Paging Doctor Gorman
Fake it till you make it, for important medical reasons
You want to know one of my all-time favorite movies? Aliens. The original Alien is well-enough made, I suppose, but the sequel just hits all the notes right. One of the many intriguing things about it, for me, is the relationship between Lieutenant Gorman and Sergeant Apone. Gorman is a new lieutenant, thoroughly trained and versed in doctrine and theory but with only one combat mission under his belt. Apone is obviously a veteran NCO who knows exactly what he’s doing, but is still unambiguously subordinate to Gorman. He has to take care of his troops and accomplish his mission while also obeying a somewhat clueless superior officer, and maintaining proper decorum and respect for the chain of command.
Sometimes, respiratory therapists are called to be Sergeant Apone. Our profession exists in part because nurses are scared of snot to advise doctors on the best way to care for patients. This is important because we occupy a niche field that a given doctor might not remember in detail from med school, assuming they even covered it then1. Frequently health care decisions have to be made, and orders given, very rapidly, with no time for debate and in the presence of coworkers, patients, and family. Under these conditions, it’s important to be able to suggest a different course of action clearly and diplomatically.2
Other times, there’s no rush, but the doctor will not be dissuaded from a course of action you feel dead certain is wrong. In those cases, you can only shrug and comply3 as best you can. Whatever happens, you must maintain kayfabe. That’s not optional. If the patient or family member says, “I’m breathing fine, what do I need treatments for?” you can’t say “because your doctor doesn’t know what they do.” It simply isn’t done. Grossly unprofessional. Bad form, old chap. Instead you tell them, “the doctor just wants to open up your lungs as much as possible to help you get better,” which is both a probable guess of the doctor’s intentions and a technically-correct brief layman’s explanation of what bronchodilators do4.
It’s easy to get judgy about this. God knows I have.5 But it’s unreasonable to expect every doctor to have the same expertise on our subject when they work on a completely different level and have to regularly employ a different set of skills while drawing on (even in the case of pulmonologists) a much broader field of knowledge. And there are a fair number of doctors out there who are willing to listen when you advise them, or even outsource the decision-making to you entirely. As you develop a relationship with individual providers, they learn to trust and lean on you more.
If you don’t work in healthcare, you might feel a touch uncomfortable reading about doctors making decisions about subjects they don’t entirely understand, and sometimes refusing to give way to persuasion6. And I’m being discreet here; I have dealt with doctors who want absolutely insane things. This is not practically avoidable, first because humans are fallible in a general way and second because healthcare facilities and institutions exist downstream of millions of policy decisions which are made in good faith but can have perverse effects nobody expected7.
I’ve been an RT for just shy of five years; COVID hit in my second semester of respiratory school. I was initially sort of excited—that sounds sort of insensitive, but I was—to think that we might be working the front lines at clinicals, fighting the fights that really matter and learning how this disease worked even as the broader medical field did. This was, in retrospect, an extremely naive expectation. A first-year respiratory student is useless, and nobody wants them underfoot during a crisis. We got a whole lot of “virtual clinicals,” an absurd oxymoron, which we spent practicing for the test that would let us become RTs. Valuable in its own way, but absolutely not a substitute for real clinicals. Even when we went back, there were frustrating limitations on what we could do; for a long time it was unclear whether we were even allowed in the rooms of patients who had COVID. Lots of clinical time was spent sitting in a conference room somewhere, only getting up once every few hours to administer scheduled treatments to a few basically-healthy people. After maybe fifteen or twenty minutes we went back to our chairs. There was nothing else to do with us.
Time still passed, I kept learning from the books, and I passed the test easily enough. I then went to work as a registered respiratory therapist with all the hands-on experience of maybe an early-third-semester respiratory student. And COVID was still a somewhat serious thing in Summer 2021. My first job out of school was at a small semirural hospital with limited resources, and I learned how to do my job by working on critically ill patients. Quite frankly I made an ass of myself many, many times, and things went worse than they could have even when I tried my best, in part because I knew I didn’t know what I was doing, and it made me neurotic and clumsy. This was unavoidable. That little hospital was, in retrospect, the perfect place to start, because they didn’t allow RTs much leeway. I spent a lot of time practicing basic, basic skills, and gaining confidence.
