The Secret Book of Doctor Knowledge!!!

Doctors are a interesting bunch, there are good ones, interesting ones, bad ones, ones we are not sure how they got through medical school but overall they are a interesting bunch.

Something that sparked my interested is how a doctor will get on a certain type of treatment kick for awhile which will make us RT's look at each other and go hmm, where did this come from and why are we doing it?  This just doesn't make any sense to do this to every patient we see.

For instance we have 2 doctors in particular who get on these treatment kicks, right now one is on this Duoneb with Ezpap QID & Q4prn for anyone who has anything to do with Respiratory, seriously do we need to add Ezpap to a patients home regimine if there are not even in for Respiratory problems and does EzPap really help treat a patient with a history of COPD?  Then we have another Doctor who is on a Mucomyst kick for EVERYONE with nebulizer treatments, yes we get that D/C'd a lot curtosy of our protocols but they also have learned they can write NO RT Protocols and then we are stuck.  

There are cases of other doctors getting on certain treatment kicks like the Xopenex for everyone kick along with not following the company's drug reps recommendations on how to order Xopenex (not created to be used Q2 or continous, still makes heartrate go up), and I'm sure there are kicks that RN's see the doctors get on, but I don't deal with that side of the house.

So this makes me wonder if there is a Secret Book of Doctor Knowledge which has all the information why these treatement are the current "Cat's Meow" in the respiratory world of care because I've look everywhere for some definitive knowledge on how Mucomyst will help all patients or what good does EzPap do for a patient with COPD and this information has eluded me because I'm assuming it's in the Secret Book which of course if probably locked in the doctors lounge.  I just wish they would give us a quick in service on this instead of looking at us like we are stupid when we question these treatments.   

I'm sure these kicks will die down after awhile of use and go away until some other little bit of knowledge gets updated in this book like a Doctors version of Wikipedia, but it would be nice to just share a little bit of information to us troops in the trenches.

Drive on!!!

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.

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.

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

Protocols Do Work.

Today I had to come into work early due to the requirement of the monthly Staff Meeting. Ohh what fun, but I did actually gain some information this time that I thought was pretty interesting.

If you have read one of my earliest posts I talked about a Therapist Driven protocol that we had implemented at my little hospital about 7 months ago. This protocol had to do with us the RT's assessing patient and then being able to adjust nebulizer, MDI and Oxygen therapy's as we deemed needed. Well we are now done with the testing phase of the implementation of our therapist driven protocol and a letter from our director is out to the doctors with surveys to see if we continue with this type of therapy.

There are some statistics that we pretty interesting that were compared from this 6 months of the protocols being in use and the 6 months prior to the protocols being in use. These stats were pretty interesting and pointed in favor of using these protocols and making them law. The only areas of care that were talked about were patients with Pneumonia and COPD issues.

Hospital staylLengths for Pneumonia and COPD decreased by 1 day in both areas. So we were able to adjust treatments for the patients and decrease their length of time in the hospital.

Now here is what I though was pretty amazing in the financial aspect.

In patients with a Pneumonia the cost of Respiratory Therapy given to the patient was DECREASED by 23% with the protocol in use. We saved the hospital 23% per patient on average if they had pneumonia.

And

Patients in with a COPD issue the cost of Respiratory Therapy given to the patient was DECREASED a whopping 36% with the protocol in use. Here we saved the hospital 36% per patient on average if they were in for COPD.

These facts speak strongly for the use of Therapist driven protocols and that we might actually know what we are doing.


During this meeting I did get into a disagreement with the director and supervisor about how we should for the first 24 hours do the treatment exactly how the doctor ordered it due out of respect to the doctor so they don't think we are just saying they don't know what they are doing.

Whats the point of doing the protocol assessments in the first 24 hours if we are not going to change anything? The doctors signed off on the protocols, so we have a right to use them as needed, otherwise you need to change what the protocol says.

I think I stunned the director when I said "So basically you two want us to suck up to the doctor's so they don't feel bad?" They said no it's a teamwork thing.

I don't know I feel as though if we don't use the protocol as written the doctor's might get the impression that we are skeptical on our abilities as therapist to assess our patients and choose the right treatments.

