee, let's just put it on and see what happens."

Well, at least I tried. 

So, what are the advantages of BiPAP?

1. IPAP increases ventilation and helps to blow off CO2
2. CPAP increases FRC and therefore keeps the lungs open so the next breath comes in easier
3. Both IPAP and CPAP help to reduce work of breathing
4. Both the IPAP and CPAP help reduce work of heart as explained above

Apperently this is not what's taught in med school.  I'll have to investigate to see if this topic was covered in the Real Physician's Creed.

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Stupid doctor orders

I have mentioned stupid doctor orders on this blog, yet I have nary defined them.  So, for the sake of discussion, what, then, are stupid doctor orders as compared to good doctor orders.

1. Stupid doctor orders: 1)Orders from a physician that lack common sense and have no purpose, and therefore have no benefit to the patient.  2) Orders that benefit the hospital by assuring the patient meets reimbursement criteria, although with no otherwise scientifically proven benefit to the patient. 3)  Orders written based on habit and with no scientifically proven value 4) Orders that are based on antediluvian theories.

2.  Normal doctor orders:  1) Doctor Orders written based on scientific evidence, or at least best practice medicine; 2) Orders that benefit the patient

3. Antediluvian theories: Theories that are old and outdated yet are still worshipped by doctors.  A good example is the hypoxic drive theory.

4.  Regular theories:  Based on a rational guess

5.  Scientific fact:  Proven by science, as opposed to proven by "oh, it sounds like a good idea."

Here are some examples of stupid doctor orders:

• Q4 Albuterol (how do you know the patient will be short of breath every four hours?)
• Q6 Albuterol (how do you know the patient will be short of breath every six hours?)
• QID Albuterol (how do you know the patient will be short of breath four times a day?)
• IPPB: (still some physicians who wish to continue the quest to overinflate god alveoli)
• Wean patient at a PS of 10 (like, that's the same as a ventilator breath that decreases WOB)
• Set Fio2 order (40%, 50%, 60%, etc.)(why not just write order to maintain normal spo2?)
• EKG because (let's have a real reason for ordering these, as opposed to just because...)
• Serial ABGs (so what's the point of having patient on EtCO2 and SpO2 monitors if you're going to continue torturing the patient every day anyway?)
• Ventilator tidal volume 1000 on a 500 pound man (Like, let's blow up the patient)
• Ventilator tidal volume 100 on a 100 pound lady (like, let's ventilate the patient)
• Breathing treatment on not breathing post operative patient (like, let's try bagging,  reintubation, or let's have the patient bring in his home CPAP because he's got sleep apneao, not bronchospasm)
• Albuterol stat post operative for stridor (that's not stridor you idiot, the patient is snoring)
• Albutetol stat for dyspnea (the patient has an f'd up heart, you idiot.  Ventolin is a bronchodilator, and will not help with dyapnea with exertion)

These are just some real life examples. 

Stupid ventilator change

One thing that bothers me is when a doctor writes an order that makes no sense.  Today I was called to ventilator patient Mr. Sick's room.  The order was to increase the tidal volume from 550 to 620. 

I said to the nurse, "Why did he write this order?"

She said, "Because his heart rate increased from 90 to 120."

I said, "The patient is in automode, and is using volume support.  He is creating his own tidal volume and respiratory rate.  So, increasing the rate will have no effect."

She said, "He's a pulmonologist who knows what he's talking about."

I said, "Well, obviously, that could be debated."

The Chart Nazis

I think there is way too much emphasis on charting in healthcare, and not enough emphasis on the patient.  The longer I work in healthcare the more I realize this.

Just to give an example, my colleagues and I have maybe one or two experiences over the past 15 years where a patient, or patient family, complained about patient care.  Every one of those complaints was based on ignorance on the part of the patient or family member, and not on poor care by one of us RTs.

My colleagues and I get on average 2-3 notes a week alerting us to a charting error.  Once we master one area, the chart Nazis, as I like to call them, will find some other area of charting to focus on.  It's a never ending battle.

It's not just where I work either. I think even as you look at government regulations over healthcare, all, or most, of them tell a physician how to treat a patient with a given diagnosis.  There is no emphasis on the individual patient.

