Respiratory Therapy 101: Just Keep Breathing

As part of this weeks Change of Shift I have been asked to assemble an article about RTs: what we do, how we think, and how we can improve our interactions with nursing. First: what RTs do!

Respiratory Therapists are usually responsible for all aspects of breathing-related care. In many different areas, we assess the respiration of patients with a variety of diagnostics and treat their disorders with a plethora of therapies. Among our arsenal of skills for assessment: auscultation of the lungs, examination of chest x-rays, sampling and interpretation of arterial blood gases, minor pulmonary function tests like vital capacities and peak flows, and full-blown pulmonary function tests in the laboratory. We also do homecare and work in sleep labs, two closely related aspects of our field.

In addition to applying our crazy assessment skills, RTs are responsible for all kinds of therapies to assist respiration. We give patients bronchodilators, perform chest physiotherapy, and work with patients to train them with various breathing exercises. We run BiPAP machines, both as critical-care machines and as sleep-apnea management systems. We manage mechanical ventilators, the machines that breathe for people when they are incapable of breathing. We intubate patients to manage their airways. We perform CPR. We assist physicians with placement of tracheostomy tubes. If there is something we can do to make a patient breathe better, we will do it.

Moving to thought. To understand how us RTs think, it is important to remember that our job focuses on what we perceive to be the most important bodily function: respiration. It has been said that if you are not breathing then you are not going to be doing anything else, and this is very true. Breathing is one of the few body functions whose immediate cessation will lead to death.

Seeing things through this lens helps us to arrange our priorities. At the top of the list are people who honestly, genuinely can not breathe. A 55-year-old patient having a severe COPD exacerbation will require our immediate attention, while a 22-year-old in for a bunionectomy who “needs incentive spirometry” will be at the very bottom of our lists. In short: the greater the likelihood of a severe derangement in respiration, the higher the priority on our lists. RTs typically take much higher patient loads than nurses, anywhere from eight or ten ICU patients to twenty or thirty medical patients on the floor. Balancing the demands of caring for so many people appropriately keeps us busy.

Now: how can RTs and nurses better relate?

I think that the first part of this is understanding one another. Too often, nurses will become irate with RTs for various reasons: the RT was “slow,” they were argumentative, or perhaps they were just blunt. RTs become irritated with nurses for similar reasons: the nurse won’t leave me alone, the nurse wants something pointless, the nurse is just demanding and rude. If not resolved this kind of acrimony leads to bad teamwork and affects patient care.

The key to getting around this is to consider the viewpoint from the other side. RTs, remember that when a nurse calls you, nine times out of ten they are calling because they feel you can do something good for their patients. Sure, there are nuisance calls (stat incentive spirometry or albuterol treatments on a fluid-overloaded patient, for instance) but most of the time when you are being called there is a reason or a way you can be of assistance. Take a deep breath, smile, and focus on assessing the patient.

And nurses, consider the RT. When you call the RT and they’re blunt, perhaps they are simply harried and being pulled in a hundred directions at once. When the RT is arguing with you, listen: we will not withhold care we feel is neccesary, but we also do not want to perform unindicated therapy because it usually means that the therapy the patient really needs will be delayed. If the RT is slow, remember: you feel busy with five patients and we often carry twenty or more on the medical floor. The bottom line is communication: speak clearly, politely, and concisely and actually listen to the other party. It is amazing how much better things run when people communicate.

So that concludes the Nurses Guide to RTs. We RTs provide valuable care to patients through our superior knowledge of cardiopulmonary function and our ability to treat pulmonary dysfunction. We aim to be a “breath of fresh air” and I think we do an excellent job. The bottom line is that nurses need RTs just as much as RTs need nurses, and if we all make an effort to cooperate and communicate we can improve lives and help people breathe. And really, that’s what it’s all about.

You may have noticed that I am not posting quite as much lately. That is because the RT Burnout Meter is about to burst through the roof. The pressure is building and the waters are getting high here at Sunny Flats, and the dam is about to burst open.

My goal is not to be standing in front of the dam when the water breaks through.

The cause of all this pressure lately is management. Specifically our managers have been under a lot of pressure to cut costs. Since we already own most of our equipment and we get most of our disposable stuff on the cheap, the only places remaining to cut costs are staff and administrative overhead. Cutting administrative overhead would be the managerial equivalent of hara-kiri, and so the only place left for cost cutting measures is…the staff.