Fortunately I have a couple of other therapist who agreed with me and backed me up in my thoughts. Good to know I wasn't alone in my thoughts. So this was to be a unwritten rule that I'm not so sure people will follow. I for one will keep doing it as I have been and that's by the book on how the protocol was written up. Can't get into trouble for that.

Statistics show that we must be doing something right, and there are no complaint's about how we have done our assessments so far. Hopefully the doctors do really see it that way and the surveys come back in good shape, then we can make this law and continue on.

Drive on RT's

I always thought is was A.B.C.

One basic principle that was driven home to me as a medical professional in either of my schools, be it my Combat Medic course, EMT course or Respiratory Therapist course has been the concept of the ABC's, also known as Airway, Breathing, Circulation. This has always been understood my be to be there order of importance when it comes to a person in medical need. Yes this is supposedly for mainly first responders and emergency situations.

Now in the Emergency Room I would think that this would come into play, because well its a emergency room. Unfortunately I have noticed at many places, and a lot where I work that I will get a call the the ER for a patient that needs a breathing treatment. This usually tells me that there is a person in the ER that is having some type of difficulty breathing, and if you look at the ABC though process it would be number 2 on the list, because if they can breath in a nebulizer tx the airway must be somewhat patent.

Here is my issue that I see more and more, I'm called to do a neb in the ER and when I get there I will get from the nurse and sometimes the doctor, "Oh I'm sorry Xray got here before you so they took the patient to get their Xray done." Or there will be Xray there and they just do the "Haha I beat you here" thing. Sometimes I even get the, "Can you give us a minute, we need to put in this foley catheter first." Then comes the "Hey come do this EKG first before you do the neb treatment."

Does anyone else see anything wrong with these scenarios? As far as I know I would think that breathing would take precedence over Xrays, plus you would get a better view of the chest with a more open chest I would think, but then I'm not a Xray person. I would also think that breathing would be a little more important than a foley catheter, but a foley catheter could help with the breathing if they are fluid overload, so lets both do our thing at the same time. And that EKG before giving this neb to a asthmatic, look at your ABC's, circulation comes after breathing.

There are many times a patient doesn't really need a neb very badly and it's not a emergency situation, but even then it's irritation to be called away from what you were doing to show up and the patient was gone to Xray. Maybe this is more of myself complaining about something, but it irritates me to think that when it comes to patients feeling better, an xray will make them feel better than the nebulizer that will ease their breathing. Personally I would rather be breathing better than getting a picture taken.

Thanks for reading

Drive on RT's

My Mirror RT.

Back again for episode ... Umm something or another.

OK so I live in a small RT cave at a small hospital in a small town on night shift. I also happen to be the only RT on at night, besides my mirror RT who works the nights I don't work. Which if you think about it is kind of funny in the way of social interaction type thing. You see here we only have a total of 9 people here in my RT department and the other night shift person is the only person I really don't know all that well. Why you ask? It's because there are only 2 of us night shifters here and if I'm working he is off and if he is working I'm off so with this little interesting arrangement we never really see each other, we will never really attend the same function together, we will never meet out with coworkers to have a drink together, nothing. The only real interaction we have together is over the phone if one of us wants to make a switch of shifts. I hear stories and anecdotes of him, some good, some bad, some interesting and there is a day shift RT who is dating him so I'm assuming she knows him well.

There is a shelf of our coffee cups here were we store our personnel cups, mine is up there right next to his and sometimes we play jokes on each others cup because he happens to have a Minnesota Vikings cub and I have a Chicago Bears cup. Yep 2 teams in the same NFL division so they play each other in the season and if the Bears lose I get a little note or something done to my cup and visa versa. Kinda makes for some fun.

There it is My Mirror RT, possibly me in a alternate universe, like I'm Spiderman and he is Venom or I'm Superman and he is Bizarro Superman. OK maybe not, I don't think we are complete opposites of each other but I just find it interesting that I have a opposite RT from when I work with whom during my time working here I may never really get to know as a coworker or a friend, just as that person on the other side of my RT mirror.

Just another tired night when the mind gets to wandering...

Cardiorespiratory Therapist?

So why does it seem that the duties of EKG's always fall in the hands of us RT's? Where we trained in cardiology, or given the knowledge of ECG/EKG's or even doing these tests on patients? I know I was never given a class on this type of testing during my schooling, but it the powers that be seem to think that EKG's should fall onto us RT's. Now I'm sure this isn't the case for all RT's who work in Hospitals, but so far in the last 11 years doing this it seem to be the standard where I have worked.

