Monday, June 30, 2008

What we see, not everyone does.

We are currently very low in our census of respiratory patients but we still have some interesting ones come in and out of my place here. Tonight I had a patient come into my ER who was very tachycardic to the tune of 170's and higher along with a respiratory rate of 40's and sweating very profusely.

What does that sound like? If you said a pulmonary embolism you would be correct. Now this really is nothing very new to most RT's but what really struck me about this one is the mortality of this person that was brought up to me. I had previously done a EKG on this patient when he first came into the ER and was called back to do another one about a half hour later. What I noticed was his rate had increased along with his heart rate and the patient just being very anxious, but he was very alert and awake.

When I finished I went out and talked with the doctor, I asked him if this patient had some sort of bad infection also because of a high fever according the the nurse. The doc said no, he has a bad PE and he was pretty sure this person was going to die.

Right there is was struck me, "pretty sure this person was going to die". Does this patient know that, are we looking at a dead man walking type of issue, somehow he can tell that this person who is alert and awake has a clock that is ready to stop. Well the doc was right, he got to the point that he needed intubated and not more than 2 minutes after the intubation his HR went from 170's to the 30's and a code was started.

After all was said and done this patient didn't make it, but between when I talked to the doctor until the code was stopped, I couldn't help but think that I was this alert person that we knew that his time was up and it was just a matter of time. I was talking to this person knowing that the doctor could be right and I could be the last person he talks to. We watched this person just fade away, did all we could to save him but in some sense we all knew there was not much hope at all.

This all started me thinking about what we see as RT's compared to other people in the world. If you think about it how many people actually get the chance to actually watch someone take their last breath? How many people get to see a person who is injured beyond recognition from a car accident? Really I don't think many people get the chance to experience the things we sometimes do and a daily basis. Yes most people will probably see a dead body after the fact at a funeral but really how many are able to see life just slip away from a person or see us as caregivers struggle to resuscitate a person and get their heart started again?

Honestly do people in our lives, friends and family really understand what we see and deal with at our job? Do you think they have a good idea of what our job involves? Unless you are around our job you can never really know what we see or do. In my 12 years as a RT I couldn't even guess how many people I have seen die, and really I feel I have been desensitized to the reality of death and dying. I often wonder that if, God forbide, one of my parents would pass away that I wouldn't be able to show much emotion but I do know I would be sad. It is possible that I am so used to seeing people die that I might not even be able to cry for my loved ones.

All in all as a RT I really think that we see more death that a lot of RN's in the hospital. Think about it, as the RT we are required to respond to all codes, not all RN's are. There is the possibility of a code happening in the floor that the RN works at, but we as RT's are responsible to respond to ALL codes in the hospital. So are we around it more, I think so. This fact I can see in the eyes of some RN's who I see in codes, it's in their eyes they just seem a little out of sorts. We on the other hand usually have been though many of codes and are a rock in the sea of turmoil called a code. Don't get me wrong there are a lot of RN's in the position to see a lot of this also, namely ER nurses, they probably see a bit more than us. They are also a special breed.

There are many jobs out there that see things that most people would not want to but that's what separates the people who are able to do these types of jobs. It's not for everyone, you have to have a certain toughness and mindset to do this type of work. We have that mindset, and it is needed to not only do you job but to be a calm face in a stressful situation.

Friends and family might know what a RT is, but will never understand really what we see and deal with as a RT. Sometimes it can get to you when you think about it.

Drive on RT's.

Sunday, June 22, 2008

Small Town Patient Privileges

Patients in a small town hospital like the one I work happen to be a totally different animal than the ones in the bigger cities. This idea I'm pretty sure Freadom over a Respiratory Therapy Cave and agree with me about because it seems that he is in this same small town hospital category.

Some of the differences I have noticed are the types of reasons that people come in for are pretty simple compared to larger hospitals but there are exceptions also to this. There are the injuries that can be more local to the type of hospital you work in. For example where I work is a large farming community, we have had rolled over tractors, getting kicked by horses, falling off of barns, and my favorite the guy who him and a couple of buddies were drinking out in the cow barn and had a little to much and passed out and coded right in the middle of cows, down in the hay and manure. The EMT's said they were worried that the cows would kick them while they were working on the patient. This guy smelled awful and had cow manure and hay all over him, unfortunately he didn't make it and the ER room smelled and had hay all over the place. Then there was the Ethenol Toxicity patient who decided to drink some straight ethenol from the ethenol plant, yep not smart it's 200 proof!!!! He was quite red.

