RDP: Bronchiolitis

Respiratory Driven Protocols are something that should be really pushed. I honestly don't see ventilator settings being a RDP type thing, since Respiratory Practitioners are quite capable of completely managing a patient on a ventilator. Doctors being able to modify the settings, sure, but only by order. It should be a very unified standard of care that an RP is completely responsible for the safety and outcomes related to ventilator care. However, there are some things, like Asthma or Bronchiolitis that I will not argue should be under a protocol guidance.

Bronchiolitis

"Respiratory eval & treat"

Evaluate for a complex Respiratory Distress Score tailored to Bronchiolitis.

Automatic: Respiratory eval for Bronchiolitis RDS Q4H

Automatic: Suction at bedside PRN

Automatic: 3% NaCl Q4H with suctioning 20 minutes after NaCl delivery

Automatic: Corticosteroid of preference Q6H

During assessments:

If wheeze of any kind: Nebulized epinephrine (racemic is okay) Q4H PRN

This bronchiolitis protocol requires a ton of clinical judgment on the behalf of the respiratory practitioner. That is fine, respiratory practitioners are fully capable of managing this kind of thing. To help maintain competence: in-services about bronchiolitis are definitely recommended too.

What do you think? Do you have a Bronchiolitis RDP?

15 Famous people with HIV

Magic Johnson

Most people over the age of 30 won't soon forget the emotional public disclosure on Nov. 7, 1991 from one of basketball's all-time greats. Magic's HIV diagnosis essentially ended a phenomenal NBA career, though he did make a few brief comebacks.

His disclosure spurred a re-evaluation of safety in sports and was a watershed moment in HIV awareness. He has thrived since, leading some to believe he was somehow cured. To combat this type of misinformation, Magic has dedicated himself to HIV education and helping those living with HIV through theMagic Johnson Foundation and several other efforts.

Rock Hudson

One of the most beloved movie stars of the '50s and '60s, Rock Hudson's AIDS-related death in late 1985 was a shock to the world. In a move that is truly emblematic of the unparalleled stigma of HIV, his publicity team had covered up his illness by saying he had liver cancer.

Hudson's HIV disclosure just prior to his death brought forth the fact that this matinee idol, a leading man in numerous romantic comedies, was gay. For better or for worse, his death sparked a landslide of conversation in mainstream media about homosexuality and HIV.

Freddie Mercury

As the lead singer of Queen, one of the top-selling rock bands of all time, Freddie Mercury was among the most recognizable faces of the '70s. He tested positive in 1987 and died of AIDS-related pneumonia four years later, one day after publicly acknowledging for the first time that he had AIDS.

Had Mercury lived in a different era, perhaps people would be thinking about eradicating HIV every time they heard "We Will Rock You" or "We Are the Champions" booming over the stadium loudspeaker. Instead, it simply became a footnote on his life.

Keith Haring

Keith Haring was an iconic artist who rose to prominence during the '80s. He was best known for his street murals and cartoonish figures. He was diagnosed with AIDS in 1988 and died just two years later.

Unlike many public figures, Haring did not shy away from his AIDS diagnosis. During those last few years of his life, he dedicated himself to raising HIV awareness through his artwork and afoundation he established that still benefits HIV causes to this day.

Eric "Eazy-E" Wright

Eazy-E was a rap legend and co-founder of the influential group N.W.A., along with Dr. Dre and Ice Cube. Their album, Straight Outta Compton, went double platinum in 1988 and cemented Eazy-E's legacy in gangsta rap history.

His lyrics jolted many, but nothing shocked people more than when he fell ill in 1995 and publicly acknowledged that he had AIDS. He died just one month after his diagnosis at the age of 31. His death was another key moment in public awareness of HIV/AIDS, particularly within the African-American

Elizabeth Glaser

Though she was not a celebrity in the traditional sense, Elizabeth Glaser gained fame and notoriety through her tremendous efforts to fight this disease. She contracted HIV in 1981 but did not find out until 1985. As a result, she unwittingly passed on the virus to both of her children. Her daughter Ariel lost her life in 1988, but her son, Jake, is alive and well today.

Following Ariel's death, Glazer co-founded what is now known as the Elizabeth Glaser Pediatric AIDS Foundation, one of the leading AIDS charities in the world. The Foundation is dedicated to preventing and eliminating HIV/AIDS in children. Elizabeth died in 1994, but her legacy lives on through her foundation. community.