For example, all patients admitted with pneumonia must be sick enough to need one of the following in order to meet criteria for admission (translated means: criteria for reimbursement):

1. SpO2 of 92% or less upon admission, or an abg
2. Albuterol nebs or mdi every 6 hours
3. Antibiotic

There is no emphasis on the individual patient there.  There's this assumption that every patient is the same, or some kind of entity.  Individualism is lost in healthcare.  And this, my fellow RTs, is what is wrong with healthcare.  

Physicians are not encouraged to think outside the box.  For example:

• What if the pneumonia patient doesn't have bronchospasm?... too bad.
• What if the patient is too sick to go home but doesn't need oxygen or antibiotics... too bad. 

Personally, I think the current state of healthcare is unfortunate for the patient, because he's not going to get the care he really needs.  I think it's bad for the respiratory therapists and nurses, because the emphasis will not be on patient care, but whether those three things were done and charted correctly. Of course RT bosses will emphasize accurate charting, which is (ahem) where the dollars are.  

So when the chart Nazis come out in groves, now you know why.  

Another frivolous use for Ventolin

I'm telling you you can't make this stuff up folks.  I was called to the recovery room to give a breathing treatment.  Upon arriving in recovery I said to the nurses:  "You need a breathing treatment, or want one?"

The nurses directed me to the patient.  "She needs a treatment," the nurse said.

The patient in question was sitting in high fowlers position and appeared to be in no respiratory disterss.  He was kid.  Right then the doctor arrived. 

"Oh, yeah," the doctor said, "His lung sounds are clear, but when his breathing slows down his sat starts to drop.  I figured a treatment might help."

I smiled and said, "So, what you want is for me to give a Ventolin breathing treatment to increase his tidal volume so his sat stays up?"

"Sure," the doctor said, confidently. 

I guess this is yet another example that proves my adage that instead of thinking just call respiratory. 

What's the dumbest doctor order?

Your humble question:  What's the dumbest doctor order ever?  Do you get a lot of stupid doctor orders.

My humble answer:  I think the dumbest order I can think of was when we were informed a short of breath patient was coming in by ambulance and the doctor ordered a continuous breathing treatment as soon as the patient arrived.  The patient arrived and, based on my assessment, the patient did not present with bronchospasm.  Air movement was good except over one region of the lungs, and the patient had a history of pneumos. I asked the doctor if she still wanted a continuous, and he said, "I ordered it, didn't I?  So here I spent an hour doing a treatment on a person because she had a collapsed lung.  And the doctor ordered it before even assessing the patient. 

Another patient came in with all the signs of heart failure.  She had dyspnea and cardiac wheeze.  The doctor ordered back to back breathing treatments and then Q1 after that.  So before she even assessed the patient to determine if a bronchodilator was effective she's decided the patient still needs one every hour after that.  My philosophy is that if a patient is still short of breath two hours after being admitted with CHF the doctor should be fired.  Yet no one ever questions doctor orders, and I didn't want to be the first. (Although I did recently question a disrespectful physician here).

You can pretty much click on the humor tab above to get a plethora of examples of stupid doctor orders. 

Signs that assume we are all stupid and lazy

Signs.  Notes.  You see them everywhere, especially at your work or office.  Most of them are written by choleric people who love rules and must have everything done their way.  And, yes, there is usually at least one choleric in every office.

They put signs up like the following:

• We do not have a maid service, clean up after yourself.
• Please shut off coffee pot when not in use
• This is a garbage, not a recycling bin
• This is for cans only, this is not a garbage!
• This room for employees and patients only! 
• This room is in use/ not in use
• Meeting this month is mandatory
• Label and date all food containers in refrigerator
• All unlabeled food will be tossed every Monday
• No drinking by computers
• No food in office

You get the drift.  These are signs written by people who have to have control.  Yet they don't realize that we are all people, and we all have different personalities, and we get busy.  These are signs written by people who think most people are stupid and lazy.