Tonight I had another one of my small town patient who received a privilege that I have not come across so far in my 12 years as a RT.

I was on my way to do a breathing treatment with a older patient at around 8 pm and when I got to her room there was no one there. Fine I thought she must be walking around the unit, we do encourage our patients to get up and walk. I see her nurse and ask if she is out walking and I'm told no she isn't, she is - get ready for this -

Ok here is the dialog:

Me: Hey Nurse Betty do you know where Mrs. Bing is at, she is due for her treatment?
Nurse Betty: No she isn't here right now, she's out.
Me: Out, not here, is she at a test?
Nurse Betty: Uhhh nope, she is at a Wedding.
Me: She is what??? (confused look on my face)
Nurse Betty: Yep you heard me right she is actually at a wedding, she left about 1 pm.
Me: Really, is she coming back?
Nurse Betty: Yea the doctor said she had to be back by 9:30 pm.
Me: So she is gone to a wedding and has a curfew. She is really sick isn't she. (dumbfounded)
Nurse Betty: (sarcasm) Oh yea she is so totally sick.
Me: Did she wear a dress? Get all dolled up?
Nurse Betty: No Idea I just go here at 7 pm.

Ok this I found interesting as she must not be very sick at all, send her home and have her follow up with a doc at the clinic. Your wasting our time.

So about Midnight I have to go assess her for respiratory status and she is there finally and I can give her the treatment also now.

Me: So I hear you went to a wedding today?
Mrs. Bing: Oh yes I sure did.
Me: Was it a good wedding?
Mrs. Bing: Yes very pretty and the reception was a lot of fun to.
Me: So what time did you get back?
Mrs. Bing: A little before 10pm, the doctor gave me a curfew. Can you believe it, I'm 86 years old and I was given a curfew. I really don't remember ever getting a curfew.
Me: Yea that is pretty funny, well glad you had fun and made it back before the doctor grounded you. Alright here's your neb.

I just really found this interesting that a inpatient is released to go to a wedding or really anything while they are sick. Granted we cannot hold someone against their will but why not just discharge this person, they seem to be okay. Oh well I thought it was funny.

Then tonight there is this younger 20 something in the ER who I had to do a EKG on. The police were here for this one because he was a bit unruly. Seem like he had a couple to many drinks or drugs of some sort. So anyways I'm in there and he threatens to spit on people so the conversation proceeds:

Big Dork: Get away or I will spit on you and give you the SARS I have!!!!
Me: I don't really think you have SARS.
Big Dork: Yes I do get away.
Me: How did you get SARS?
Big Dork: I don't know, how can you get SARS?
Me: It's not in the United States, have you traveled overseas recently?
Big Dork: Yes I've traveled overseas recently.
Me: Where to, because there are not to many places that have SARS?
Big Dork: What places have SARS?
Me: Japan, China, over in that area.
Big Dork: Well yeah exactly, that's were I went to Japan.
Me: Yea Okay, if you spit on me SARS or not I will let that cop beat on you.
Big Dork: I'm not really going to spit on you.
Me: Ok hold still so I can run this EKG, thanks all done and good luck with your SARS.
Big Dork: Thanks, can I have a glass of water.
Me: Let me ask you nurse, cya.

That was just plain funny, I like funny drunk/high people you can mess with then and they will never even really notice you messing with them.

Well hope this was as entertaining to you as it was to me tonight as it did make the night more interesting because I actually had no patient that were due anything overnight. Easy night

Drive on RT's

Tuesday, June 17, 2008

What do Cord Gas values mean?

In the different hospitals I have worked at over the years where the respiratory therapists either draw or run the umbilical cord gases I have often wondered about what the normal values of a cord gas was. Just from running a lot of cord gases I have came to my own conclusion of what a cord gas value should probably be but have never really looked into what the real normal values are and what a value out of the norm would mean.