Now being a male RT doing EKG's can become a little touchy at times, but we must know to remain professional at all times also. Ok now I'm not trying to sound perverted but really is it to hard to ask for a hottie patient to do a EKG on every now and then, I think not. Really think about it what is our EKG population like and the problems the come with it.

As a man we have to handle these women's breasts which are in general terms a taboo region just to bear in front of a stranger. With the older women you can't help but wonder is this offends them due to how they were brought up. Middle age women usually there is a husband in the room with them and they of course are watching another man handle their women and I have yet to meet someone like Suzanne Summers in this age group. Then comes the large overweight women where you need a crane to lift those monsters to get a little sticker under their, sure wish they came with a kickstand. You actually wonder if they feel bad putting you under all that stress of lifting those things.

Now we get to the younger population of women, which is usually not the case for EKG's but it does happen. As a guy you might think great a woman I really don't mind touching but then professionalism takes over and you attempt to put these stickers on with averting your eyes as to not make her think you are staring at her in a way other then medically. Then there is the possibility of teenagers getting a EKG also and as a Dad with 2 girls, I do my best to keep them covered up because I don't want a parent thinking anything or being uncomfortable with a man touching their daughter.

As for the guys, who cares they don't. Just get it done and move on, these are the easy ones and the easiest to find their landmarks.

Over the multitude of EKG's I have done at this current hospital I work at my initial worries I had doing these has since gone out the door but those were real concerns at one time. Professionalism has taken over and I just get it done, try to make the patient feel comfortable and work on getting them covered back up as soon as possible. Yes I still get a little grossed out from the underboob sweat along with other funky things that are under there with the bigger women but we drive on and get the job done.

Yes some of use are CRT's .... CardioRespiratory Therapists, but please don't ask me what I see in that EKG because I cannot tell you because I'm only trained to put stickers on you.


Next Episode: What to look for on a EKG/ECG.

Moments of Busy.

As you might of noticed from my last post that we are really not all that busy here in my RT Cave, but we do have our moments of busy and last night was one of them.

I get here at my normal time of 1830 figuring on a pretty decent night. I do the normal thing, put my coat and my food in my locker and fridge and then page the RT on shift to see if they need any help, usually it's a "Nope, I'll be right up.". Well not this tonight it was more of a "Could you get started on the treatments and meet me in the ICU, or I'll find you when I'm done." Ok still nothing to really get me thinking busy, I mean our treatment load is 2 QID's and one Q4, sure I can knock that out.

After I get those 3 really tough nebs (sarcasm) done I head off down to the ICU to see if my partner needs any help, well yep she does with a patient who is vented. Now I notice that she is bagging this patient and the vent is next to her and running, so I ask whats going on? She had been bagging this patient for over a hour now because the vent will not ventilate the patient. I go ahead and check out the vent to make sure it's working properly and passes all the self tests ... Yep works just fine, this patient is crap.

I go ahead and take over the bagging and get some report, this patient is septic in falling deeper into ARDS (Adult Respiratory Distress Syndrome) and is so tight that on Assist Control the most tidal volume we can get in is 30-50 ml's, not good. Alright next try is Pressure Control, great we have a Inspiratory Pressure up to 40 with no peep and can only get about 100-150 ml's VT, still not good.

My Partners pager goes off ... now what. Of course it's nothing good, we have another patient that I had done a neb on just about 20 mins ago now crashing so off she goes and there I am bagging a patient who cannot ventilate and is stiff as a board.

So it's now a Hour and a Half later, my hands are cramping and I'm still bagging and trying to figure out what to do, well dialysis is called in to get some fluid, almost 5 kilo's are wanted to be taken off, and hey here comes my partner with the other patient behind her while she is pushing a bipap machine, great what the hell is going on there. Turns out he has a reaction to a antibiotic that was just given to him that looked just like orange juice, now I'd think that would be rough going in on the veins. With further questioning I find out that the med he was give required you to premedicate the patient with Tylenol and Benedryl before it's administered, wow hardcore stuff there.

Finally 2 hours later my partner is able to give me some relief in the bagging area and the dialysis is started finally and a half hour later we are able to ventilate with PC on the ventilator, phew finally we can step back and relax a bit.

