Let me tell you how I became Director of Cardiopulmonary Services: I have been in the right place at the right time. It started five years ago when I got the respiratory therapy scholarship from the hospital. It was the first and only time they offered the scholarship, and in exchange for my tuition to RT school I had to sign a contract saying I would work at the hospital for 3 years. During my interview I stated my goal was to be there long term and to one day be department director.
I started out working as a student, low man on the totem pole, but I immersed myself in the department. I asked for any and all extra duties. I learned how to do everything: cardiac rehab, PFTs, EEGs, in addition to regular floor/OB/ER duties. I wrote protocols and started an Outpatient Bronchiolitis Clinic, which was a huge success in the community and with the physicians. I became an Asthma Educator and started that program as well. I gained the trust of the physicians and didn't crumble when the pressure got to be too much. If I was scared I made it a point not to show it.
I did everything I needed to do, but I was still low man on the totem pole when it came to seniority ... and then ... my co-workers started leaving. One for a better job opportunity, one for love, one due to a disability and, most recently, one --my former boss -- back east to be with her family. And there I was, the one who knew the department better than any other.
Now you may say, "You haven't been in the game long enough to be the boss," or "You haven't put in the time." And to that I say, It's only been 5 years, but it's been a long 5 years ... and I am ready for this challenge, and there is no RT on this earth more capable of running my department than I.
Kevin E. Johnson BA RRT AE-C RCP
For those of you who are regular readers of my blog, you already know that our department's longtime director has resigned. She is around for another week but has her mind on her next adventure in life, so in a way we are a department in limbo... a chicken without a head, if you will.
In the past, I have always filled in whenever our director was going to be away for a while and I have somewhat assumed that role in this interim period. But I feel like a substitute teacher -- no real authority, but doing the work anyway. I did turn in my letter-of-intent to take over as full-time director, but that was a week or so ago, and I haven't heard anything since. I think I have a pretty good shot at the job, but who knows?
When our director announced her resignation I had two thoughts go through my head: I want that job! and Am I sure I want that job? Sure it would be nice to be the boss, but along with that title comes a lot of extra responsibility and additional "stuff" that I would have to take care of -- some of which wouldn't necessarily have anything to do with patient care and respiratory care in general. I already feel I work more than I should, and worry often that my family life is suffering because of it. So do I really want to take on more? But then again, I would be the boss! I would be the one driving the department in the direction that I feel would be best. I would be the one with the vision, and there are so many things that I would like to implement.
I guess I will know the fate of my career and my department sooner than later, but it still feels like an eternity. As Tom Petty said, the waiting is the hardest part.
I had expected the news for some time, and had known it was a possibility for even longer. But it was still a shock last Monday when our long time department director, Nancy Mitchell, gave her notice that she would be moving back home to Illinois to be closer to her family.
It is very hard for me to imagine the department without Nancy's steady presence. She has been the one constant in the RT department over the last t10 years and due to her constant pushing and persistence, we are one of the more progressive small departments out there. Because of Nancy we are a totally protocol-based department. Because of Nancy we have an incredible bond with the providers that allows us to use our critical thinking skills and apply what we have learned in school to the benefit of our patients and the organization as a whole.
On a personal note, because of Nancy I am the respiratory therapist that I am today. We didn't always see eye to eye on everything, but ultimately there hasn't been a bigger influence on the way I practice respiratory care than Nancy Mitchell. I will always remember one of the first things she said to me on my first clinical rotation, "I may not know all there is to know about respiratory therapy, but by the time I leave the patient's room they think I do." This has always stuck with me, because it speaks to the overall demeanor that I feel is required for those in our profession, which isn't always looked at with the same esteem and respect that you might find heaped upon others in the field of healthcare. You must, above all, be confident in yourself and your ability, because more often than not our patients are as lost and confused and scared as they have ever been in their lives and we owe them the comfort of our confidence. We as respiratory therapists must be "all that and a bag of chips," as Nancy says and as Nancy is...and this is something I am always striving for.
We as a department are all very happy for her as she takes on this new adventure in her life and I am sure that whatever hospital she ends up working at will become much better because they hired her. Nancy we love you dearly and hope you stay in contact. Have fun with those grandbabies!
A local community college offers an RT-to-RN bridge program that is two years if you choose to work full time or one year if you want to be a full time student. A lot of RTs in the Kansas and Nebraska area are taking advantage of this program, some driving as much as 200-plus miles one way in order to attend classes and clinicals through the college.