Yes. Our management has decided that they are going to reduce our minimum staffing requirements. They have decided that instead of the 25 therapists we normally staff between the ICUs and the medical floors, they will slash our daily operating numbers to a maximum of 18 therapists, which is a 28% reduction in daily staffing.

The big giant obvious problem with this is that we have not reduced our workload by a similar percentage. So what you end up with is a respiratory care department that is chronically understaffed and overworked even beyond the usual. The reduction in therapists per day has affected our daily operations. While we normally staff 2 therapists per ICU we are down to about 1.5 on average; one therapist to a unit plus a couple of drifters who float between units. We have cut our ER staffing in half. We have cut floor staffing and people are routinely going out with 25, 30, 40 patients to see. This is a huge problem not just for respiratory therapists but for PATIENTS, whose care is going to suffer.

Working in the ER with 50% fewer therapists means more missed therapy, more missed diagnostics, more delays in an already slow ER. Critically or seriously ill patients are not being seen as rapidly. The quality of our assessments and interventions is diminishing because we are being asked to do the same amount of work with half as many people. I have personally been on the receiving end of rage from ER doctors and supervisors who are pissed that we are slower and less efficient than usual, and all I can do is shrug and tell them that we’ll do what we can. They hate that but it’s all I can do.

In the ICU, patients are being seen but therapists are being stretched too thin. Thorough assessments and the time to perform quality work are considered luxuries where they once were considered necessities. A distraction such as an emergency bronchoscopy or a trip to the CT scanner would once have been considered a mere nuisance. Those things now are day-killers that will put an RT so far behind that there is no hope of catching up. We can no longer be proactive members of the team; we have been reduced to running between rooms and trying to get everything done without missing something important.

On the floors…well, people just aren’t getting seen. The apathy is unbelievable and I can’t say I blame the floor therapists: there comes a point when you are so overburdened that you can no longer care.

On top of all this, management continues to add paperwork and administration to our job. We now have equipment checks to document, “safety rounds” to complete (a particularly bitter irony, as conditions are rapidly becoming less and less safe despite cubic tons of paperwork), and we must track our time in 15-minute increments as if we worked at a law firm and not a hospital.

The bottom line is this: management is asking us to do more with less and it can not be done. They can either spend money and have quality patient care, or they can cut their budget and demand more from us and get shitty patient care. Unfortunately our managers have chosen the second path. They have been warned of the errors of their ways and they have ignored increasingly frantic pleas from the staff, the doctors, and even other administrators. They insist that The Numbers work out, that it will all be ok, that we RTs are just lazy whiners. It saddens me that we have forsaken the patients and the staff in favor of The Numbers, but so be it.

I only regret that this will not change until a patient is killed or harmed by our unsafe working conditions. I hope and pray that something will change before somebody dies…

…but I am not optimistic.

A big hearty thank you! goes out today to “Too old to work, too young to retire.” TOTWTYTR is a paramedic who writes a blog about many things, but the post that caught my eye was entitled The One Where He Rants About Pulse Oximetry.

Pulse oximetry is vastly overused by everybody. Instead of taking two minutes to assess a patient, to look at a patient and watch them breathe, people will slap a probe onto a finger and then write down a number. I can guarantee you that if somebody sees a Pox reading of less than about 92 in the ICU, I will be getting a phone call regardless of the patient’s respiratory status. I have had people call me to look at patients who have “sats in the eighties!” and it turns out that the probe is on wrong or the patients hands are cold or they have parkinsons or…the list goes on.

As they tell us in training: look at the patient, not the numbers.

Go and read TOTWTYTR’s blog. It’s well worth the time.

One of my hobbies is to get people going. If you know exactly where the line is, you can walk along it for a few minutes without stepping over it. This gets people pretty worked up, but when they discover that you’re just kidding they usually see some humor in things. And the agitation is good for them: the increase in blood pressure, heart rate, and respirations is sort of like exercise. I view my hobby as a public health service: getting people going is good for them!

So the other day when I ran into my boss standing near our hospital’s infection control officer I had to see what I could do. I walked inconspicuously past, then stopped and smiled.

“Hey boss.”

“Hey, RT. How’s it going?”

“Just fine. My patients are eating so I figured I should too, (insert phony conversational laughter here.) Say, infection control, have you seen that guy in CCU with the crazy infection? What is that?”

The infection control officer frowned for a moment.