Now This patient pretty much stayed the same during the night. I ran three ABG's on the patient and from number 1 to number 3 the biggest change was a PO2 from 45-49 to good in the oxygenation department and spo2 was showing in the low 80's, but Doc said he was good with that and really didn't know what else to do because nothing was working.

Now getting a chance to think of everything that happened you start to notice the limitations of a smaller hospital. Heli-Ox would of been nice but we have none of that. PRVC mode might of worked but we don't have that on the PB 840 vent, there is VC+ which is supposed to be like PRVC but didn't really work to well as I tried it. Would of been perfect patient to transfer out but the weather was crap. So what do you do? Improvise and do the best with what you have, what else can you do, in a way it does make you use you knowledge a bit more versus using technology so much.

I must say I do like interesting patients and this one is interesting. Tonight I get the honor to having this patient again and so far nothing is improving, just a little increase in the saturation of oxygen area, but that could be due to the peep going from 12-16 cmh2o today. So tonight my last day before Christmas working I am still slow, with a Ventilator and a Q4 neb but as we all know anything can change at anytime.

Happy Holidays.

A Good Holiday.

Well I haven't written in awhile due to the holiday's, I was a little busy. I hope everyone had a great Thanksgiving, I did.

So what's new in my RT world. Well as we know I work in a smaller hospital and one thing I recently noticed is that our ICU is being used as a Drunk Tank, or detox for alcohol. Well what I mean is lately we have had a bit of patients in the ICU who were just in for alcohol poisoning as their diagnosis, in my opinion they were just intoxicated, drank a bit to much and maybe a little depressed due to the holidays coming up. Yes this is a small town hospital and from what I have heard there is only like 6 police in this town so really that probably don't have the resources to service these people in the jail like they did on the Andy Griffith show when Otis would get drunk and then come to the station to sleep it off. Now really is this a good place to put these people? All of them have been men and normally the majority of RN's working in the ICU are women and these drunk men can get a little unruly at times so it doesn't make much sense to me because if there is a physical problem or threat I'm usually one of the people who are called, not that I mind because I enjoy messing around with the drunk people, makes me laugh, but it could become dangerous for the RN's sometimes I'm thinking. In all honestly when I first started here I asked about security and people snickered a bit. Then I was told that if a security risk should come up like a combative patient or family member that the call will go out overheard for the men to come to that area. Kind of funny because on any given night there are maybe a total of 3-5 men in house at night and sometimes less I'm sure. Lets see tonight there is me, a Doc in the ER and a old lab tech, and possibly a guy from engineering. I'm alright, I lift weights a few days a week, was a soldier for 10 years, played football and I workout on a heavy bag a couple times a week so I'd like to think I can hold my own. It just made me laugh a bit that there were really no type of security here in this small hospital, I came from a hospital where there were uniform security, no guns but night sticks and pepper spray, oh and handcuffs to.

Since I have been here for the last 8 months there has been no calls for security so maybe it's warranted for the no official security force, but with all the drunks being admitted lately the time may come sooner than they think.


Oh well, happy holidays everyone hope it's not to busy.

Sometimes it gets busy.

I've been off for 3 days now and I walk into work at the beginning of my 12hr shift with a note on the desk that says "Come down to ICU and join the fun!", now this is probably not a invitation to a party in the ICU I'm thinking. Nope it isn't after I answer the phone right after I read this it's a coworker wanting me to come on down asap, ok let me just hang my jacket up at least and grab my stethoscope and off to the ICU I go.

In I walk and there my coworker is getting things ready for the Doc to intubate a patient. I can hear this patient outside of the doorway...wow major fluid issues, then I look, puffy like the stay puff marshmallow man and gray, yep this is gonna be fun. We finish getting the intubation stuff ready and the Doc slides the tube in, I place the CO2 tester on and give that first breath and it takes all my hand strength to get a breath in, wow is this patient tight...then I see it, pink frothy and bloody THICK secretion up the tube. Yep that could be a problem, time to suction. Finally I look up and see one of my coworkers, she looks about ready to cry...it's been one of those days I can see. The vent is set up and we place the patient on and that vent is just high pressuring, wow this person is tight from fluid time to try pressure control. I adjust the pressure and I times and I get volumes anywhere from 70 - 250ml's, not good we need a bit more but I have the pressure already up to 35 cmh2o time to continue bagging.