I have asked many of these RTs, while they are doing their nursing clinicals at my hospital, why they are doing this? I have gotten various answers but they all boil down to these responses: "I'll make more money," "I want to go on to become a nurse practitioner/anesthetist/director," "There is more opportunity for an RN vs. an RT" and "I'll get more respect."
I can't deny that these are all good reasons to switch from an RT to an RN, and I have strongly considered it myself. However I just do not think I could work as a nurse. I am not knocking anyone who wants to make the change, but I feel there is something about me, and those of us who are RTs, that is in our very genetic makeup that has led us to the profession.
Maybe it is the chip on our shoulder and the badass attitude that radiates from our pores. Maybe it is our cool under pressure. Maybe it is our love of specializing in one particular system instead of just a general surface knowledge of the human body. Maybe it is our ability to quickly assess a situation, think outside the box, address the root of the problem and determine the best mode of care while cutting through all the conventional healthcare dogma that plagues a nurse's decision making. Maybe it is our inability to address nonsense with anything but sarcasm and the confidence that we know what we are doing and that all others should stand aside.
Maybe it is all of these things, or maybe it is because I have no desire to work below the belt line... but I just don't think I have it in me to be a nurse. I am a respiratory therapist.
Well, I had my first asthma education referral today. I think it went pretty well, but I have to say I felt a little bit out of my element. It was a whole new mode of respiratory care that I had to get in: RT as an educator.
I have to say I was a bit amped. I had armloads of literature and lists of topics that I wanted to cover. I couldn't wait to impart the knowledge I had stirring in my brain and finally use that AE-C credential I had worked so hard to attain.
Between all of that and five cups of coffee, I was going to give this patient a PhD in asthma in one hour-long session. Then I got some words of wisdom from my boss, a wise and seasoned RT vet. "Slow down," she said. She told me to keep in mind that this patient will have little to no background and if I walk into the room and punch them in the face with all of my education they won't learn anything. I took those words to heart, and I really think I made a difference today and can't wait to see the patient at our next session.
Now, I would like to think that I educate my patients any time I walk in a room, but I know that really isn't so. I found out today there is a big difference when you actually sit down in a room, just you and the patient, and discuss their disease process and what they can do to improve and control their condition.
I am very thankful for the advice I got today because in the hustle and bustle that is floor therapy, sometimes it can be all about getting in and getting out and moving on. Education requires you to slow down and ensure understanding while developing more of a relationship with your patient. This is all new and exciting for me and I can't wait for another referral. It is awesome to work in a profession that offers so many avenues.
All across Kansas, RTs are doing a mad dash to secure last minute CEUs before the March 31st deadline arrives, or run the risk of the dreaded audit. The Kansas State Board of Healing Arts requires all Kansas RTs to have 12 CEUs per year, six of which have to be live.
You wouldn't think it would be that hard to stay up on, but it can get difficult to attain live CEUs out in rural areas, such as northwest Kansas where I call home. Getting non-traditional CEUs, such as Respiratory Care Journal CEUs, is no sweat. You could knock out six of those in one day. Live CEUs require that you go to a conference or seminar or something along those lines, and there aren't many of those out in my neck of the woods. Every now and then local hospitals will host a speaker or seminar that allows for RT CEUs but this is rare and if you are unavailable for a particular session you are pretty much S.O.L.
One of the big complaints of rural RTs is that hospital education coordinators are too focused on bringing in educational opportunities that apply strictly to nursing. This could be that most education coordinators in rural areas are former nurses themselves and just don't think about respiratory CEUs. It could also be that there aren't that many live RT CEU presentations available for them to bring in.
Fortunately, this last year I was able to obtain almost three times the amount of required CEUs due to various conferences and educational classes that my organization sent me to. But this is not the case for others in my department and it was not the case for me the year before. I remember desperately searching the web and various RT association websites to find some live CEUs that were within a reasonable driving distance with the deadline not more than a month away. I was able to get them all in time, but there really has to be an easier way.
It wasn't all that long ago that I was about to start the last semester of RT school. I remember that January going out to clinicals feeling like I had a pretty good handle on what was going on and was really just counting down the rotations I had left before graduation and, after that, the much-heralded BOARDS!
I remember having the distinct feeling that I was working for free, as often times the institutions where I was doing clinicals would send me off with a phone and a list of patients and/or vent checks that needed to be done with little to no preceptor supervision. And I have to say I was a tad bitter about that. I had a wife and kid at home and one on the way and we needed money. I knew that this season in my life would pass, and though it was close, my days of being an official money-making RT seemed a long way off.