“That’s a weird case because we don’t really know what he has. It’s some unknown new pathogen. We’re hoping we can figure it out. It would be awful if that spread around.” I nodded knowingly and crossed my arms, putting on The Serious Face.

“Well I’m doing my part. I believe that exposure is the better part of immunity.” The boss became perceptibly nervous as I said this, shifting her weight between her feet and looking uncomfortable. The time was right to deliver the killing blow. I took a deep breath and carefully controlled my expression.

“That’s why I never ever wash my hands.”

There was an awkward pause. I stood straight and focused on not smiling. The Boss began to laugh nervously. The infection control officer seemed extremely startled and there was a glorious moment of complete awkwardness as the two of them stared at me in disbelief. Finally I couldn’t control myself any more and I burst into laughter. Once the two of them realized I was just kidding they began to chuckle nervously, and I reassured them that I was merely joking and made my escape before retribution could begin.

Another notch in the gun, so to speak. I’ll just have to steer clear of the boss and hope she doesn’t manage to get me back.

As promised, something funny to compensate for the bitterness. From Basic Instructions, I give you one of my favorite images of all time (click to enlarge):

It’s perfect, isn’t it?

(Image stolen from Basic Instructions without a hint of a scrap of permission. Copyright belongs to the comedic genius Scott Meyer.)

I’d just like to take a moment to remind my readers that this blog is intended mainly to be a source of entertainment, not a source of education or reliable medical information. I am a certified and licensed respiratory therapist, but I am not a physician and I do not know you or your circumstances. I would be happy to provide information within my scope of practice, but you’re better off checking with a physician or other healthcare provider face-to-face than you are getting information from a blog written by a stranger on teh intarwebz.

I bring this up because I got an email some time ago from a fellow RT. It seems that a colleague of hers who was in possession of a little knowledge made an interesting string of decisions. My fellow RT explains:

I have been subscribing to your blog for a while now and I just have to tell you thank you for the shit you have stirred up in my Neonatal ICU. I am a Respiratory Therapist of 8 years…

I have a patient who was a 25 weeker and is now 7 months old. He has been in the unit since birth and required at least CPAP of +10 . He has severe tracheomalacia .

Well he REQUIRED it until 20 or so days ago when Nurse KnowItAll convinced the physician that he “really didn’t need it at all”

He was switched to a trach mask on Feb 6 and continued to struggle to breathe until a few days ago. You see we do primary nursing, so these nurses seem to think that they know ALL aspects of the patient’s care, including the Respiratory part.

We called in the big dog, the Pulmonology Medical Director who recommended CPAP for this patient. Nurse KnowItAll blew her top and very loudly made her case for no CPAP known. Needless to say, he did not go on CPAP that shift.

 The next day the Big Dog came through again and voiced his dismay as to “why they ask for my consults and then don’t listen to me”……..the patient went on CPAP much to my joy. I had been saying all along that the baby needs help breathing.

The next day Nurse KnowItAll was back on shift and royally pissed. She even brought forth some “information” that CPAP is not FDA approved for infants at home. She was trying to convince folks that he could not go home on the LTV 1200 that we had him on, because it was CPAP.

Where do you come in? I know you are wondering that very thing.

 Well the next day Nurse KnowItAll was not there but Nurse SweetandNice was and she pointed out the medical article that Nurse KnowItAll had printed off to prove that my tiny patient was not benefiting from CPAP because he had an uncuffed trach.

 I immediately recognized the title!

Respiratory Therapy 101-Just Keep Breathing. It was your blog from June 6 2007 entitled CPAP and uncuffed tracheostomies:just say “no”.

I laughed my ass off. This was her medical research that showed that my patient could not use CPAP. Clearly she missed the all important word FENESTRATED in your argument against CPAP for your elderly patient.

Soooo we have now called a patient care conference for next week, and I plan to tell them that her research is just a blog (No offense really, I love your blogs)

If nothing else thanks for the laugh and for giving me the opportunity to tell Nurse KnowItAll that she really is a dumbass!!!!

It’s time for installment number four in my long-neglected series on The Rules of the House of God. Today’s rule: The Patient is the One with the Disease.

At first, rule four seems obvious. Many of you are saying, “Of course the patient is the one with the disease. That’s why they’re the patient, you jackass.” But if one looks at the rule in the context of the book it becomes more meaningful. It confronts some of the demons that young, idealistic people in medicine often have to face: the hypochondria that comes from seeing endless streams of sick people, the paranoia that comes with the hypochondria, and the specter of mortality.