Isaac Asimov

Isaac Asimov was one of the most prolific authors of all time, best known for his science fiction novels and short stories. He died of AIDS-related complications in 1992, but his HIV status was only revealed by his widow 10 years after his death.

Because of the tremendous stigma associated with HIV, particularly prevalent in the early '80s, Asimov's family had been advised to keep his true cause of death a secret.

Arthur Ashe

As the first African-American man to win a Grand Slam title, Arthur Ashe broke down the color barrier in tennis. An accomplished champion and Hall of Famer, he is perhaps best known for his humanitarian and civil right efforts.

He was diagnosed with HIV in 1988, but didn't go public until 1992. He died a year later from AIDS-related pneumonia. During his final year of life, he was instrumental in raising HIV awareness through various efforts, including a speech at the U.N. on World AIDS Day and the creation of an AIDS foundation.

Liberace

Liberace was a pianist and entertainer who became a worldwide icon in the '50s. He appeared in films and television shows, and released numerous albums. He was the highest paid entertainer in the world for over a decade and was known for his opulent lifestyle.

He died of AIDS-related complications in 1987, but the cause of his illness during his final years was kept secret from the public until after his death.

Anthony Perkins

Anthony Perkins was a film and stage actor who will always be remembered for his unforgettable turn as Norman Bates in Alfred Hitchcock's Psycho. He had a productive career that spanned nearly 40 years.

Oddly, Perkins only discovered he was HIV positive in 1990 after a National Enquirer article exposed that he had AIDS, leading him to get tested. He had suspected that he might be HIV positive, but chose to ignore it for fear of what it might do to his career. He died two years later from AIDS-related complications.

Robert Reed

Robert Reed portrayed perhaps the most beloved father in the history of U.S. television. As Mike Brady on The Brady Bunch, he was the head of a highly traditional household. It was hard for some to believe that the man who played this almost puritanical character was in fact a gay man who tested HIV positive before his death in 1992. Like a number of others on this list, the word about his HIV status only spread after he died.

Greg Louganis

Greg Louganis is an Olympic diver who won multiple gold medals in the '80s. He was one of the most recognizable faces in American sports during that decade. He tested positive in 1988, the same year he won two gold medals at the Seoul Olympics.

Louganis went public with his HIV status seven years later in his autobiography, Breaking the Surface. Having now lived with HIV for more than 20 years, he has been a champion for numerous HIV causes.

Alvin Ailey

Alvin Ailey was a renowned choreographer and a major force in modern dance beginning in the 1950s. He formed the Alvin Ailey American Dance Theater in 1958, a groundbreaking dance company still popular today. Though based in New York City, the group has performed all over the world.

Ailey died of AIDS-related causes in 1989 at the age of 58. Like a number of others on this list, Ailey had his doctor hide his true cause of death to protect his family from the stigma of the disease.

Gia Carangi

Gia was a world-famous fashion model in the '70s and '80s. She was among the most sought-after models of her time and graced the cover of such magazines as Vogue andCosmopolitan. Her career was cut short in the early '80s after she developed a debilitating heroin addiction.

She was later diagnosed with AIDS and died of a related illness in 1986 at the age of 26. Her death was largely kept quiet; few in the fashion industry even knew of her passing, and her funeral service (which was held in a small funeral home) was modest.

Her story was eventually told in Gia, the aptly titled HBO biographical film starring Angelina Jolie.

Pedro Zamora

Pedro Zamora gained fame as a cast member on the third season of MTV's The Real World in 1994. Having worked as an AIDS educator following his diagnosis in 1989, he viewed The Real World as a unique opportunity to educate on a mass scale. His appearance on the show had a major impact in raising social consciousness about AIDS, particularly among young people.

Zamora grew ill as the season as wore on and was hospitalized with progressive multifocal leukoencephalopathy (PML) just a few months after shooting wrapped. He died at the age of 22 in November 1994, one day after the final episode aired. His impact has lived on through numerous charities formed in his name.

This list only covers 15 of the most notable HIV-positive celebrities. There are many more famous people with HIV -- some are out, but many are not, while there are others who might have HIV (or even died from HIV), but have never been tested.

Pulmozyme (rhDNase) in neonates.