Looking back, it passed in the blink of an eye and it seems like such a long time ago. In hind sight, I think my overall attitude towards my last semester (GET ME OUT OF HERE SO I CAN MAKE SOME MONEY!!!) might have hindered me and cost me some valuable learning.
For example, I remember my very last clinical rotation. I was working in a NICU with some good therapists and getting some good experience. However, I was presented with the opportunity to leave the clinical about 6 hours earlier than I was supposed to ... and I took it without a second thought. I knew I had enough clinical hours to graduate, and I was done, ready to get out of there and on with my life. But thinking about it now, who knows what I missed during the rest of that shift. Maybe nothing, but maybe I could have been in on something that was once-in-a-career awesome. Maybe I missed an experience, a success or a failure, that could have made me a better therapist once I was out there making money.So to the RT class of 2014, I know you are feeling the drain right now ... probably wondering why you aren't getting paid for the load that is no doubt being put on your shoulders. But, trust me on this, it is almost over. You will never have the opportunity again to learn and experience being a respiratory therapist in the bubble that is clinicals ... growing under the tutelage of a preceptor, screwing up on their licenses. Remember that when you finally become a money-making RT, all your failures and successes are on you. So enjoy your last semester!
Q: What do a unicorn, a leprechaun
and a stat Incentive Spirometry have in common?
A: They don't exist.
So why does it seem like I am getting called into the ER more and more to instruct patients on the use of IS? Short of breath? They need an IS. Broken ankle? Send them home with an IS. I
have tried to argue the utility, but it seems to be of no avail. And it isn't just in the ER that I have dealt with unindicated IS orders. It is on the floor and outpatient as well.
I don't understand the love affair providers have with the IS. Lately I have read several studies that say IS is basically useless, yet there it is attached to every order set from chest pain to post op. IS Q1h, IS at bedside, IS before meals, IS when the sun goes down... Is so much IS necessary? I say no.
I really think it is something that providers can order just to say they ordered something. After all, though it might be a waste of time and resources, it doesn't hurt anything or anyone to issue and instruct. But I am a huge opponent of unwarranted therapy. So though it might not hurt the patient to learn this exercise, it kills me a little inside.
Don't get me wrong. I do think IS has its place. If a patient is unable to ambulate then IS should be used in conjunction with deep breathing and coughing exercises. But really this is the only time that I see it as warranted. I have tried to explain to providers that if a patient is able to ambulate on their own, IS is not indicated... but so far my cries have fallen on deaf ears.
The AARC guidelines don't recommend IS for use pre- or post-operatively. Yet physicians, guided by classic textbook dogma, insist that every patient has one. I even got an order today to instruct
a patient on IS pre-op with an ordered goal for the patient to achieve a certain volume.
Maybe it is just at my hospital, but it seems to be getting out of hand.
Sometimes it is tough for me to leave work at work. The worst for me is when I am lying in bed in the middle of the night and I suddenly wake up thinking about a patient we intubated or a patient I have on the floor. I always think, "Did I do everything right?" or "Is my patient getting everything he needs from respiratory therapy?" And if I get called in to the ER in the middle of the night, it doesn't matter what time I get back home, I might as well just forget about sleeping. I replay every single detail in my mind until my alarm goes off and I have to get up and shower.
Sometimes it isn't even anything major. Like the other day I was driving home after closing and I could not remember if I turned a patient's flow meter back to the bubbler or left it on the neb. I was 99.9% sure that I did, but because I do the little things now on autopilot without even thinking about them, I couldn't be for sure that I did it. I called the nurses station and had the patient's nurse check and, sure enough, she told me I had turned it back. The tone in her voice was less than thrilled that I had disturbed her from whatever she was doing ... but I had to make sure.
I have had jobs where five minutes before I clocked out I had already left work behind, but I love being an RT. I know for the sake of my stress level and the sanity of my wife that I should leave work at work -- but it is hard for me to separate the RT from myself.
Scenario: You were a survivor of a plane crash somewhere over the Pacific and are the only RT trapped on a deserted Island. You will have to administer respiratory therapy to the inhabitants of said island for an indefinite amount of time. You only have three tools of the trade at your disposal. What are you bringing with you?
1) My stethoscope. How could you be an RT anywhere, let alone on a deserted island, without your ears? Plus I figure, as well as being handy for listening to breathe sounds, I could use it to diagnose what trees might have delicious varmints living inside of them as well as where a pneumothorax might be located.