I have done some research online to see what I could find out. Here are some fact about umbilical cord gases and the normal values:

  • The umbilical cord blood is studied for the status of the fetal acid base. Cord gases are obtained to detect the presence or absence of acidosis and to decide whether the cause of the acidosis is respiratory or metabolic. Establishing the source and type of acidosis make it easier to a.) plan resuscitation b.) treat complications.
  • Umbilical cord blood pH and acid-base balance is most useful in association with the delivery of an infant with a low APGAR score.
  • Only newborns who have a persistent APGAR score of 0-3 for 5 minutes or longer and an umbilical artery blood pH of less than 7.00 are at risk of manifesting anoxic brain injuries.
  • Premature infants are at higher risk for intracranial hemorrhage and subsequent neurological dysfunction, such as cerebral palsy. Without umbilical cord blood gas analysis, these neurological complications could be incorrectly attributed to intrapartum or birth asphyxia, especially if the latter is solely based on APGAR scores. Normal umbilical cord blood values in the premature infant virtually eliminate the diagnosis of significant intrapartum hypoxia or birth asphyxia.

The information I used above was found from different sources who are all basically saying the same thing. Now how about those normal values and the values the show a respiratory or metabolic acidosis.

As a reminder the umbilical cord is backwards as the Venous side carries the oxygenated blood and the Arterial side the unoxygenated blood. Doctors prefer to use the Venous cord blood but can assess PH with he arterial side also. Also these values are not set in stone, they are just a reference point, I have came across values the differ but very slightly.

After Birth­Normal Fetal cord blood pH and gas values:




7.25 - ­7.35 7.28


28­ - 32 mmHg. 16­ - 20 mmHg.


40­ - 50 mmHg. 40 - ­50 mmHg.

Base Excess

+/- 0 - ­5 mEq/Liter +/- 0­ - 10 mEq/Liter

Abnormal Venous cord blood pH and gas values

Respiratory Acidosis

Metabolic Acidosis


<>< 7.25


Variable < 20 mmHg


> 50 mmHg 45­ - 55 mmHg.

Base Deficit

< 10mEq/liter
> 10mEq/liter

Respiratory Acidosis

Metabolic Acidosis

Low pH Low pH

High pC02 Normal to high pC02

Normal Base Excess High base excess

As always I hope you have learned or been refreshed on this topic, I know just researching for this information I have learned a bit of information.

Thanks for reading.

Drive on RT's

Monday, June 16, 2008

Some are more sensitive than others.

Over the years of being a Respiratory Therapist I have learned a few different schools of though on the use of oxygen and how effective it is at different levels.

It has varied from:

  • 100% Nonrebreather to in reality a 70-80% nonrebreather. A lot of nurses actually believe it is really 100% oxygen the NRB is giving.
  • OWL protocol, or Oxygen With Love. This actually really seemed to work and what it was used for was to decrease the occurrences of retinal detachment in babies in the NICU. The protol was to keep the SPO2 level between 88-92%. We all know that high levels of oxygen can cause retinal detachment in infants, well this protocol actually worked, it decreased the amount of infant that needed eye surgery due retinal detachment from around 60% down to below 20% at the hospital I worked at. So did it work, I think so.
  • You need a bubbler with oxygen. No you don't, not always. I do give them our for levels over 4 lpm on the nasal cannula IF they are at that level for awhile, or they are getting bloody or burning nares.
  • All Post-Op patient need 2lpm of O2 for 12hrs after surgery. I think not.
  • Anything under 2 lpm with a Nasal Cannula is a worthless on a adult.
That last one is a area that I'm dealing with right now. All of the other hospitals that I have worked for we were in the school of thought that under 2 lpm, you might as well just take them off because it doesn't do anything for that patient.

For some reason that has been true so far for me and my patients, until I started here at my current hospital. I recently had 3 different patient who I just couldn't wean off of oxygen. They were a 15 month old, a 60 year old and a 83 year old and they were all on the under 2 lpm levels of oxygen, which seemed to be the kicker.

Now that 15 month old I do understand that pediatric patients do respond to lower levels of oxygen flow, which is why they make a low flow oxygen flowmeter which goes from 0.1 to 1 lpm. This patient had a possible pneumonia but great sounding lung sounds after a day, but we could not get this child off of the 0.1-0.2 lpm of oxygen. She would drop to the mid to low 80's without it and as soon as I put it back on, poof back up to the high 90's.