Back with the bagging the monitor starts alarming we look up and just watch the QRS's widen on this patient until it turns into V-Tach, not good. Check for a pulse, there is one and she converts back, phew dodged that code. A couple minutes later there it goes again, V-Tach, this time is stays, and we shock, back to a normal rhythm but a BP of 30 systolic. Again back to V-Tach and it stays, but there is still a good pulse so my coworker asks the patient to squeeze her hand, which she does, asks if she is in pain and the patient shakes his head no, can you move your feet, they move all over. We look up and still a full out v-tach on 2 different monitors and a good pulse with good responsiveness but the BP is still 30 systolic, now this is something I haven's seen before, a responsive patient in a condition like that. The doc now decides that there is now way this person can be responsive with a BP that low so it must be wrong. Now we need blood work and a ABG.

Here is where I feel like a stud. A doctor has already tried a A-Line and wasn't able to get any blood, another RT has tried to get a ABG already and nothing, so I say let me do it. I fell zero pulses in either the radial or brachial areas so it's time to use anatomy. I grab my kit, take aim and go for it...nothing...readjust...nothing...again and I strike blood!!!! WOOT!!! The syringe fills and I get the gas, it was said it couldn't be done.

Finally this patient stabilizes for the most part and we are able to ventilate but for most of the night it's back and forth....V-Tach and Sinus heart rhythm until finally in the morning things just give up and HR drops, BP drops and QRS's widen and the patient passes on.

Busy night, and from what I hear busy day I was told from the RT who looked like she was going to break down said and ultimately did break down and cried in a back room. I don't know exactly what all went on during the day but it was enough to get to her and she still felt like she should stay and help us until things got caught up with. I told her to get out of here, go home, have a drink and relax we will be just fine.

Yes our small hospital's can become very busy at times and it ways can be more stressful because of the small amount of staff we have to run with, but you adjust, adapt and make it work with what you have, all in all people do understand that you can get busy.

What is this post about, nothing educational just a post to talk about my night and how it can be. But ya know these are the nights that make this job fun, I enjoy the stressful situations like this.

Keep it up RT's and drive on.

Different Hospital, Different Rules.

As you might have noticed that this blog is just ideas that come into my head or interesting things that I come across at my place of work. The idea behind "Different Hospital, Different Rules" is about how hospitals differ on how the utilize their Respiratory Therapists. Now you might ask where do I get my knowledge about this, well it comes from the 6 different hospitals I have worked at in my almost 12 years as a RT and I welcome comments on other hospitals out there to on how they utilize their RT's.

This might be more geared to new RT's or students to give them a idea how you will work in the real work, but also can give insight to RT's who have worked in the same place the entire time they have been a RT. I personally think it is interesting as to how many hospitals really don't have a clue on what we learn in school and what our scope of practice could be. Without further chatter, here is how mine are different.

William Beaumont Army Medical Center, El Paso Tx - This was my first stop as a RT, here we had 2 ICU's and a step down unit along with 3 floor units. This hospital took civilian population along with military also. The RT's did the ABG's on the floor but not in the ICU or the ER, but we did run a ABG lab and ran the blood. Did all the nebulizer tx's but the mdi's were turned over to nursing on the floors. As for the Vent's we were mainly button pushers there were not protocols for us for anything. We did respond to all and every code in the hospital.

Kenner Army Health Clinic, Ft Lee VA - One of the rare opportunities for a RT to work in a clinic setting. Here myself and another RT ran a PFT lab 3 days a week along with giving nebulizer treatments if asked to in the hospital. There were not vents here and VERY RARELY were there codes. On the days we didn't do PFT's we were supposed go to the different areas and work as a CNA or Medic (all Army RT's have to go through combat medic course) but respond to any respiratory issue that might arise in the clinic. Most of the time we would just hang out, here I became proficient in the downloading of MP3's and how to look up information to help place bets on games. We were also able to take a 1 1/2 hour lunch so I would go and bowl 3 games almost everyday of the week, I got pretty good. All in all they really didn' t know how to utilize us. Not sure if we were supposed to be there really.