Some of us are lazy for sure, but the majority of us have more important things to think about than whether or not we leave a cup of water lying next to the computer, or have a container that's been in the fridge for two weeks.  Some people are clean and organized (the cholerics and melancholy) and some people aren't (sanguine and phlegmatic). 

I think a few signs or a few rules are good, but when you start to get a collection of them they become too hard to follow and too hard to enforce.  It's better just to have one really important sign, like this:

• Work hard
• Do your best
• We respect your hard work
• We know who the hard workers are, and we appreciate you

Yet communication in this positive way is rare and far in between, and usually comes just prior to communication that relays something you did that was wrong, such as a charting error that has nothing to do with the patient/ customer.

Signs are dumb.  I'd like to rip them down, and sometimes I do. Likewise, few of these prodigal signs say please and thanks.  I'd like to put my own sign up (just one) to put an end to such frivolity:

• Quit putting up stupid signs!  And Thanks

None of these signs are necessary.  If you're anal retentive and want to clean the fridge, clean it.  You'll be more respected that way anyway. 

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Yet another example of what's wrong with healthcare

It was kind of a culmination of all I've written about on my blog the past year was when our hospital Quality Analyzer came into the office and said, "I need to speak with Rick."

I spun around my chair and said, "Hi, Gerri, what can I do for you?"

"I was just wondering if you gave any breathing treatments to the kid in 310 today?"

"Um," so what was the right answer? The truth perhaps?  The kid in 310 was admitted with croup yesterday and was ordered to get racemic epinepherine breathing treatments prn. After an awkward moment of silence I settled on the truth.  "I didn't give one."

"Oh, I was hoping you did one and forgot to chart." She smiled. "The patient was discharged and now his insurance is refusing to pay for today because we didn't do anything today. If you did a treatment..."

"Do you want to to go in and chart a treatment I didn't do so we can get paid."  A provided her with an eerie smile.

She gave me the thumbs up.

Of course she was joking and so was I. Yet this is a perfect example of what is wrong with the healthcare industry. A patient needs to be admitted for observation, and yet because we didn't do anything the patient's insurance won't pay.

"Well," I said, "I guess for now on we'll be giving Q4 breathing treatments on all of Dr. Kipper's patients."

"Sure thing," she said, giving me the thumbs up signs again.

Dr. Kipper was new. The other pediatricians had already learned to order Q4 ventolin and racepic epi prn. That order makes no sense medically, and is a complete waste of time and money and results in RT apathy.

Yet that person sitting in a chair in Washington who makes all the laws was smiling somewhere in a leather chair in Washington as she unwrapped her paycheck.

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Order sets are stupid, IMO

Based on my experience as a departmental representative at various administrative committees, I am privy to some wisdom not available to the general public. For instance, many hospitals have order sets that are hidden under the guise as protocols.

No, they are not protocols. Protocols increase personal accountability and responsibility. Protocols increase personal thought and intellectuality. Protocols preach individuality.

Yet order sets, while started with the intention of doing what is best by best practice medicine, generally make it so each patient is treated the same. Order sets take away personal accountability, individual thought, personal accountability and responsibility.

Protocols improve morale, and order set decrease morale. Order sets decrease morale because all we do is a bunch of procedures not because they are needed, or even because a doctor wanted them, but just because. Order sets are cook book medicine.

Order sets (which, again, go under the guise as protocols and guidelines) not only result in decreased morale, they increase the cost of medicine because, ahem, someone has to pay for all of this impractical medicine.

CMS only pays a flat fee (because of DRGs), and those obtaining CMS services get free healthcare (well, free to them anyway. We have to pay for their free). Therefore, the one's who will pay are those of us who pay premiums for health insurance.

We will pay more. This goes along with the premium hikes we will now have to pay because Obama care provisions to force insurance companies to pay for dependents until they are 25, and previous medical conditions (liabilities).

Consider the following:

1. Of the 20 EKGs I did today, only 15 were needed. All were ordered not by a doctor but by an order set.

2. Of the five ABGs I did today, none were needed. All were ordered not by a doctor but by an order set.

3. Of the 30 breathing treatments I did today 28 were not needed. All 28 were ordered not by a doctor but by an order set.