Then the 60 year old I had. This person was a long term smoker, probably had COPD also so I would assume that this person lived in the low 90s to the high 80s. But what was interesting is that on RA this patient would drop down to 80% so we would put 0.5 lpm O2 on and the sats would jump back up to 97% right away. Seriously 1/2 lpm and the spo2 would jump that high. I was amazed. I had always learned that under 2 lpm was a waste of oxygen and equipment.

Now the last patient, my 83 year old was the same way. I was doing my oxygen rounds and I checked her spo2 on 1 lpm and she was 99% on the 1 liter. Great I though, I can take her off the oxygen, which I did. I then came back in a hour just to make sure that the sats were fine and wow was I shocked. 78% on RA!!!! I'm thinking, "Really no kidding, that 1 liter made that much difference with her!!!". Well it did, I put her back on the 1 liter of O2 and BoooYahhh, it shot right up to 97%. Amazing.

This was in the same night, all three of them had their oxygen issues. This night right here disapproved the idea to me that anything under 2 liters per minute of oxygen is worthless in adults, I was a skeptic but now I think I might be a believer. Even most of the books say a nasal cannula is set between 2-6 lpm and 24-36%. Now 1/2 lpm is 23% according to the formula:

21% + (oxygen liters per minute *3) = fio2.

That there is under the book definition of the nasal cannula, but it seems to do some good. Oh well as long as they are not dying on me and it's that 1 lpm that is keeping them from doing so, I will keep using the lower levels now as needed.

if anyone has any information or web sites about the lower levels of oxygen on adults I would be very interesting in that information, because like I said I have always heard it worthless under 2 lpm, but apparently some patients are more sensitive than others.

Drive on RT's and thanks for reading.

Diagnosing my Grandfather

My Grandfather was in the hospital again this last week for a couple of days because of shortness of breath and he has a doctor that seems to just beat around the bush by not giving my grandparents a definite diagnosis. He was told that he did have a blood clot behind that knee that is taking Lovenox for at home, yep my Grandmother is giving his shots in the stomach. I saw her do it today, she does a good job.

The problem my grandparents are having is that this doctor has never given a good distinct diagnosis of what is causing his breathing issues that he has been into the hospital for two times this year and has also been in before, so as a good RT I am going to lay out the facts and give my diagnosis. Maybe a good case study here.
  • He is 86 years old
  • Has had 2 heart attacks both with CABG surgery
  • He smoked for over 50 years, quit about 15-20 years ago
  • He does a lot of woodwork with lots of sawdust
  • He gets very SOB when it is hot and humid
  • Has a productive cough
  • When SOB he sleeps better sitting up
  • Breathing treatments do help him
  • He gets bronchitis fairly often
  • He is diabetic
  • He is very active, does woodworking, walks to mow lawn, plays with grand kids
Ok from what I have here I really think that he has a good case for COPD. I understand that there could be some heart issues here, but I would rule out COPD and would like for him to have a PFT test done. There is a good possibility that a corticosteroid would do some good for him and a rescue inhaler.

This particular doctor will not say what this could be. He has said there could be a touch of emphysema, and that the cough is "chronic in nature", but he will not send him for the proper tests to check to see if the lungs have problems. This is driving me nuts. How hard is it to order a PFT testing to be done? Why not send him home with some MDI's. He did send him home with a antibiotic called Avelox that after reading is supposed to be good for upper respiratory infections. This med only takes 4 pills to kick bacterias butt, pretty cool and powerful.

This is added as a late entry, but this doctor also stated to my grandparents that the Sawdust from his hobby has no effect on his lungs as the particle size is to large to get into his lung. Huhh. Yep he said it's gets stuck in the upper airway and that's why there is sawdust in his sputum when he coughs because it is filtered out by the nose and upper airway. Yea ok quack.

Well that's the deal, I really hate this cannot make up my mind mentality of this particular doctor and I'm glad he is not from my hospital.

Let me know what you think.

Wednesday, June 11, 2008

Cover your workers, don't set them up for failure.

My wife as I have said before is a ER nurse at another hospital and she came home the other night just a little bit distraught about something that happened at work where a couple good points or we can say lessons came out that can come into play for all medical professions.

I was night shift and she had a patient who was a child and a very overbearing mother to go along with the child. An I.V. was placed in the patient and it took about 6 nurses and tech's to hold this 8 year old child down who was biting and kicking to get the I.V. done. I.V was finished and blood was drawn.