Provena Covenant Hospital, Urbana IL - Now here is my first place after the military, and this is quite possibly the best place I worked to use my RT skills. Here we used many protocols on vents, treatments, and oxygen. Vent protocol was great, the Doc would give us ABG parameter and we adjusted the vent to stay in them until he have us a wean to extubate order and it was all up to us. We decided when to draw ABG's, and what to do with the vent. On the floor we were able to change treatment orders as they fit into the protocol parameters, this was nice. In the ER though we pretty much were given what the Doc wanted done, but we had some say in how things were done, there we also good chances to intubate depending on what Doc was on. Now this was nice, we did all the ABG draws from sticks to Arterial Lines even in the NICU and as for the Arterial Line we put in all the Arterial Lines. If there was a order for a A-Line we were called, now talk about fun. We also did O2 rounds throughout the hospital, which is easy work along with maintaining the Glucose check machines, don't ask how we got those but we just maintained them didn't draw sugars for them. Overall this was a nice teaching hospital that utilized our skills nicely, but I still wish we could of intubated more often though.

Freeport Memorial Hospital, Freeport IL - Smaller community hospital here. One 10 bed ICU, a pediatric unit, 3 floors and a ER. During the day we also covered the Bronchoscopy lab and assisted along with PFT and EEG's. No protocols here, mainly a Neb Jockey and Button Pusher besides being able to turn over the patients who were on maintenance medications to the nurses if we were becoming to busy, we didn't have many RT's here. ABG's were all done by RT's and we ran them on our machines. In the ER there were times when we got the chance to intubate patients, but not to often. Really it is just a place where RT's go through the motions but are able to assess patients and make recommendations. We could have been better utilized here.

Rockford Memorial, Rockford IL - Bigger hospital, 2 ICU's, Large NICU, PICU, Peds Unit, Oncology Unit, 4 different Floor unit areas and a busy ER. When is came to vents we were button pushers, Doc wrote the orders and we changed it, unless it was a CABG patient and we had free range to wean to extubation. In the NICU we seemed to be just there to push buttons, very protective Doc's up there until they get to know you. Now here I did train and was on a Neonatal Transport team where we would fly or drive to get babies going bad from different hospitals, or transport babies to Chicago, this was fun to do. You did more on the team than in the hospital since it was just you and the nurse. Great experience. We were the only PICU in the area so all the very sick kids came to us. Now this hospital was in the rough side of town so the ER could get hopping with drug OD's, shootings, stabbings, drunks ect. It wasn't uncommon to have our ER or ICU's locked down for fear of either retaliation or someone trying to finish the job, could become interesting. Of course since we had a NICU there is a OB for birthing babies and as the NICU RT we in on every C-Section and rough vaginal birth so we had to be NRP certified. So I've seen some interesting births here good and bad. On the floors we are mainly a neb jockey with but also respond with the Rapid Response Team along with doing EKG's on the floors. One aspect we did nothing with was ABG's, lab took care of all this analyzing and the RN's did the drawing, I didn't like that to much. This was a good hospital to gain experience and to what people might call getting hardened to seeing different things.

The Monroe Clinic, Monroe WI - Current place of business, a small town community hospital where we only have 1 RT at night...Me. Why did I come from the excitement of the big city, well a couple of different reasons: 1. Better Schedule 2. Was getting burned out and to hardened 3. Money. Now here one thing I noticed right away that I like is the attitude difference from the bigger city hospitals, a lot more friendly both the staff and patients. Freadom over at the RT Cave talks about working in a small town hospital and puts it well and I totally agree with him. Here at mine we have a ICU, 1 Floor Unit, 1 Pre-Op unit on days, L & D, and a ER. Those are what we cover as RT's. In the ICU's we are mainly button pushers but have the luxury of most Doc's listening to our opinions. We do all the nebs, mdi's, I.S.'s, ABG's, EKG's and stock oxygen tanks throughout the hospital along with maintaining our ABG lab. Sounds like a lot but it really isn't much. Just recently we installed a medication and treatment protocol here that is great at containing all the unnecessary neb orders, we can now change the orders to what we deem appropriate and I'm sure we will be working on more protocols later. The day shift RT's also help in the Bronchoscopy Lab and do cardiac stress tests as they are scheduled. I do enjoy this hospital so far and yes it is comfortable and I can see us gaining more and more responsibilities as time goes on.