But even with proper training, a respiratory therapist fresh out of school isn’t going to be very good. The same is true of RNs, doctors, and everyone else. The “official” book way of doing things is often oversimplified or flat wrong, and clinicals can’t help you make good decisions quickly because students aren’t allowed to make decisions about patient care. That has to wait until they’re licensed and thus poorly supervised. I snark, but there’s no other way to do it. At some point, you have to spread your wings and hope you fly, and this will happen in a patient care environment where there are consequences. Healthcare professionals get better with practice, the same as anybody else8.
In some ways, healthcare is like the military; we exist in a separate world, where we have to deal with humanity at its absolute worst, and a lot of the boots on the ground are unprepared kids still reeling from the aftershocks of adolescence. By necessity. But society adores us—support the troops! Healthcare heroes!9 They throw money at us, tons of money, just stupid-huge piles of cash. The American healthcare industry gets way, way, way more money than the poor impoverished military-industrial complex. In return, all they expect is that we be polished perfection everywhere they look. They don’t want to know about the weird world we live in, by turns boring, soul-crushing, and absurd. They don’t want to know about the inevitable consequences of bad calls a million miles upstream. They don’t want to walk in the room just as Private Hudson is asking Lieutenant Gorman how he can get out of this chickenshit outfit.
Presumably, if you’re still reading this, you’re a bit curious, and would like to peek behind the curtain. If not, let me assure you, the doctor just wants to make your lungs as open as possible.
If a doctor went to med school long ago, they might have some quaint ideas about patient care. Or the only doctor on the scene might be a general practitioner or hospitalist who’s used to covering the broad strokes, not dealing with patients abruptly experiencing respiratory distress. Or a specialist in something like infectious disease or nephrology which touches only tangentially on respiratory care.
“I’m a bit concerned that if we do X he might Y” is a good way of putting it. Even so you have to be willing to do what the doctor says anyway, unless it’s something utterly insane that might endanger the patient and/or lose you your license. Then you stand your ground.
Or, in the case of some therapists (YOU KNOW WHO YOU ARE), sabotage or semi-comply with the orders in a profoundly passive-aggressive fashion. I’m not encouraging this, but it absolutely does happen. RT exists in this sort of limbo where most providers simply fire off orders and assume they will be executed without following up, so one can get away with those sorts of shenanigans.
In my last post I neglected to mention the obscure use-case of hyperkalemia. If you have too much potassium in your blood, a very high dose of albuterol, administered very rapidly, will temporarily (for about an hour) force some of it out of your blood into the surrounding tissues. This is something like a fourth-line treatment for hyperkalemia—plenty of better ways to deal with it—and requires a concentrated form of albuterol which I’ve never even seen. If you try to use regular albuterol for this you’ll take half an hour to nebulize an equivalent dose, which is waaaay too long. Your hospital may still have it as a standard part of its hyperkalemia protocol. Mine does. Sigh.
"I guess her med school didn’t have a board book for that.”
There are doctors who really know lungs. They are semi-rare, but awesome. There are other doctors who don’t know lungs, are aware of it, and will listen to you—still great. The problem is when they don’t know what they don’t know, and refuse to admit or accept it. On the little things, it’s more sensible to give way, if they’re making a technically suboptimal choice but it’s unlikely to hurt the patient. If you get a reputation as an argumentative ass, it’s that much more difficult to persuade when it really matters.
Fair warning: this will be a recurring theme on this Substack. “It sounded like a good idea at the time” is responsible for more human suffering than tuberculosis.
Perversely, there are people pushing to make respiratory therapy a mandatory four-year degree, a bachelor’s rather than an associate’s. To lobby for this is, in effect, to say that an RT with two years of school and two years experience is inferior to an RT who’s fresh out of four years of school. Which is insane and stupid. But it would make the credential more prestigious—can’t let those nursing programs look down their noses at us!—and probably improve our wages by making it harder to increase the supply of new RTs. Existing RTs would have to be grandfathered in; everybody else would have to work harder and longer than we did. This is called “climbing to the top of the ladder, then pulling it up behind you,” a dick move perpetrated on many other professions, and is a common reason why we can’t have nice things. Incentives!
I have been thanked for my service, when I was out in scrubs in the wider world. I didn’t know what to say, and responded with a very bashful “you’re welcome.” What I wanted to say was, “uh, they pay me for this. Fairly well for a two-year degree. And if you’re talking about COVID risk, I’m a rail-thin thirtysomething with no real risk conditions. It ain’t touching me.”