4. Of the six stress tests completed in my department today, none were needed. All were ordered as a result of an order set.

Order sets wouldn't be so bad in and of themselves, but most of the items on them are pre-checked, at least at my institution. To not order something, the doctor has to scratch out the item and sign. And then risk a lecture by the Quality Review lady. So it's easier for them not to bother.

If order sets were as they were initially intended, a list of all possible procedures the doctor might want to order, then order sets wouldn't be so bad. And balanced by good protocols to eliminate ordered procedures that aren't needed, order sets would also be good.  Yet that's not how it is when you resign yours institution to cook book medicine.

Thus, most items on order sets are ordered whether needed or not. Common sense is not the result of an order set. Common sense and individual thought are down the drain.

The following are unintended consequences of order sets:

• Lots of not needed procedures
• Wasted money
• Increased workload for RTs
• Increased burnout
• Loss of confidence due to loss of ability to decide what patients need
• Loss of morale due to inability to use common sense
• Poor attitude at bedside because after the umpteenth not needed EKG or treatment you get irritated by it all. It becomes a job rather than a profession, like working an assembly line at a factory
• Poor patient care due to low morale and in a hurry to get all the procedures done
• Feeling of irritation by RTs because we're doing a bunch of BS
• Increased apathy
• RTs develop RATS, which isn't good for the institution (and I'm not talking about the creepy little critters either.)

In the ideal world order sets are counterbalanced by protocols.  But in the real world idealism in merely a pipe dream. 

Yes, there are some advantages to order sets. Yet the disadvantages are way more than the advantages. There's an old saying: Something is worth the investment only when the advantages out weight the disadvantages.

And in this case, the few recommending these order sets (mainly people sitting at a desk in Lansing or Washington) have a clue of the negative consequences. Or do they? Perhaps the intent is to collapse the health care system. Perhaps that's the intent. If it's not, I have a hard time justifying it.

Thoughts?

RTs might be the smartest of s-m-r-t

I said, as I read the order for Q5 hour Xopenex on an RSV patient with clear lungs who didn't need to be admitted but was, "That kid don't need no frickin treatments."

"You say that about all treatments," the RN supervisor said.

"That's because there's no scientific evidence treatments treat anything but bronchospasm."

Sometimes I wonder if it's just RTs that questions stupid doctor orders. Is it just RTs who wonder why things are ordered without scientific evidence they do any good?

Is it possible the smartest of the medical profession are your humble RTs?

In lieu of the evidence, I'm obligate to assume this is so until further evidence reveals otherwise.

So, congrats fellow RTs, you're apathetic because you're of the smartest lot. In fact, I think it was Ben Franklin who said, "I'd rather be the dumbest lot on earth than the smartest person with no one to have an intelligent discussion with."

I wonder if he had RTs in mind when he said that. I doubt it, but it makes you think doesn't it.

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Please help clue me in

Explain this:

Pt admitting ABG at 1500: ph 7.41, CO2 58, po2 72 on RA, HCO2 32

2300: Pt extremely lethargic, rr shallow and irregular, ls diminished, although no other signs of respiratory distress.

Dr order: ABG and decrease oxygen to 1lpm and do ABG in hour

ABG results at 0100: 7.29, co2 92, po2 82 on 1.5lpm, hco3 35

RT recommendation: bipap

DR. order: breathing treatment and send pt to critical care, another abg at 0300, and decrease oxygen to room air.

0300 abg drawn: ph 7.23, co2 102, po2 some how 108, hco3 37

RT recommendation: Bipap

Dr. order: continuous breathing treatment with compressed air then repeat abg.

Dr. called back 30 minutes later after talking with pulmonologist and ordered bipap.

So what the hell with all the breathing treatments? It was obvious oxygen wasn't causing his distress. It was obvious the breathing treatment wasn't curing it. So what the...??? And why did this otherwise good doctor delay using bipap so long for?

If there are any RT wizards, doctors, nurses, students, or housekeepers out there with a clue as to what this doctor was expecting, please clue me in.