What does this posting say, I like to think that we are not fully understood by the places we work at and it's not very often that all our skills are fully utilized. If we were there could be a lot of useless calls to Doctors through the day and especially in the middle of the night. Hope everyone understand that each hospital out there seems to be unique for the RT's are used and that you should find one you feel you fit in with.

At any one place you could be a button pusher, neb jockey, ABG King, Transport RT, intubate patients, run EKG's, perform a stress test, insert a A-Line, restock Glucose machines, do PFT's or EEG's and the list goes one, we can wear many hat in this profession but either way it is a good and rewarding profession.

Drive on RT's....

RT's vs. RN's

I was out just searching around the old Internet when I ran across this discussion: Respiratory Therapist VS Nursing and it got me to thinking of the differences between the two. Now I know there are nurses who appreciate us RT's and on the flipside of the coin I know there are RN's who think of us as a highly paid nurses aide or trained monkey. So what are the differences between us? Who really works harder? So here I go with another list of the differences between RT's and RN's.

1. You can become a RN in either 2 or 4 years of college. Wow you there are 2 and 4 years school's for RT also, along with the 8 month route with a commitment to the Military.
2. RT's specialize, RN's don't but they can specialize.
3. RT's know a lot about the Respiratory system, RN's know a little about a lot of different systems.
4. RN's have a bunch of patients on a floor, RT's have a bunch of patients on a lot of floors. So we walk further.
5. RN's make more money, that's a given but we seem to be creeping up.
6. RN's do have more opportunities of different places to work like hospitals, clinics, doctor's offices, jail's, factories, home health, and of course as a school nurse. RT, well not so many. Mainly just hospitals and home health.
7. Everyone knows what a RN is, but not everyone knows what a RT is, we are small stealth unit like special forces.
8. RN's are stuck on a floor so a lot of times they don't really know many people in the rest of the hospital. RT's get all over the place, so we know people all over the hospital.
9. RN's get a big todo for nurses week. RT's have to do something to get RT week known.
10. RN's are the one's who call RT when the patient is going downhill fast.
11. RTs get to shove RNs out of the way to get to the head of the bed during a code. (Thanks Freadom of the RT Cave)
12. RT's don't have to talk to the family (Thanks Freadom of the RT Cave)
13. When a codes over RT can split, while the RN has to clean up. (Thanks Freadom of the RT Cave)
14. RTs have to pay more than twice as much for their license, at least in Michigan, (Thanks Freadom of the RT Cave) and in Illinois and Wisconsin which is cheaper than Illinois.
    

Ok this is mainly just for fun and that's just a short list off the top of my head. Overall nurses work hard and so do RT's, just in different ways and of course both are needed to make the hospital run smoothly. My wife is a ER nurse and I have utmost respect for her as a ER nurse because I know the crap they deal with and the disturbing things they see. All in all it takes a certain type of person to be either a RT or a RN, but RT's don't let those "high on their horse" RN's talk down to you like we are a hired hand and they are the ones in charge. Sorry a little rant there, could be from running into a certain type of RN, or not.

Anyways...

Drive on RT's and Happy Respiratory Therapy Week.

Respiratory Therapy in TV and Movies.

Have you ever caught yourself watching a movie or TV show, where there are hospital scenes, looking for respiratory related things in the show? Finding something done correctly is hard to do. What got me on to this idea? Well I was watching the movie with Billy Bob Thorton called "Astronaut Farmer" and there is a part where he ends up pretty injured and in the hospital supposedly on life support. Looking a little closer in the scene I notice that he is connected via endotracheal tube to a Vision Bipap and with a closer shot he is on a t-piece connected to that Bipap. Finally the scene pans out and I notice there is a Puritan Bennet 840 Ventilator on the other side of the bed with NOTHING connected to it, now granted the average person will not notice these things but Us as RT's should notice these things. So yes this is what has me thinking where have I scene RT issues in movies and TV shows and what better way to get this going but to start a list.

