Respiratory Therapy 101: Just Keep Breathing

The COW implementation at work has arrived. It has been an interesting couple of days, but I am too tired to write more at this time, so it’ll have to wait. So I leave you with two things: first, the promise of an excellent music video that relates to the ICU will be here tomorrow. Stay tuned for that…and for my signoff tonight, I leave you with a thought:

An excellent name for a new brand of Whiskey would be “Gilgamash.” You could even write a book about the distillation of said whiskey entitled “The Epic of Gilgamash.”  This is only funny to me because I have not had nearly enough sleep and I have been working waaaay too much overtime.

Funny video tomorrow, COW philosophy later.

ERDoc85 has an excellent post about his take on the “healthcare crisis” up at M.D.O.D. Go check it out.

The fact that anybody would believe that a large, sharp object designed to cut the heck out of shrubbery was an appropriate tool for solving a domestic conflict demonstrates that there is something seriously the matter with people. Every now and then a patient or their circumstances gets my attention and makes me think, makes me wonder what the hell is wrong with people.

And then I remember that they’re people, and inclined to do stupid things. And I sigh and go about my business and think it to death in my head.

I’m off tomorrow. I could use the break.

I’ve been able to avoid hecklers and internet controversy for some time, which is just fine with me because I really don’t want to spend time on internet drama. But I think I’m going to tempt the fates and weigh in on some point/counterpoint going on elsewhere in the land of medical blogs.

It all begins with an excellent post over at Musings of a Highly Trained Monkey. She has written a deeply amusing letter entitled “Letter to a frequent flyer with actual medical problems.” The tone of the letter is a mix of the frustration of dealing with ignoramuses who refuse to help themselves mixed with a heavy dose of sarcasm and some delicious false sympathy. Here’s how the letter ends:

So you can understand how sad we are tonight, having seen you for the last time in our ER. We worked so very hard to make sure you could come back and see us another day. Your visits mean so much to us, after all. But alas, asystole is not a rhythm oft recovered from, and though the medics did their best, as did we, your family will just have to spend the 0300 hour in bed from now on, as they won’t need to be here, by your bedside in the ER.

Though the tube in your throat isn’t helping your COPD much anymore, and the 20 g in your thumb won’t be used for Cardene or Insulin tonight, and well, we didn’t bother with the catheter, since there’s no such thing as a stat Foley, we can tell you with utter certainty that you are in no way hypertensive.

And we consider that a success.

Thank you again for choosing us for your medical care-
The ER Staff

Of course, some folks don’t take kindly to it when we make a mockery of our patients. They especially don’t take it kindly when we seem to rejoice at the passing of a humongous pain in the ass. Another ER blogger has written a respectful and eloquent response to what she perceives as a troubling lack of sympathy:

All of us, even the most healthy of us have vices as do the frequent flyers. Some of our vices are seen, some are unseen. All of us do things that we should not do but seem powerless to stop. This powerlessness can be anything from overeating, undereating, smoking, to biting our nails. The fact is that all of these things are vices. Yes, some are worse than others; and some are less detrimental to our health, but each habit is hard to break. I try hard not to pass judgement on others who *I* think should do this or that, but it’s in the back of my mind that if they only did “this” than they would be much better. I am not them; and they are not me. I have not walked in their shoes nor have they walked in mine… (snipped here for length)

…I hope I never forget that everyone is special to someone. Every death is a loss; and it is more of a loss if we are not adversely affected by someone’s death.”

Point, counterpoint. An interesting glimpse of two different viewpoints. Where do I fit in in all this madness? Somewhere in the middle. I find MonkeyGirl’s letter to be deeply amusing on a number of levels. After all, I deal with patients just like this every single day and I have to admit that I really don’t like them or think they deserve treatment. Of course, they are human beings just like me, and on that level they deserve to be treated equally. Who am I to judge this woman who I’ve never met before?

But on the other hand, as human beings we are naturally inclined to judge one another whether we like it or not. And quite frankly I don’t see why I should have any respect for somebody who doesn’t want to take any responsibility for the consequences of their own actions. Why should my tax dollars have to subsidize the care of a disgusting apathetic blob of wasted carbon who doesn’t even want to participate in their own care beyond screaming at medical staff? Why should we have to spend hours of time and thousands of dollars to treat this woman when she obviously does not value her own life enough to even pretend to want to take care of herself?

Furthermore, the assertion that every death is a loss is pure bullshit. I spend a lot of time with the dying. And I would agree that most deaths are very, very sad on some level; just the other day I had to terminally extubate an 85-year-old lady who’d never been really sick before. She was the only thing left for her husband. When she died, she left her husband alone. For sixty years they’d been together. But the children were far flung, the friends were far off or dead, and nobody else was there for him. Our resident pastor sat with him while she died. The man was utterly devastated. It was a tragedy for him. I felt sick after.