My wife grabbed the labels off the chart the tech had put on there and labeled the blood tubes and send then to lab. 1o minutes later the lab calls and said they were the wrong labels they were for another patient.

Not good but can be fixed, the patient has a I.V. so we can just draw more. Now lab comes down to draw more blood from the patient and is told to wait a moment so we can get the labels together. Lab does not hold on and goes ahead and throws her fellow workers in front of a truck. This young lab tech goes into the patients room and proceeds to tell the patients mother that the Nurse screwed up the blood and didn't put the correct labels on the tubes.

Good job young lab tech, not mom is irate and comes out of the room into another patients room and starts yelling and dropping the F bomb all over the place to my wife right in front of another patient. Calling her the worst nurse ever, this hospital sucks, I'm taking my child outta here (go ahead), among other colorful things.

Now how could this of been avoided? Of course double checking the labels, yes that is a lesson learned. Also though this lab tech could of easily told the mother that they needed more blood for another test, or that the blood in a tube clotted, anything but YOUR NURSE SCREWED UP, and this could of all be avoided. The patient had a I.V. so there would not be another needle stick at all. Easy fix.

The security was called for a irate parent, the nurse supervisor called the young lab tech and chewed her out and the doctor said nothing was wrong with the patient anyways, plus my wife was upset and said some things to the parent.

What did we learn from this besides checking your labels:

1. Cover the integrity of your fellow employers and the reputation of the hospital if it is possible.
2. Do not set people up for failure, help each other out and things run smoother for everyone.

It's easy, just use you brain and common sense.

Thanks for reading, Drive on RT's.

The PediaRTritian is born

Pediatrics are an interesting bunch, sometimes they receive treatments like adults and others times they are treated totally differently. Either way we all know pediatric patients do cause some nervousness with certain people.

I like to think that I have quite a bit of experience with pediatric patients. Lets see I worked in a level 3 NICU which I was also on the neonatal transport team where a RN and RT would fly or drive babies born with problems, normally respiratory problems. I have also worked in a Pediatric ICU along with different peds units. On top of all of that I also have 4, yes I said 4 kids at home. I've been around the peds population a bit.

So you ask where am I going with this? Well it has to do with the small town hospital I work at currently. Now this is a small town hospital that really doesn't get a lot of pediatric patients at all.

It is that time of the year for evaluations and I was called into the supervisor's office to do a little evaluating of me for the past year which I had just started working at this hospital. So I'm going through the Blah Blah Blah, your doing fine, Blah Blah Blah, what can you improve on, etc etc and this comes out.

Supervisor - "A RN wrote you up some months ago about not feeling comfortable with you as the RT of a peds patient, but was comfortable with your other night shift cohort."

Look on my face: WTF? I do remember this patient.

Me - "How so, I took great care of this patient."

Super - "Well this was a new nurse and she said that you didn't help her very much."

Me - "Help her with what, I did my RT stuff and the patient was in no distress."

Super - "She was just new and nervous and wished that your were more around to help her be comfortable with a respiratory peds patient."

Me - "Really? But isn't she a nurse who went through school? I'm not sure I understand what she was getting at, but I guess where I come from there are nurses who are pediatric nurses."

OK so after chatting a little while it basically came down to the supervisor, who is also the floor's supervisor, letting me know she want's us more involved in the care of peds patients with respiratory problems. Just help our more because the RN's don't get a lot of peds patients and get a little nervous around them.

Correct me if I'm wrong but do we not get the same amount of respiratory peds patients as the RN's do as inpatients? Granted I probably have more experience that most of the nurses on that floor with peds but still, what more can I do besides educate those RN's who are not comfortable with respiratory issues, I will not sit there and hold their hand. I guess I just don't quite get it.

Once again another added responsibility of what the RT can do is added to the list, the PediaRTritian is born. Tonight it also just so happens that there is a peds patient on the floor for us to see and besides just doing my nebs and RT stuff, I am stopping down about every 2 hours to check with the RN to see how she thinks the baby is doing, what else can I do. This just frustrated me a bit that I was told that a nurse wasn't comfortable with me and now we are wanted to be MORE involved with peds patients, but I am not going out of my scope of practice.

Now that RN who wrote me up, well she quit soon after that because that peds patient stressed her out to much and took a job at a clinic where she doesn't deal with peds patient. Now was it me or just a new RN freaking out a little to much and not being comfortable with her own training. I've also been informed that there are RN's here who flat our refuse to take peds patients even to the point of calling off work if there is that possiblity. Amazing.