My List to Respiratory Therapy things in Movies and TV shows

1. Astronaut Farmer - Billy Bob Thorton connected to Vision Bipap with a T-Piece and a PB 840 Ventilator next to the other side of the bed.
2. ER - Many shows the yell "Page Respiratory", but you never see them. The Doc's bag the patient then they either die or move off to O.R.
3. Sopranos - Tony's nephew Chris is in the hospital and a Incentive Spirometer is on the bedside, and there is a Episode where Uncle Junior gets fitted for a CPAP machine for his sleep apnea, and a scene he falls asleep and his girlfriend puts in on him. I'm actually impressed here, to items you wouldn't think directors would think of for a show.
4. Sherlock Holmes Returns (TV) - on there is a film credit for Peter Kelamis as the Respiratory Therapist. This I came across in a google search, click on the link to see, never actually saw the show but now I'm curious.
5. Million Dollar Baby - Hillary Swank's character Maggy Fitzgerald is shown talking, while she is being ventilated via a tracheostomy tube in her throat. Although people can talk using "fenestrated" tracheostomy tubes, they can't be ventilated at the same time. But then again how many people actually know this.

Anyways I'm sure there are many others out there, I know I have seen a show/movie where the MA-1 ventilator in the corner breathing away and the patient is sitting there talking with a cannula on. I think there is a shock factor of the bellows moving and the sound of, shuuuu hahhh shuuuu hahhhh. I will continue to explore this RT related issue on the silver screen and would appreciate any noticeable scenes anyone else might have seen. Maybe somehow I could become a consultant for Respiratory Therapy on upcoming movies and TV shows, I would love to show the proper way to do mouth to mouth to Halle Berry or Jessica Alba and check some lung sounds, hell I'll even do a EKG on them. Could happen right?

Talk care and keep breathing.

Why Respiratory?

So what makes a person want to become a Respiratory Therapist (RT)?

This isn't a job that most people think of to go to college for in high school, I know it wasn't mine because my thought in high school was to be Architect which also didn't happen. The Military was my calling, from there I just kinda fell into the job of RT.

Most people I have talked with over the years became a RT due to an opportunity to that brought the job or course of education to become a RT in front of them out of luck. Some reasons I have heard have been:

• They are a asthmatic and have been around RT's.
• Physical Therapist didn't pan out and they heard about RT.
• Lost their Job and was given money to go back to school and it look like a good paying job.
• Was looking for a medical Job that only took 2 years and RT sounded fun.
• A parent was a RT and introduced them into the profession.
• Didn't know what to major in, the Counselor suggested to look into it.
• Ect Ect Ect....

Ok my story how I become a RT is that I was a combat medic on the Army and my 4 year Enlistment was coming to a end and I want something to make myself more marketable in the civilian world so I looked through the different medical military occupational specialties (MOS) I could go to in the military. The one that came up for me was Nuclear Medical Technician, sounded good so I signed up. About a month after I has submitted all my recommendations I received word that the last slot of the year was taken, needless to say by a soldier in my platoon. Well now either stay a medic (which is not all bad) or find something else. Started looking again and this 91V MOS came up and had a 3A bonus attached which amounted to about $12,000 bonus and of course money will spike your interest. Well guess what it happened to be Respiratory. Great a nice bonus, low promotion points to get promoted, now what does a RT do, something with breathing, I know what that respiratory system is, and here I am a RT.

I did a little more research before I went to the school, but when I signed up I didn't know much of that we did, I went for the money and it turned out pretty damn good. I got out of school, received my bonus and them my SGT stripes 3 months later and enjoyed my job, sweet deal.

Well that's my thoughts for today, I'm sure more RT's than any just kind of fell into this profession and didn't plan this out as a teenager. That's my theory and I'm sticking to it.

Little bit about me

Well first posting on this blog, just wanted to say a little about me as a Therapist.

I've been a RT for 10 years now, received my training at Ft. Sam Houston in San Antonio Texas through the U.S. Army Academy of Health Sciences. Here I earned the MOS 91V, or Respiratory Therapist. Nice way to go through school, 2 years crammed into 8 months. Basically 20 out of the starting 80 graduated, but attrition rate here. Anyway I did this for 4 years working as a RT in San Antonio Brooke Army Medical Center, El Paso Texas at William Beaumont Army Medical Center, then in Ft. Lee Virginia at Kenner Army Health Clinic. Before all this I was a Combat Medic for 6 years, and served in 2 conflicts during this time, Desert Storm and Somalia. So there you have it 10 Years of Army Medical training.

Well now I'm out of the Army since 1999, and have worked a some larger hospitals. Now currently working in a small hospital as a night shift therapist where we only have one therapist on during night shift. I like it that way.