That being said, I’ve extubated plenty of people who died alone because nobody loved them. And I’ve seen plenty of people die who really deserved it. And I’ve seen a lot of deaths that were blessings to the family rather than tragedies. The assertion that every death is sad is pure, unadulterated bullshit. This brings me back to my original point.

While I can see both sides in this internet debate, I have to side with Monkey Girl. Sometimes it’s okay when people die. And sometimes, it’s not really a bad thing. Not everybody is a special, productive person who affects the lives of others. Some people are just not that special. Deal with it.

So, the other day I was griping about my brief rotation on the floors, more specifically about how our treatment load vastly exceeds safe workload levels. A couple of you asked me about protocols in the comments: why, at a hospital as large and advanced as Sunny Flats, are there no RT protocols? This is an excellent question.

The thing is, we have a respiratory-driven treatment protocol on the floors. It’s quite comprehensive. How it works is, the RT examines the patient and their history and assigns a numeric score to certain values. For example, clear lung sounds score a zero, while diffuse audible horrific rhonchi and wheezing would score a five. A clear chest film as read from our radiology system would score a zero, while atelectasis or infiltrates or pneumothoraces would score higher numbers. Patients are assigned to certain groups based on their score: higher scoring patients are placed into higher priority groups and are assigned more rigorous therapy.

The system sounds complex but it’s more or less foolproof. We have a simple flowsheet to fill out that takes about fifteen minutes to complete, including assessment of the patient and research in our computerized records system.

The problem with our system is that not all RTs are allowed to fill out these flowsheets. That is the job of a special therapist, who I call the Protocol Driver*. The Protocol Drivers job is to assess all of the patients on our service on admission and then once every three days. This seems like an excellent system: the regular RTs go about their duties without having to do the flowsheets, and the Protocol Driver separates the wheat from the chaff. That is how it works in an ideal world.

In the real and highly non-ideal world in which we live it works differently. While I respect the protocol drivers as human beings, they are typically very old RTs who have been doing therapy one way for forty or so years. They are reluctant to question physicians and reluctant to rock the boat and risk losing their retirement benefits. In short, they are afraid to use their awesome assessment powers to weed out our useless treatments.

An example: Mr. Hypothetical, a 38-year-old male, is admitted with chest pain. He smokes a half pack a day and had asthma-like symptoms once when he was five. His FP, seeing that he smokes and that he may have had a reactive airway problem 33 years ago, orders him on Q4 Proventil by checking the box on the standard admission order form (which is another rant in itself.) In an ideal world, the protocol driver would assess Mr. Jones, see him in no acute distress, change his nebs to PRN only, and then refer him to pulmonary rehab for smoking cessation. In the real world, the protocol driver simply writes CONTINUE THERAPY AS ORDERED and refuses to make any changes. Instead of separating the wheat from the chaff, the drivers are flinging all of the stalks of wheat into a giant grainy pile of doom.

So why has this been allowed to go on for so long? I think I have an explanation. You see, many (not all! many but certainly not all!) RT managers fear big changes because of the potential they have to alter the RT empire in ways potentially disastrous to the RT managers career**. The thinking is something like this: if the protocol drivers make a lot of changes and eliminate a lot of treatments, our workload will drop. We will become less visible to the other hospital staff, and it could affect the number of RTs on staff. We could lose revenues and, more importantly, we could lose RVUs***. But if the drivers are old RTs who fear change, they won’t buck the doctors. We can claim that we have TDPs to boost morale and attract RTs, and yet we can continue to generate RVUs and keep our presence in the medical floors.

In short: having an ineffectively administered but well-constructed therapist-driven protocol is a boon to management because (A) the ineffectiveness of the program insures the continued presence of high workloads, used to generate high budget requests and high power; and (B) the presence of a TDP, no matter how effective it is, will draw therapists to the hospital and boost morale.

Cynical? Yes, but too often the cynical analysis is the accurate one.

*A song could be written about this. I have the tune to “paperback writer” in my head. If anyone can write a song about the Protocol Driver, I’ll post it here.

**The irony is that a well-run, highly modernized, protocol-driven department could be an enormous boon to a managers career. Change and risk are double-edged blades.

*** RVUs, or Relative Value Units, are the units used to calculate how many RTs are needed to perform a given amount of work.

Good post up at Snotjockeys Revisited about some newfangled RT activism. It also contains some good insight. Clicky clicky.