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Word of the day:Brook: To tolerate or endure, to withstand, bear or suffer

I will brook no inferences at doctors who write orders that make no sense

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Sometimes I feel stupid

Does anyone besided me feel really stupid giving a breathing treatment on a young, physically fit, post-op patient who has clear lung sounds, has never smoked, has clear lung sounds with great air movement, and does a 5,000 on the incentive spirometer?

You walk into the room, "Are you short of breath?"

"No."

"Do you smoke?"

"No."

"Have you ever smoked?"

"No."

"Have you ever been short of breath?"

"No."

"Well," respiratory therapist clears throat, resists the urge to sigh, "your doctor wants me to give you a breathing treatment."

"What's that?" The patient rightfully asks.

"It's something to dilate your lung muscles and help you breath better."

"But... I can breath just fine."

"Funny how healthcare works, isn't it."

"Well, I guess if the doctor thinks this will benefit me somehow, I'll do it."

"Yeah, and he thinks it will benefit you every four hours too. So, I hope you don't plan on getting a lot of sleep."

"Well," the patient said, "I think I won't be needing it at 4 in the morning, though."

It's at this point I often inform the patient, if I think they can handle it, that they probably don't need the treatment, and have a right to refuse. The frugal one's will call the doctor's bluff, take a hint, and refuse the useless therapy that costs $89 a pop, and that's being conservative.

Yes, I feel stupid on these occassions. I feel like I want to tell the patient their doctor is a dink.

Then again, bored, many of these patients say, "Go ahead! I'm bored. Give me the treatment anyway." Which reminds me of a new type of Ventolin called "GoAhead-olin."

Check out the Ventolin types above (or click here) as I've updated the list.

Is it our duty to question stupid doctor orders?

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

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

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

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

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

"Actually, that's not the reason."

"Well," she said.

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

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

"Yeah. I'm non confrontational."

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

"True," I said.

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

"I see what you mean."

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

Anyway, that's something to think about.

Reason for stupid orders: stupid people

I'm telling you folks, you can't make this stuff up. I gave a breathing treatment in the ER an hour ago on a patient I had to wake up to give the treatment to, and auscultation revealed crackles in the bases but otherwise good air movement and no obvious signs of bronchospasm.

While the treatment was going I said to the RN, "Why did the doctor order this treatment?"

"I don't know. You'll have to ask her."

When the treatment is finished I chart, "No difference with bronchodilator."

So, because the doctor ordered Q1 hour breathing treatments on this patient for whatever reason, I travel back down to give the second one. The RN I talked with earlier pulls me aside and says to me:

"As soon as you left after that last treatment you gave he coughed up a big loogie. That's why Dr. Q1 orders these treatments. If you ask her, that's what she'll tell you. She's pretty smart I say."

I concentrated hard not to roll my eyes. But I did manage to say, "That was just a coincidence."

"I don't think so," she said. "Those treatments really work."

I'm telling you folks, you can't make this stuff up.

Respect garners respect, yet they don't know it

We RTs at the RT cave were told by the head RT boss that we don't take our jobs seriously enough. We make too many needless mistakes in our charting. We complain too often about stupid doctor orders. We make up fake diagnoses that better explain why the patient is really in the hospital, such as exaggeration of asthma.

Yet, at the same time, during a meetings a year ago one of my co-workers brought up the fact that one particular doctor in the ER "doesn't know what the #$#@# she is doing. She orders treatments every hour until discharge on CHF patients, and does Q30 minute Xopenex treatments for croup."

So, as a group, we wanted this doctor investigated. We wanted it documented that she orders more procedures than any other doctor.

The next meeting the results were it: This particular doctor in question did not order more treatments than any other doctor.

However, this study did not take into consideration that the doctor in question works nights, where fewer patients are admitted. Yet, based on the results, the RT bosses dropped the issue.

Recently the issue was brought up again. In fact, this time we kept a stack of dumb doctor orders by this doctor. The RT Boss looked at that stack and said, "Look, we need these procedures to keep our jobs. With the economy the way it is, you should just be happy to be working."

I discussed this with another of my co-workers, who said this: "How can they expect us to take our jobs seriously when they don't take us seriously."

Point made.