Respiratory Therapy 101: Just Keep Breathing

Alright, RTs and readers. A quick question for you all: what kind of footwear do you wear, and how comfortable is it? I have cross-training sneaks that I wear at work, and they’re not terrible but I find that after a twelve-hour day either my feet or my knees are going numb or just plain hurting. I’ve noted that a lot of my co-workers and co-therapists have Crocs on…you know, those dorky-looking clown shoes. I ask them how they feel on the feet, and…well…people say that despite the clown look, they’re durn comfortable.

So my question to you all is: do you wear crocs, and if you do, are they comfy? I’m considering making the switch…dorky or not.

Today we have Part II of Freadom’s guest-posted series on Bronchodilator Reform. Why not head over to the RT Cave and thank him for these awesome posts?

Today we have a special event: the very first Guest Post here at RT 101. Freadom, the mastermind behind The RT Cave, has agreed to write an article for me on bronchodilator abuse and the reasoning behind it while I resolve more technical issues here. So without further ado I present to you…

Bronchodilator Abuse

By Freadom

Many RTs, along with myself, have been on a crusade for bronchodilator reform. It is our humble goal to end bronchodilator abuse. By this we are not referring to asthma and COPD patients abusing their inhalers, but doctors ordering bronchodilator breathing treatments on patients who don’t need them.

Where I work there are no treatment protocols, so the problem is worse than at hospitals with protocols. Yet my RT friends who work at hospitals with protocols still complain to me about useless breathing treatments. Either it’s in the form of doctors overruling the protocol, or senior RTs who like to play it safe.

So it can be stated here that breathing treatment protocols seem to help, but do not end bronchodilator abuse.

Why is this? Because HMOs and THE government require certain procedures be ordered in order to meet criteria. If criteria is not met the hospital does not get paid.

Pneumonia is a great example. Some unwise person who has no clue what a bronchodilator even is decided that to for them to reimburse for the diagnosis of pneumonia, Q4-6 bronchodilator treatments need to be given.

The idea here is that if the patient isn’t sick enough to need a treatment he’s not sick enough to be in the hospital. Well, we humble RTs know this is ridiculous, but that’s the rule we have to live by. And that’s why our pneumonia protocol calls for Q4-6 Ventolin.

And this is why every single pneumonia patient has to be on Q4-6 Ventolin treatments regardless of whether or not they are having bronchospasm. When we are busy to begin with, this can be quality that could be spent with a person who REALLY needs the services of an RT.

Likewise, since 50% of patients admitted to hospitals are diagnosed with pneumonia, and many of them just because of this reimbursement criteria. That’s the only reason I can explain why so many patients diagnosed with pneumonia have clear lung sounds, a normal x-ray and labs.

The first step in ending bronchodilator abuse is educating folks that Ventolin is a bronchodilator and not a cure all for all annoying lung sounds and diseases. The second step is protocols.

The final step may be going beyond doctors and hospital administrators and finding your way to Washington on a quest to get Senators to pass laws (not that I like laws, but it was the government that caused this problem in the first place) banning Insurance companies and government agencies from setting quotas for reimbursement criteria.

Anyone up to the task?

Thanks, Freadom!

Ambulance Driver makes some sweeping predictions over at EMS1.com. A sample:

“Congress enacts sweeping legislation to provide free health care to all citizens, and President Obama immediately passes national health care into law. Within six months, fibromyalgia and dental abscesses rise to the top two most common emergency department triage diagnoses, and patient volume doubles. After a few well-publicized incidents of cardiac patients dying in ED waiting rooms, Congress promises swift action. In its best “the beatings will continue until morale improves” management style, CMS threatens to cut reimbursement to underperforming EDs until they shape up. “

They other predictions are quite likely prophetic, too. It frightens me but I can see the method behind the madness…guaranteed he’ll have at least a 60% accuracy rate if we look back a year from now.

Guest posts to come eventually. I’ve emailed some of y’all, but if anybody’s up for a guest post while I’m in Technology Fail Land, hit me up.

My technical issues continue. A new PC is en route but the shipping from Hyderabad or wherever the hell they manufacture these things is taking a huge amount of time.

Meanwhile, a joke a patient told me. I went into his room and announced my business.

“Hi there. I’m Keepbreathing from Respiratory…would you like your seven o’clock treatment?”
“Respiratory, eh? Well I think I’ll pass for now…in fact, I’m waiting for my E.G.G. to come.”
“E.G.G? What’s that?”
“You’ve never heard of an E.G.G?”
“Not once, sir…some sort of brain test, or an esophageal procedure perhaps?”

There was a little pause as he eyeballed me.

“An E.G.G. is an Egg, son. Stop thinking medical.”

More whenever I return to the modern era.

