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....

You Heard What?

A patient comes into the ER the other night with complaint of chest pain so I'm called down to do a EKG on the 35 year old with chest pain. I get into the room start to do the EKG and she becomes very shy about me putting on leads. Every lead I put on she quickly pulls up her gown and the lead falls off. "Sorry ma'am I have to get this back on could you please wait until we have the EKG done, I will go as fast as possible." So I finally finish and EKG is showing normal sinus rhythm and she going into this excruciating pain look and perfectly complaining "Owwww it's hurting right over my heart and very heavy right now with the pain going to my jaw and radiating down my arm." So I give the EKG to the Doc and she say this person has been here like 20 times in the last week, she is a nut case. Great so off I go.

35 Minutes later I'm called to come down and do a nebulizer treatment in the ER and when I get there the Doc tells me it's in the same room as the nut case. I ask "Is she short of breath, she didn't seem short when I was in there and didn't complain of that?" Now here is the response I received from the great and powerful doctor, "She is having a slight wheeze with a forceful exhalation, so maybe she has a little asthma component with exertion." Okay key phrase here if you didn't notice it, "With a FORCEFUL exhalation...".

Damn right she does with a FORCEFUL exhalation, so do I watch.....wheeeeezzzzeeeeee....See I can do it also and I have no breathing problems what so ever, and I'm sure you can do it to. The Doc actually told her to breath out as hard as she could, what the *&^%!!!

Well so I didn't actually say all that to the Doc. But I took a peak flow meter in the room with me to check the patient, we use the low flow ones in the ER (don't ask why) but it only goes up to 375. I give the PF to the patient and she all about blows the room off the room with that thing, plus her lungs are clear as a bell. Off I go and let the doctor know my observations and she is stunned and says "Wow maybe I just heard something at the right time, I guess her lungs are good, but lets give the neb anyways because I might soothe the patient a bit." Alright whatever again the nebulizer works as a pacifier.

After the nebulizer the doc then tells me that she is indeed a nut case and a attention seeker and it's thought that she does a bit of research so she can use the correct symptoms of the problem she is seeking help for. Ya have to love these types of patient and how they can just take up your time and run you schedule right into the ground.

Oh well all is life in your friendly community hospital. I work in a small town hospital now instead of the big city one I used to and when you compare the to there is a difference but in a small town one it seems there are a lot of bored people, namely elderly, who just want some attention so they go to the ER. Job security is the way to look at it.

Until next time, don't inhale chasing it with a exhale.

Reading Chest Xrays

I was thinking the other day that it would be nice to be able to read a chest xray better than I currently can so I set off to find some information on looking at different xrays and what I'm looking at. Now let me clarify that I'm talking about reading just chest xrays as this is most revelant to the job of a Respiratory Therapist, we don't really need to know if a patient has a tib/fib fracture of his left leg, that doesn't really help me out much. Well doing some searches here on the old internet I ran across a couple really good sites in my opinion on reading chest xrays so instead of writing a whole article and teaching a class on reading them because I'm not a pro at this here are a couple of sites I recommend.

• Wikipedia on Chest Xrays - Really good information article on chest xrays.
• Introduction to Chest Imaging - This many great image examples from the University of Virginia Med Program.
• Chest Xray Atlas - This has older images but also good explanation on what your looking at with many different items with xrays.

Now for the ABC's of the technique to read a chest xray:

A - Airway: are the trachea and mainstem bronchi patent; is the trachea midline?
B - Bones: are the clavicles, ribs, and sternum present and are there fractures?
C - Cardiac silhouette: is the diameter of the heart > ½ thoracic diameter enlarged)?
D - Diaphragm: are the costophrenic and costocardiac margins sharp? Is one hemidiaphragm enlarged over another? Is free air present beneath the diaphragm?
E - Effusion/empty space: is either present?
F - Fields (lungs): are there infiltrates, increased interstitial markings, masses, air
bronchograms, increased vascularity, or silhouette signs?
G - Gastric bubble: is it present and on the correct (left) side?
H - Hilar region: is there increased hilar lymphadenopathy?
I - Inspiration: did the patient inspire well enough for 10 ribs to be counted, or was the patient rotated?

Well I hope this bit of information has helped someone look at a xray and see it better, I know doing this has helped me and will help me in the future with my patients.

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.

Free Rice!!

Here is a link I ran across on another board I go to: Free Rice .

It is a site by the world poverty organization where you play a little vocabulary game and for every word you get correct they will donate 10 grains of rice to the United Nations for starving countries.

Kinda fun, I just donated 240 grains whoo hoo. And don't worry there are not signups or personal information to give them, Just Play.

Desaturating while giving a Neb Tx. What to do?