Pulmozyme is being used off-label increasingly across institution neonatal intensive care units.

It purges free-floating (extracellular) DNA by ripping it apart and cleaning it out.  Which in refractory atelectasis appears to be one of the contributions to its refractory-ness.

Some limited research[1] suggests it might be beneficial.  Respiratory Therapists may be using this more and more frequently in non-cystic-fibrosis neonates.

Previous research produced positive outcomes.[2]

1. Mackinnon R, Wheeler KI, Sokol J. Endotracheal DNase for atelectasis in ventilated neonates. J Perinatol. 2011;31(12):799-801.
2. Hendriks T, De hoog M, Lequin MH, Devos AS, Merkus PJ. DNase and atelectasis in non-cystic fibrosis pediatric patients. Crit Care. 2005;9(4):R351-6.

Spanish Phrases for Respiratory Therapists

Spanish Phrases for Respiratory Therapists

Quick and dirty spanish thats easy to remember

Are you in pain?

Tiene algún dolor (or just "Tiene dolor?")
Pronounced: Tee-in-ae Al-goon Doh-lor

Take a deep breath

Respira profundo

Pronounced: Res-pida pro-foondo

Take a deep breath and cough

Respira profundo y la tos

Pronounced: Res-pida pro-foondo ee la tos-ae

This medicine helps make breathing easier.

Esta medicina ayuda a respirar menos trabajo.

Pronounced: Es-tah med-icin-a ae-you-dah a res-pidar (or just say res-pida) men-ohs tra-bah-ho

Do you need anything?

Necesitas algo?

Pronounced: Ness-a-seetas al-go

If yes, and you can't understand what they want, it might be something complex, so call for a translator.

Do you have any questions? If yes, call for a translator.

Tiene preguntas?

Pronounced: Tee-in-ae pre-goon-tas

For help press this red button for help. (while pointing at the nurse call button)

Por ayuda pulsar el botón rojo.

Poor ae-you-dah pul-sar boo-tun roe-hoe

My name is _____________

Mi nombre es ____________, or mi llamo es ____________

I am a respiratory therapist

Yo soy terapeutas respiratorio.

Yo soy tera-peu-tas respir-a-torio

National Board for Respiratory Care Continuing Competency Program (is a scam)

INTRODUCTION

Individuals credentialed by the NBRC have demonstrated a level of excellence in professional achievement indicating their knowledge in respiratory therapy and pulmonary function technology. Enhancing and maintaining that level of knowledge is a key component to one’s professional development and career advancement.

The NBRC’s Continuing Competency Program has been designed to enhance and/or contribute to the continuing competence of credentialed respiratory therapists and pulmonary function technologists and demonstrate concern for patient safety. Individuals participating in the Continuing Competency Program are required to provide evidence they are continuing to meet current standards of practice and have successfully renewed their national credentials issued by the NBRC. Individuals may confirm they meet active status requirements and renew their annual dues through our website, www.nbrc.org. Through implementation of the Continuing Competency Program, the NBRC further demonstrates its compliance with the accreditation standards of the National Commission for Certifying Agencies (NCCA).

Credentials awarded by the NBRC on or after July 1, 2002 are valid for a period of five years and are subject to the Continuing Competency Program requirements. The recertification period of five years was adopted to coincide with the NBRC’s examination development policy to conduct job analyses approximately every five years to update examination content.

The five-year period is calculated from the end of the calendar month in which the credential is issued; an exact expiration date is printed on an individual’s credentialing certificate.

Participation in the Continuing Competency Program for individuals who were credentialed PRIOR to July 1, 2002 is voluntary and will have no effect on their credentials.

THREE RENEWAL OPTIONS

It is important to note that the requirement for participation in the Continuing Competency Program does not automatically mean “retesting.” Retesting is one of three options for satisfying the Continuing Competency Program requirements.

Option 1 – Provide proof of completion of a minimum of 30 hours of Category I Continuing Education (CE) acceptable to the NBRC.