Trauma Junkie at Surviving RT School came up with an idea for an RT-related blog carnival. Named “A Source of Inspiration,” it’s modeled after other famed internet blog carnivals, such as Grand Rounds or Change of Shift.

The first inaugural issue has just been posted at Surviving RT School. Why don’t you all go over and check it out? It’s well worth your time, I promise. Clicky Click!

My PC recently experienced some severe technical problems. For a while, I thought it was getting better, but it may in fact be…well, dead. Posting will be light for the time being, but a new computer is en route and with any luck I will be back to my normal level of productivity soon.

Dr. Tom Bibey, my favorite bluegrass musician/physician, has penned what could be my personal theme song. The chorus:

Two more cups of coffee,  and I’ll be good to go

Put on another pot of that mud, in hopes that I might know

How to find a way to start my day and go where I need to go

Two more cups of coffee and I’ll be good to go

Go on over and read the whole song. I loved it.

You know, one of my biggest pet peeves is people who complain about something they can change and then fail to act to change it. 35-year-old smokers who never exercise and complain that they can’t breathe and they’re always sick. 50-year-old guys who weigh 400 pounds and bitch about being fat or tired, but who haven’t walked more than 10 feet in 20 years. 

But sometimes, you see someone making a difference, making a change. You see a smoker who’s trying to quit. You see that portly chap at the gym. You see the guy with high cholesterol changing his diet instead of just using statins. It’s inspiring and I see far too little of it.

Well, I found someone to lift my spirits a little. The Hungry Addict chronicles the adventures of a guy who has decided to shape up and change his life. Personally, I found it to be inspiring: a regular guy who decides to commit to a goal for his own betterment. Something I need to see more of, and to be more like. Go, read, and be inspired!

And be nice. As Ambulance Driver said, “It wouldn’t be nice of me to send you to his house if you were going to shit on his rug.”

At work, they often make the mistake of putting RT students with me. I am instructed to precept them, to tell them things that will make their brains swell with knowledge and their careers long and fruitful. Unfortunately, I have no such advice.

When people meet me they often assume that I am a very studious person. Not necessarily so. In RT school, I was sort of the Class Slacker…you know, the guy who always showed up but was always spaced out, the guy who was perpetually turning in papers in the nick of time or forgetting this and that, the guy who put off everything until the last minute and yet somehow managed to pull a solid B. Yeah, that was me.

I often tell my students that, while I may have forgotten the RT formulas for things like the Alveolar Air Equation or the AaDO2 or whatever other formulas there are, I have never forgotten the best advice I ever got.

The best advice I ever got came from a very special book. And that advice is:

DON’T PANIC.

It sounds pedestrian, flippant, even silly. But it is none of these. It is in fact the best advice you will ever get.

In respiratory care, much as in Anesthesia or Emergency Medicine, your job is mostly routine. 95% of the time, you are sitting there, drinking coffee, pushing another neb, checking another vent, idly wondering when the shift will end or when something interesting will happen. And then all of a sudden, that 5% that is sheer ass-clenching terror happens. Somebody codes. Somebody loses an airway. Somebody is experiencing truly frightening dyspnea. Somebody is having an actual emergency and you have to do something about it.

In these emergencies, people will often panic. People will flip out, get twitchy, freeze up, or some combination of the above. Panic will get you nowhere. The Rules even have a variation of the Don’t Panic theme enshrined in #3. 

But you, the superior (or just less panicky) RT, will simply remain calm. Grab the ambu bag and open the airway while others mill about aimlessly in distress. Carefully lift the jaw with the laryngoscope and visualize the cords. Deliberately manipulate that ET tube back into position. Carefully administer that scary asthmatic in real distress their treatment. Do not waver. Be like a rock in the stormy seas: the waves may break on you, but they will not break you. That is what it means not to panic: an island of calm in a maelstrom of chaos. 

Sometimes to illustrate this, I tell my students the story of my RT final. It was a late December day in RT school, in my Respiratory Physics class if I am not mistaken. The class seemed disturbed. People flipped through books, looked over index cards, read notes. I was curious.

“What is going on?” I asked a mate of mine.

“Today’s the final, dude,” he told me.

Now. Here I could have panicked. I could have screamed in terror and flipped out and grabbed a book to start cracking. But no! I did not. I sat there, evaluated my options, and simply went for a coffee before the final began. Panic would have killed me: I would have second-guessed everything, been unable to focus, been distracted by my fear. But because I did not panic, I managed to score a solid 90 on the exam. Not bad.

So we can see that there are many lessons to learn in RT world. There are equations, variables, ventilators, pharmaceuticals, and many other things to learn about. And that is all valuable knowledge to have! Regardless, to me, there is one simple lesson that matters more to an RT than any other: just don’t panic, and you’ll be okay.