Hypochondria

Hypochondria is an easy thing to develop. It is especially easy to develop when one spends a lot of time with sick people. It is not uncommon to face patients day in and day out who present with minor complaints and wind up becoming critically ill or dying. People present with a chest cold and wind up dead a week later; the headache becomes a brain tumor or viral meningitis; toe pain turns out to be terminal bone cancer.

When I first got into Respiratory Therapy, I was very young and very idealistic. I wanted to help people and I wanted to feel like I was saving lives and making a difference. I assumed that fixing people’s breathing would be easy and that it would be appreciated. I was completely unprepared for the magnitude of the suffering that my patients were experiencing. I simply had no idea how sick people could get, and what really got me was that these people were exactly like me, and too often there was nothing I could do to alleviate their suffering. I felt powerless and frightened.

Paranoia

Eventually it began to wear me down and I started to get paranoid. I’d have a stomach cramp and immediately wonder if my appendix was about to burst. I’d get a headache and flash back to a patient with viral meningitis whose new home was heavy on lush hardwood and conveniently located beneath six feet of sod. It began to affect my attitude and my performance: since these patients were doomed anyway, why were we bothering? What’s the point? I got depressed. The job wasn’t what I signed on for; by virtue of a sheltered rural upbringing and simple naivety I was unprepared to face sickness and suffering.

And then one day it hit me: no matter how bad I feel I’m not the sick one. I can stick a needle into some guy and not feel a thing*. As the rule says: The Patient is the One with the Disease. Realizing that helped me get over my shock and my frustrations enough that I can function relatively well as an RT and as a human being…although I do still have a tendency to question the reasons for much of what we do.

The Specter of Mortality

To me the rule is definitely about hypochondria and the process of learning to deal with suffering, but it is also about mortality. In the book, Shem embodies mortality in a patient known only as The Yellow Man. The Yellow Man is a patient who develops hepatitis under a suspicious set of circumstances. One of the resident physicians working alongside the narrator misses this diagnosis. Because of this, the patient worsens, becoming progressively more and more sickly. The mental and physical health of the resident begin to suffer; he feels overwhelming guilt about the part he played in The Yellow Man’s illness. Eventually the Yellow Man dies, and the resident commits suicide by flinging himself from the roof of the hospital**.

Reading into the story a little bit, it becomes apparent that the resident felt deeply guilty for what happened to the Yellow Man. In his efforts to help, he hurt; and instead of learning from his mistake and moving on, he became consumed by guilt and responsibility. Ultimately, he took on the disease of the Yellow Man; not in a literal sense but in the sense that he was unable to function normally as long as the Yellow Man remained ill. The resident embodies the rule: he fails to learn that the patient is the one with the disease, and as a result he is unable to function. He is so stricken with grief and guilt from his mistakes that when the patient dies he commits suicide. The lesson is vital: if you forget that The Patient is the One with the Disease, bad things will happen. Always.

Conclusion

And so we can see that the rule isn’t a callous statement about physical pain or a degrading statement about the health of sick people. It’s a warning, a reminder that if you forget which side of the bedrails you’re on you’ll be unable to function. It is vital to remember that the patients are the sick ones. It doesn’t mean that we can’t feel bad for them; quite the contrary. It’s a reminder that if you carry the sympathy too far, if you take things personally and dwell on them, you’ll die a little bit inside every day.

Be careful out there. Don’t forget which side of the rails you’re on.

*except one time when a guy kicked me in the head while I was getting an ABG. I felt that one.

**It’s not a “warm fuzzies” sort of book.

After a couple of epic weeks of almost nonstop work I finally have some time off. I need it badly. In this last two-week pay period I slammed 164 hours out at the hospital. That’s only four hours less than the number of hours in a week. I’m amazed that the hospital let me do that, but they’re so understaffed they can’t say no and the patient load is way up lately owing to a unique combination of illnesses and stupidity in the local area. The simple truth is that they’re desperate for staff and it’s (arguably) safer to have some very tired and fatigued staff than to have no staff at all.

As for why I would even work that much, I’m poor and even after Uncle Sam takes away most of my overtime to subsidize the lazy ignorant unemployed bastards I spent my workweek taking care of*, I’ll still come out ahead. Someone asked me if I was “desperate or just stupid” to take this much extra time, and I honestly couldn’t answer them. But none of it seems to matter at the moment…because until I have to return to work on Friday, I am off.  I plan to knock back a few frosty cold beverages and spend my time reading some very non-medical books. I suspect that this little break will be enough to recharge the batteries and chase away these nagging feelings of burnout and apathy that have been chasing me around lately. I may update between now and then, but I may not.