Yesterday was a jolly day at the hospital. I was relegated to the floors, which at this hospital is a very different experience from working in the ICU. The biggest difference is the thought pattern required to work the floors versus that required to work the ICU. When I am in the ICU, I tend to have between six and nine critically ill patients. They are usually intubated or on non-invasive ventilation. They usually have a pretty thorough regimen of therapy including various nebulized medications, the odd bit of chest PT (despite a recent article contraindicating it in ventilated patients but that is a different story) and adherence to our work-intensive vent weaning protocol. That plus various other tasks keeps a day in the ICU fairly busy. There is always something to be doing, but it feels productive. And it is possible to be caught up if you are efficient!

Floor care, on the other hand, consists almost entirely of nebulizer therapy. However, because many physicians delight in ordering inappropriate or useless nebulizers, the workload tends to be astonishing. I had something like 25 patients on three floors and 55 treatments to do today when I got my worklist. Now, consider that we are “supposed to” spend 15 minutes per treatment and you have a solid 13 and 3/4 hour day. Add to that the requisite documentation, chasing of patients, finding of charts and so on, and you have the makings of a 16-hour day. So when working the floors, the idea is not to get everything done: it is to get that done which is actually necessary. It requires total focus on separating the wheat from the chaff, and as such it’s a whole different world. How our managers justify that kind of workload is beyond me, but the floor therapists have proven remarkably good at compensating for their workload by prioritizing. The day and night shifts assist one another by marking the report sheets with NT next to patients who actually need therapy, and instead of passing verbal report on 25 people in a row we simply discuss those patients who need treatment the most.

The thing is, I whine about going out with 55 treatments. Several days ago we were short by a couple of techs and the floor people had to go out with 75 and 80 treatments each. Can anybody say “Unsafe staffing?”

With the advent of the new computerized charting system, I’m wondering what will happen to our staffing. When RTs start to have concrete evidence that is readily available that they are pushing out 50-some treatments in 12 hours, will we get more floor therapists? When charge capture inevitably rises (since our documentation is synchronized with our billing) will we gain the revenue to begin staffing at safe levels? Or will things simply continue as usual, with our discontent mapped out in colorful computerized graphics? I’ll be curious to see. Meanwhile, I’m hoping that I will be assigned once more to the units when I return to the hospital on Tuesday. We shall see.

Here’s an interesting situation that I ran into today. I was in the ER treating a child with a persistent cough (who would doubtless be cured by my nebulizer) and chatting with the mother. The mother was a thirtysomething lady, with a weathered appearance, slightly unkempt, bad teeth, slight odor of cat pee about her. The baby was well-nourished, slightly lethargic but not in any visibly acute distress. He was a normal size for his age. He was pale but the mother’s complexion suggested paleness. All in all, a normal Scumble County family: economically depressed and undereducated but basically okay.

But then things got weird.

The mother was giving the child a blowby treatment while I documented on our charting forms. She was chattering away at him as mothers are wont to do with babies. She kept a rolling patois of nonsense going, and then she stopped and looked at her baby.

“Boy, he sure is liking this stuff.”

“Some kids love it, some kids hate it. Doesn’t he take it at home?”

“Yeah but he’s taking it better here. This must be the good stuff!” She breathed in deeply, catching some of the mist from the nebulizer. She paused for thought and continued to nebulize her child. Suddenly she spoke. “You know what he looks like? he looks like he’s gettin’ stoned on this!” She laughed a delightfully coarse cackle, catching her smokers phlegm in her throat and rattling as she laughed.

This I could take. But it got weirder.

I was done my charting so I watched her interact with the baby. She was a normal, happy mother. But suddenly the patois changed.

“Ohhh, you’re such a cute little boy! Yes you are!  Breathing your medicine! Getting stoned, smokin’ on your pipe! This is the good stuff isn’t it? Yes it is! This is the meth-am-phetamine!” She continued on like this for several minutes until her nebulizer was done.

So, the question in my mind was this: I am a mandated reporter. If I suspect child abuse or endangerment, it is my legal responsibility to report it. It is illegal and unethical for me to ignore what I believe to be a dangerous situation. So, what is the situation exactly? The baby seems healthy apart from a cough. The mother is attentive and caring towards her baby. She smells of cat urine, an odor associated with methamphetamine, but then she claims to have cats. She has bad teeth, but she lives in Scumble County and probably can’t afford a dentist. She’s pretending to give her baby a meth neb, but then some people have an odd sense of humor. Perhaps she was just being weird.  The situation didn’t make me immediately think “holy crap I need to call the sheriff,” but it did make me feel a little uncomfortable.

So, the question is: what to do? Is this covered under mandated reporting, or is this simply a Scumble County redneck who has poor taste in joke-making?