Category I Continuing Education is defined as participation in an educational activity directly related to respiratory therapy or pulmonary function technology, which includes any one of

the following:

• a. Lecture – a discourse given for instruction before an audience or through teleconference.
• b. Panel – a presentation of a number of views by several professionals on a given subject with none of the views considered a final solution.
• c. Workshop – a series of meetings for intensive, hands on study or discussion in a specific area of interest.
• d. Seminar – a directed advanced study or discussion in a specific field of interest.
• e. Symposium – a conference of more than a single session organized for discussing a specific subject from various viewpoints and by various presenters.
• f. Distance Education – includes such enduring materials as text, Internet or CD, provided the proponent has included an independently scored test as part of the learning package.

The NBRC intends for the completion of continuing education credit to coordinate with the requirements of state licensure agencies.

Individuals can use the same continuing education hours to satisfy state requirements as well as NBRC Continuing Competency Program requirements. Individuals may also use AARCCRCE credit to fulfill the NBRC Continuing Competency Program requirements.

Option 2 – Retake and pass the respective examination for the highest credential held that is subject to the CCP. Individuals may retake the examination anytime during the fiveyear period. The new five-year credential period will begin on the date of successfully passing the examination. Individuals holding multiple NBRC credentials, who elect to renew their credentials through the examination option, must do so by successfully completing the examination for the highest-level credential held that is subject to the CCP.

Option 3 – Pass an NBRC credentialing examination not previously completed. Passing an NBRC credentialing examination not previously completed automatically extends the renewal period of all of the other credentials held by the certificant for an additional five years, calculated from the date of the successful examination. Therefore, all credentials held by an

individual will expire on the same date, allowing future recertification for all credentials held to occur simultaneously.

The Continuing Competency Program is not retroactive; therefore, this program does not affect credentials achieved before July 1, 2002. For example, individuals who hold NBRC credentials completed before July 1, 2002, and then who pass an NBRC credentialing examination not previously completed after the effective date of the Continuing Competency Program, are required to participate in the Continuing Competency Program only for the credential achieved on or after July 1, 2002. However, individuals may elect to voluntarily participate for all other credentials held.

CONTINUING EDUCATION DOCUMENTATION

Practitioners completing the Continuing Competency Program requirement by Continuing Education (CE) are required to submit the Continuing Competency Program information online prior to their credential expiration date. Individuals may complete the application process and pay fees online at www.nbrc.org. Failure to comply by the deadline may result in the expiration of an individual’s credential.

Contact hours may be obtained from accredited providers on continuing education in respiratory care approved by the American Association for Respiratory Care (AARC). All AARC-approved providers and those accepted by state agencies regulating the respiratory care profession will be accepted by the NBRC.

Individuals who meet the requirements will receive confirmation of their recertification through receipt of a new certificate and wallet card issued on the last day of the month after the month recertification is due. Certificants whose information is incomplete will receive instructions for correcting the deficiencies and completing the recertification process. Specific CE subject matter requirements for each credential held, or for multiple credentials held, are listed in the following table.

Credential(s) Held That Have Composition of An Expiration Date - CEUs Required

CRT only

30 hours general

respiratory care subjects

RRT (including CRT)

30 hours general

respiratory care subjects

CPFT only

30 hours pulmonary function or

pulmonary diagnostic technology subjects

RPFT (including CPFT)

30 hours pulmonary function

or pulmonary diagnostic technology subjects

CRT-NPS or RRT-NPS

15 hours general

respiratory care subjects and

15 hours neonatal/pediatric subjects

CRT-SDS or RRT-SDS

15 hours general

respiratory care subjects and

15 hours sleep disorders testing

and therapeutic intervention subjects

CRT or RRT and CPFT or RPFT

15 hours general

respiratory care subjects and

15 hours pulmonary function or

pulmonary diagnostic technology subjects

CRT-NPS or RRT-NPS and CPFT or RPFT

10 hours general respiratory care subjects,

10 hours neonatal/pediatric subjects,

and 10 hours pulmonary function or

pulmonary diagnostic technology subjects

CRT-SDS or RRT-SDS and CPFT or RPFT

10 hours general respiratory care subjects,

10 hours sleep disorders testing and therapeutic

intervention subjects, and 10 hours pulmonary

function or pulmonary diagnostic technology subjects

CRT-NPS or RRT-NPS and CRT-SDS or RRT-SDS

10 hours general respiratory care subjects,

10 hours neonatal/pediatric subjects,

and 10 hours sleep disorders testing and

therapeutic intervention subjects

CRT-NPS or RRT-NPS and CRT-SDS or RRT-SDS and CPFT or RPFT

15 hours general respiratory care subjects,

5 hours neonatal/pediatric subjects, 5 hours of

sleep disorders testing and therapeutic intervention

subjects, and 5 hours pulmonary function or

pulmonary diagnostic technology subjects

PROGRAM FEES

Individuals who renew their credential(s) by taking the examination for the highest level credential held or taking another NBRC credentialing examination not previously completed (Options 2 and 3) will NOT be required to submit Continuing Competency Program compliance information and need only pay the examination fee. The examination application and fee serve as the required documentation for credential renewal.