2) Crate of Albuterol inhalers. Does this count as more than one item? Survey says, "No." I thought about saying Albuterol via nebulizer, but the Albuterol and the nebulizer would have to be counted as separate items and with my excellence in MDI instruction I am sure I could have my fellow castaways demonstrating adequate, if not proper, technique. Sure, it would be nice to have spacers to use with these MDIs but I don't feel that they would ultimately be necessary and I would have to count spacers as a separate item as well. This game has rules after all. What I am envisioning is something like a "Lost" scenario where the asthmatic girl keeps having flare ups and they have to give her some sort of herbal remedy to keep her asthma in check. Well, I am no herbologist, in fact I am not even sure that is a word, the point being my foraging skills would be worthless when it comes to finding homeopathic remedies ... but a few puffs of ventolin would do the trick.3) Blood gas kits and Istat. Again, this does not count as two items. Not only could I get accurate ventilation and oxygenation status updates, but I could also use the needles from the gas kits to start makeshift IVs. And if there was someone who was mechanically inclined, they could possibly rig the Istat battery to some sort of radio and get us off the island.
For the most part I love my patients. However, there are some patients that I cannot stand and they seem to have all shown up in the last week. Allow me to elaborate on the three patient archetypes that drain my patience.
Archetype 1: The Know-It-All Patient
We all know the Know-It-All -- the patient who was just a few credits shy of being an MD. The patient who saw that episode of "House." The patient who has "been in the hospital before with this" and knows what needs to be done. The patient with the WebMD app who is sure that they have this syndrome or are suffering from that ailment. You can't tell them otherwise, they have made up their minds that they are sick and know what the proper course of care should be. Medical training be damned!
Archetype 2: The Unaware Patient
This is the patient who is 5'3" and 300 pounds who can't figure out why they are short of breath when ambulating from the couch to the refrigerator. The patient who was unaware they were supposed to have that script refilled once it ran out. The patient who takes their Advair PRN. The patient with three stents who continues to pound down cheesburgers as if they are limited on time items. The diabetic who brings in a Big Gulp and asks for extra ice cream sandwiches. I could go on for days but why bother, they wouldn't know I was talking about them anyway.
Archetype 3: The Catalogue-Every-Detail Patient
BM at 1500? Better log it. Scratched eyebrow post meal? Better put that in the books. Aunt's cousin's niece had scabies as a child? Count it. This type of patient I don't mind because I do feel it is important to keep track of certain health occurrences, but do they always have to share every minute detail? Common sense would say no, but, when dealing with patients, common sense isn't always the law of the land...
I recently changed positions/responsibilities at my job to Cardiopulmonary Outpatient Services Coordinator. This is just a fancy way of saying I am now running all of the outpatient stuff at our facility. Our outpatient services has been an after thought for some time now and the cardiopulmonary department director thought that, in light of the ACA push for outpatient and preventative medicine, this needed to change and she thought I would be a good one to do it.
This position didn't come with a significant bump in pay but it does offer better hours (I get to come in at 0900!!) and a schedule that is
more flexible around what I need to do (for any of you parents out there, you know how priceless this is) and I will no longer need to work PRN weekly.
As Outpatient Services Coordinator I will be responsible for all cardiac and pulmonary rehab patients, PFTs, cardiac and nuclear stress testing, bronchiolitis clinic, and cardiopulmonary specialty clinician requests. This
new position will also allow me to use my AE-C and get referrals from the clinic to do asthma education, something I am really looking forward to. Right now I am trying to get all of our outpatient programs organized and polished up and then in a month I am going to do a presentation to the providers about what all we have to offer.
What this change in position also means is that I will now rarely work the floor or ER (which breaks the heart of the trauma junky inside me) and I will no longer be able to work PRN weekly. Working PRN is kind of a double-edged sword in that I do love working at different facilities and working with RTs that I don't see every day and get the experience of a busy ER, but it also involves getting up super early before
it's light out to drive 45 minutes away from my wife and kids and not get home till long after it's dark. There are some days when I work PRN that I don't see my kids at all and this really gets the "cat's in the cradle"
spinning in my brain. So in the end, though I will still work PRN every now and again to help out when short staffed, I think the trade off is worth it and I am looking forward to this new phase in my career.
Patient's don't always die with dignity. We all know this. Either their families won't let them, they won't let themselves or, worst of all, their provider won't let them. Only one of the three do I find acceptable. Patients should be able to choose their end-of-life care -- excessive or minimal, it should be up to them. But there is really no excuse for a family or provider to make that call.