Pretty soon RT's will run the hospitals.

Keep it up RT's and drive on.

Monday, June 2, 2008

Kids Site about the Human Body

The picture on my last post came from this site:

It's a site made from a 2nd grade class and here's is what it says it's about:

The Human Body

A Telecollaborative Project for St. Mary's Grade 2 Class with Mrs. Vaage and Mrs. Nugent

I though it was a pretty neat site, there is a gallery of pictures of the human body drawn by the kids and in there are little articles about the different body parts written by the kids.

Fun little site I thought I would share.

Nebulizers or MDI's inline with a Ventilator?

Here at my hospital we seem to go through streaks of how we give medication to patients on ventilators. For a couple of months we might use MDI's and then we might just switch over to Nebulizers inline for a couple of months, and it is normally the same doctor who will oversee these patients on vents, it would be our pulmonologist who does it.

Tonight I just came back from being off for 2 days and we now have 3 ventilators running and all three of them are getting nebulized medications. One of the vent patients used to be getting MDI treatments but has now been switched over to nebulizer treatments. So I got to thinking which is better? Could this just be because he has Xopenex ordered as one of the medications along with Atrovent? Shouldn't be the reason we carry these by MDI also I have heard, even though I have yet to see a Xopenex MDI here at this hospital.

Doing some reading online and my own personal experience I have found different pro's and con's of using either a nebulizer or MDI with a ventilated patient, this is what I'm going to try and share with everyone, and I am looking forward to any opinions you might have for either side.

Metered Dose Inhalers Inline with a Ventilator
  • MDI's have to be perfectly timed with a vent cycle
  • MDI's give better deposition
  • You need more puffs from the MDI to get a regular dose to a patient due to the moisture in the ETT that will cause the medication to stick to the ETT or inspiratory limb of the vent circuit. I have seen anywhere from 4 to 24 puffs given at any one time.
  • MDI's treatments are faster than nebs.
  • Need to give a pause after the breath otherwise the majority of the medication could possible go out the exhalation limb.
  • You have to push the MDI right after the inhalation cycle starts or if your to early a lot of the medication goes out the exhalation side, you can actually watch this.

Nebulized medications Inline with a Ventilator
  • Becomes a vapor like the humidification
  • Do Not have to time with the ventilation cycle
  • Same dose as you would use with a non ventilated patient
  • Does take longer
  • Does increase measured exhaled tidal volume and minute volume
  • decreases the trigger sensitivity of the pressure supported breaths due to higher flow making a bigger negative pressure necessary, increasing he work of breathing in the patient
  • may cause problems with the internal ventilator components due to the medication sticking to the components
  • should possibly use a extra expiratory filter and maybe a inspiratory filter to protect the ventilator
Those are just some quick little notes of interest I have come across in my researching information for this article along with information I have learned as my time of being a RT.

Some more information I have learned about the placement of the nebulizer and MDI's when you give the treatments I have found and some I have known or used in the past.

When giving a MDI through a ventilator you should put the MDI inline as close to the wye as possible and up to 6 inches behind the wye. Always give the puff timed with a inhalation cycle or it will go down the exhalation side and not to the patient.

With the nebulizer inline I was really curious about the best way to place the nebulizer inline as to get the best treatment and from what I found which was the consensus was to put the nebulizer as far back from the wye on the inspiratory side as possible. Some even will put it behind the humidifier as they found that the aerosol of the nebulizer will mix with the humidified water aerosol, which are basically both the same. The reason it is said to place it farther back is so the inspiratory limb on exhalation will fill up with the nebulized medication aerosol and on inhalation there is a larger concentration of medication given to the patient. There is also the old law that says a gas will go towards the area with the least resistance, so if its closer to the wye the exhalation flow will be the area of least resistance due to the flow and there is a entrainment aspect to that side of the tubing also. Which makes sense to me.

I now after reading am more partial towards the use of nebulizers inline with a vent than MDI's at this time. I also will be moving my nebulizers farther back from the wye, which I will do here in about a hour's time. I lot of my questions were answered by doing some research and I hope I might of given you some more information that you never really knew.

One more thing, DON'T Forget to remove the HME before you give a treatment!!!

Drive on RT's