Only individuals who renew their credential(s) through the CE route (Option 1) will be required to submit complete Continuing Competency Program information online, the required ocumentation as needed and fee. However, no fee will be required if the individual has maintained active status with the NBRC in each of the four consecutive years following their initial credentialing and one-year “exempt” period. The Continuing Competency Program fees for the CE route are listed in the following table.

(Active) $0 - Active Individuals who renew their active status in each year of the five-year credential term

(Inactive) $25 per year inactive - Inactive Individuals who do NOT renew their active status.

(Lapsed) $150+Examination fee - Lapsed Individuals who fail to apply for the program or who fail the examination and do not complete one of the other options for renewal

NOTIFICATION PROCEDURES

The NBRC will provide general information about the Continuing Competency Program to credentialed practitioners each year through the annual renewal process.• One year before the expiration date of the individual’s credential, a reminder notice will be sent directly to the individual at the last known address, including information on documenting requirements for the CE option of the Continuing Competency Program.

• Six months before the expiration date, a follow-up notice will be sent.

• A final reminder notice will be sent 90 days before the expiration date.

The NBRC will consider individual requests for extensions of the recertification period due to personal emergencies and other extenuating circumstances on a case-by-case basis. If a person attempts an examination but receives a failing score, the individual may attempt the examination as many times as desired, provided the individual’s credentials have not expired. Examinations must be scheduled and completed by the deadline to comply with the program. The individual may also elect to satisfy the Continuing Competency Program requirements by completing any of the other options (CE, another examination not previously taken) as long as this is accomplished

before the credential expires.

Individuals who fail the examination and do not complete one of the other renewal options will have two years following the expiration of their credential to reapply for testing. Individuals successfully completing the examination will have their credential reinstated without being required to meet the then-current admission requirements.

VERIFICATION OF COMPLIANCE

The NBRC will audit a random sample of Continuing Competency Program compliance documentation and will confirm the validity of all submitted information with the appropriate parties. Cases in which it appears false information may have been provided will be referred to the NBRC’s Judicial and Ethics Committee for investigation and possible disciplinary action according to the committee’s Operating Policies and Procedures.

What to do if your credential expires:

• If you are within 6 months of credential expiration, you have the option of entering your CEUs online and paying a $250

reinstatement fee. Please note: this is a completely online process and CEUs must have been earned during the 5-year credential term.

• If the grace period option is not utilized, you have two years following expiration to apply for testing and to reinstate your credential. You will be required to pay the new application fee and a $150 expired credential fee. If you successfully complete the examination, your credential will be reinstated without having to meet the then-current admission requirements.

However, if two years lapse and you have not successfully passed the examination, you are required to apply as a new applicant and meet all admission policies in effect at that time. Please note: if you have more than one expired credential, you must apply for and pass all examinations to reinstate all expired credentials

WHY DO I NEED TO COMPLY?

In order to maintain each credential you have earned subject to the CCP, you must follow one of the three methods for compliance. Once credentials expire, they can no longer be used because they are federally registered trademarks that are reserved for the use by those individuals who successfully complete the examination(s) and participate in the mandatory Continuing Competency Program. This means that any use of this credential designation, whether using it to sign a patient chart or medical document, applying for a state license as an individual holding the credential, or seeking employment as a therapist with the credential, violates the NBRC’s Judicial and Ethics Policies and can result in disciplinary action by the Board.

The status of your credential may also affect your state-issued license to practice respiratory care. Many states require that you hold an active credential in order to maintain your license. By allowing your credential(s) to expire, you may be putting your license to practice and your livelihood at risk. If you believe your credential is at risk for expiration, you are encouraged to check with your state licensure agency to confirm the requirements of maintaining your license. A directory of all state licensure agencies can be found on our website.