There are times when a patient is on a large amount of O2 and a nebulizer tx has to be given, but we know that a standard neb given with only 6-8 lpm is not enough flow or fio2 to keep O2 saturation >= 90% (our current protocol), so what do you do?

Drawing on my personal experience and reading about other RT's idea's and experience here are some ways to help keep the patients saturation at appropriate levels or at least close appropriate.

1. Place a nasal cannula under the aerosol mask or run with a standard HHN.
2. Place 6 inch large bore tubing in the holes in the aerosol mask, looks like elephant tusks.
3. Tee in the nebulizer into a non-rebreather mask. This gives the highest fio2 in my opinion.
4. With a regular HHN instead of using a 6 inch reservoir tube on the end, increase the length of the reservoir tube to 3 lengths of 6 inch tubing or whatever you think will work, this will decrease the amount of room air that patient with entrain.
5. You could always just put the HHN under the Non Rebreather mask but this can also cause comfort issues for the patient in my opinion.
6. If they just need a little extra fio2 you can always use a HHN with nose clips, this way it decreases the amount of inspired Room Air through the nose.
7. Place the HHN in the side port of the aerosol mask and run oxygen from the normal port of the aerosol mask.

Alright there are a few different ways to increase fio2 while running a neb and I'm sure there are many other rigged ways I would like to hear about, but you must also think, is the flow of the extra oxygen going to hinder the deliverance of the medication of the neb or not? I guess if this situation comes up see what works and go for it.

If anyone has any other ideas of ways to complete this task feel free to post a comment or criticism on the ideas I have posted here. Thanks for reading and responding.

VAPaWAY

Don't ask me how but I ran across this european website about Ventilation Acquired Pneumonia (VAP) called VAPaWAY.

Here is their mission objective:

The VAPAWAY website is dedicated to bringing together European physicians, nurses and other related professionals to discuss and agree on how to develop and disseminate a European consensus on VAP prevention.

Definitly respiratory related. Currently there are 7 different articles in about VAP which all look interesting. No I haven't read them all, scanned a couple, but they look promising. Also I noticed a nice set of links on the site that all real with medical information that I have never seen before.

All in all it deals with a type of pneumonia which we all know us RT's love to deal with. I could be a promising site, it looks professional and could become something worth checking out periodically in the future.

www.vapaway.eu

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.

Don't smoke with Oxygen: NO REALLY.

We always warn patients not to smoke with their oxygen running at the same time. Why? Because it's damn flammable!!! Well there is a lady in Michigan who not only didn't heed the warning not to smoke with oxygen running once but she did it twice, I guess old age does make you forget things.

Anyways here is a article about a 90 year old Ann Arbor Michigan lady who set her couch and herself on fire while smoking when using her oxygen delivery system.

Article about burning lady on oxygen.

We all know the people who have the old burn marks on their face like whiskers on a cat, but we can talk until we are blue in our faces about to smokers about the how flammable oxygen is, but there are still going to the stupid ones who don't believe us, Oh well we can only educate but cannot make them smart.

Check this image out of a burnt oxygen regulator for you entertainment...yes they do burn...HOTTTTT!

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.

Protocol's

Well I noticed reading at RT Cave that he is in a smaller hospital were they are not just implementing RT Protocols, well here at my small hospital we are now just starting to implement RT protocols also that started on October 1st.

Our's are just for the delivering of medication, Incentive Spirometers and Oxygen, it goes something like this:

1. Respiratory Order
2. We grab out assessment sheet and assess the patient in the different catagories which are:

• Respiratory History
• Surgical/Trauma Status
• Adult and Peds Respiratory Pattern
• Chest Xray/Abg/Spo2/Fio2 (All one catagorie, doesn't make sense to me)
• Cough
• Breath Sounds
• Activity (ambulatory, non ambulatory ect)
• Level of Conconsious

3. Assign points of severity of those catagories and get a total
4. Use total and assesment to adjust therapy as needed.
5. Reassess Q48 or more and adjust therapy as needed.

O2 Protocol is just set up to keep Spo2 >90%, this is nice because of so many Doc's ordering so many different levels, 93%, 90%, 95% ect, how the hell do you keep that straight.

Now the I.S. Protocol is nice, Surgeons would routinely order EZPAP tx's Q4 x48 hours then QID until discharge, crazy I know this would range for any surgeries from Abdominal to foot surgeries. Now we have to ability to just do I.S. or change to EZPAP as needed. If the I.S. is less than 50% of predicted then go to EZPAP until I.S. is over the 50% mark. So far it works pretty good but were still learning its only 2 weeks in.

Anyways I'm all for Therapist driven protocols, let us do what we were trained to do! If this goes off well maybe in a year or so we would work towards Vent Protocols. I did work at a hospital with a great vent protocol, we were in charge of it and the Doc would just write ABG parameters, easy right.

Until next thought, keep em breathing.

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.