Healthcare is a tricky field to work in. It seems like often times we are fighting a losing battle against time and/or disease, and sometimes we are too invested emotionally or otherwise in our patients to see what is reasonable and what is not. Unless an intervention is in line with the patient's wishes, why do we go to extreme measures to "fix" our patients if our battle is obviously a losing one? More often than not we are sacrificing the patient's quality of life to satisfy our own need to feel like we are doing something.
Death is a complicated thing and it would be nice to have an outside panel to take these complicated issues to when said issues arise. I am not advocating death panels or anything, just an in-hospital board that could make the call or stop treatment when treatment is fruitless and/or the patient's dignity is no longer considered and/or the patient's wishes are not being followed. The hospital where I work does not have an ethics committee. But there are many times that I wish it did have an outside entity to take a reasonable assessment of the situation and say "enough is enough" when, indeed, enough really is enough.
I would be interested in hearing from any readers out there who have served on an ethics committee or have one available in the organization where you work.
In light of the holiday I would like to post the top 10 things I am thankful for as an RT:
10. My trusty pulse ox. I know you are just a trending tool, but what a trending tool you are. We have been through a lot together. That 80-year-old with the cold hands. Wait, all those 80-year-olds with cold hands. I did a clinical at a facility where RTs did not carry pulse oxs ... not sure how an RT can function like that.
9. My COW - Computer On Wheels. Before I had my COW I had to jot all my charting on a scribbled up note pad of nonsense and then try to decipher when I got back to the department, praying I got it all done before they stopped serving breakfast. Now I chart at the bedside and know breakfast will still be nice and hot when I get done.
8. Well-fitting scrubs. I have worn scrubs that were either too big, too small, too tight, not enough pockets, too many pockets ... scratch that, you can't ever have too many pockets, but you get the point. Scrubs that are ill fitting or ill equipped for the job can ruin a shift.
7. Protocols. Evidence-based medicine at it's streamlined finest.
6. Providers that are open to suggestion and conversation. Really, is there anything better than when you make a suggestion and it is taken into consideration and used. Even if it isn't used, in my mind there is nothing better than an open dialogue between an RT and a physician that leads to optimum patient care.
5. My watch with a second hand. I broke a watch one time and went a week before I got another one. A watch with a second hand might not be something you notice every day, but you sure notice when you don't have one.
4. PRN work. What other line of work, other than healthcare, can you go to another facility and plug right in and do your job and get paid well to do it?
3. Good nurses. This could easily be #1. There is nothing better than a helpful, confident and competent nurse.
2. My "ears". Do I really need to explain this one? I would be like a carpenter without a hammer if I didn't have my stethoscope.
1. My coworkers. I work with some wonderful RTs, and I want to take a second to list them by name: Jennifer, Nancy, Jenny, Kerri, Chris, Jason, Tiffany and Kim. I have learned so much from all of you and am thankful to have you as coworkers and confidants. You are all great RTs and it is a pleasure to work with you. You make it fun to come to work and I can't thank you enough for that.Happy Thanksgiving!
It seems like I got my AE-C at the right time. Instead of having to renew via exam every seven years, certified asthma educators can now renew via CEUs every five years. After taking the exam and the months of prep that went along with it, I can tell you that this is a good thing.
One of my RT instructors while I was in school was an AE-C, or she was at one time. She had let her AE-lapse because it wasn't worth it to her to spend the hours studying, pay another $200, and retake the exam when her seven years were up. This instructor is one of the smartest people I've ever met but she told me she did not think she could pass the test again without a few months prep and didn't have the time nor want to spend the money.
Now you might think, (annoying self-righteous voice), "Well if it isn't worth it to you to go through all that to renew your credential, then you don't deserve to have it, meh!"
It isn't like that. Imagine if you had to renew your RRT or CRT every 10 years or so by retaking one or all of the exams you already passed. We all know that real hospitals don't run like the NBRC hospital, and over time we have all forgotten all the formulas and mundane information that we had crammed into our heads to spew all over our exams, only to start working and realize that NO ONE uses the Alveolar Air Equation or air entrainment ratios in every day practice. (For those of you who do -- annoying sarcastic voice -- Congratulations! You are so cool! ) The AE-C is no different. I can't tell you the oddities I had to memorize that I will no doubt have forgotten in seven years.
This is what happens when you require renewal via exam instead of CEUs: You lose quality therapists because they either view it as not worth the hassle to renew, or because they have forgotten the mundane details that the exams require you to know for the exam only.