*Not that I am at all bitter about this. You know, putting my energy and my finite time here into futile anti-Darwinistic care for people who may or may not actually deserve it for a measly paycheck, half of which is confiscated by a government who will simply use it to pretend to solve problems by flinging cash at them. Rant over…

There are days when I feel like a rat on a sinking ship. Today was one of them.

I was floated to the floors again today. Normally I don’t mind, but this is my fourth different assignment in five straight days and some consistency would be nice.

Adding to my woes, I went out the gate this morning with somewhere in the vicinity of 65 treatments to do over 12 hours, coupled with various other modalities like incentive spirometry and sat checks. Adding to the added woes, I was on one of the two floors in our hospital on which the therapist is responsible for doing all of our own protocol evaluations. There were six of them due, and at an average of fifteen minutes each that adds up to an hour and a half of evaluating.

Factor that in with our “one on one” treatment policy, add up the expected number of minutes assigned to each task (here we have time allotments that management uses to measure productivity; it’s part of the new computer system) and my grand total for the day was somewhere in the 900 to 1000 minute range. While we ideally would not be assigning therapists 1000 minutes of work daily, we were eleven RTs short today. That is almost 50% fewer RTs than we need.

Of course, there are only 720 minutes in twelve hours. You do the math. It’s disheartening to leave the office in the morning and already know that there’s no conceivable way to do your job in anything approaching a safe or effective way. Trying to manage so many patients and perform so many procedures is like juggling eggs: drop one thing and suddenly you’ve got a huge mess on your hands.

Making this worse was the fact that even if I were somehow to cram 1000 minutes of work into 720 minutes, say by doing a totally half-ass job on everything, there are the inevitable emergencies and urgencies that make hospital life so interesting. Today I had one drain-circling patient, one “bored pulmonologist who read an article about PE” patient, and one code.

So, after today I was thinking about this. The root of the workload problem seems to be staffing. If we had been fully staffed today with our full complement of 25 RTs instead of having a mere 14, the workload would have been a lot lower, probably in the much-more-manageable 500 to 600 minute range.

Of course, the reputation we have for sending people out with that workload has prevented local RTs from working here. A lot of new hires work one day on the floors and then never return. Students don’t want to work here because of the load. And now experienced RTs are beginning to quit, making the workload worse, which in turn leads to worse staffing and so on until either our department crashes or somebody does something.

A good place to start would be hiring travelers to fill in and even things out while we get some new people on board. Another good place to start would be to encourage more aggressive use of the protocols to eliminate excess and stupid work. A third good place to start would be if some of the management team left the office and helped out on the floors. This might not accomplish much in the way of labor but it would do a hell of a lot for morale.  I’ve suggested these things but nobody who can implement them seems to listen.  I feel like the only sane voice in a sea of madness, but that could just be my enormous ego.

The hell with it. I’m going to bed.

About a month ago, I got an e-mail from a student who was doing some research on different healthcare-related careers. Originally she had wanted to do nursing, but for a variety of reasons she opted to do some research on other opportunities. As part of that she e-mailed me some questions. They were thoughtful and they seemed to cover the bases pretty well, so I asked her if I could turn them into content here and she said sure. So, time now for…

Q&A With A Real Respiratory Therapist!

Q: How do you like your job as a respiratory therapist?

A: The pay varies widely between places and positions. I was a “travel RT” for some time and made excellent money with great benefits. Working as a “staff” RT I’ve found the pay to be decent but behind that of nursing. When I worked in the northeast, the pay was much better than where I’m working now by an enormous factor. Right now it’s a living, but the pay does depend on the region you’re in and the hospital you’re at. Don’t be afraid to ask for what you really want, but don’t be surprised or let down when HR and the RT manager laugh in your face and hand you the bag of peanuts that is your first week’s pay. That’s almost exactly what happened with my current position, but geographical necessity dictates that I stay here until an opportunity arises to return to the higher-paying lands of the northeast.

This concludes our first Q&A With A Real Respiratory Therapist session. If you have a question you’d like to ask me, feel free to fire an e-mail to anonymoustherapist at gmail dot com and I’ll try and get back to you. Thanks to KV for the questions in this session.