American Association for Respiratory Care

The websites for the AARC and NBRC and CoARC are all terrible, *terrible*; but the websites for the individual state societies are *way* worse.

Alabama - http://www.alsrc.org/
Alaska - no-website
Arizona
Arkansas
California
Colorado - http://colosrc.org/
Connecticut
Delaware
District of Columbia
Florida - http://www.fsrc.org/
Georgia - http://www.gasrc.org/
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas - http://www.krcs.org/
Kentucky
Louisiana
Maine
Maryland
Massachusetts - http://www.msrcol.org/
Michigan - http://www.michiganrc.org/
Minnesota - http://www.msrcnet.com/
Mississippi
Missouri
Montana
Nebraska - http://www.nsrc-online.org/joomla/
Nevada
New Hampshire
New Jersey
New Mexico
New York - http://www.nyssrc.org (and another? http://www.nyssrc.com/ )
North Carolina - http://www.ncsrc.org/
North Dakota
Ohio - http://www.osrc.org/
Oklahoma
Oregon - http://osrcnw.org/
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah - http://www.utahsrc.org/
Vermont
Virginia
Virgin Islands
Washington - http://www.rcsw.org/
West Virginia
Wisconsin
Wyoming - http://www.wysrc.org/

------

Canada on the other hand, has some really nice websites.

Manitoba - http://www.marrt.org/

British Columbia - http://www.bcsrt.ca/

Some days off

I have a few days off. I hope to blog something big sometime this week :-)

My worth to my hospital.

Nursing just got a 15% market increase on their hourly wage. Respiratory therapists are not included in the raise. We are already $6 less an hour than the supposed average touted by jobs.gov and they give a raise to RN's but not to RRT's?

Yet again we're treated like the bedside clinicians we are...........

I am considering Speech Pathology or Nursing.

a comic for you

I added text to this for fun, I will make better ones later, but for now, enjoy!

off for a few days

I have been captain cystic fibrosis for the last two weeks and its been fun but I think I move into the PICU this next schedule. Its both awesome and awful that at this hospital they move "regular" therapists all over the place. Once I have had a year of RRT experience I can join a specialized team and stay in one place all the time but I am not sure I like that idea.

I have been trying to use my off-days to meditate a lot and listen to music. I need a hobby because during my off days I feel like I need to be productive or else they're wasted.

I am open to suggestions for hobbies. I have a really short attention span (ADHD) and so I rarely love video games, but I have been trying some out. Mario Brothers for the Wii is pretty awesome actually.

Maybe I should learn to cook exotic foods.

On-call?

I did my first on-call shift yesterday and I got called in. Usually the on-call therapist is what is considered a "resource therapist" but they gave me a full assignment, 3 cystic fibrosis patients. I was beyond exhausted when I finished my shift. That does mean though that my next scheduled day which is Friday, I will get 8 hours of overtime, yay, sortof :-)

I am now alone.

I was already alone, but now I have successfully passed the rigorous orientation process and now I am considered a stand-alone therapist.  I begin night-shift (I requested night-shift, there is actually a waiting list for night shift at this place) in November, I pre-signed up to work Christmas and Christmas-eve in exchange for having Thanksgiving day and New Years Eve off.  I am excited to have a schedule a month in advance, it is actually pretty nice for planning things.

I ran across this photo GuitarGirlRN posted that I thought was fun.

Today

I was given 7 ventilator patients.  I had hyperinflation therapy on all 7, and then I had 2 non-invasive patients requiring Intermittent Pressure Ventilation therapies.  All of these kids were Q4H.  I ran my ass off today and I could not tell you anything other than their last name and chief diagnosis.  Today I do not feel like a therapist.  Today I feel like a monkey trained to push buttons, write down numbers and retape ET tubes.

Goodnight.

Baptized in blood

For those non-RRT's that are reading this, I implore you to attempt to see passed your profession and try to consider what it would be like if you were the only person in the room with your credentials and expected to operate entirely solo.  The only real resource for an RRT is either a pulmonologist, a critical care physician, or a physician very well versed in pulmonology.  I didn't really understand this until working at the place I work.  I am sortof at a disadvantage when I say this though, because I am sure a room full of seasoned nurses and doctors are an amazing resource to the RRT, and a seasoned RRT is just as valuable to them (though the pay-scale would not suggest this).  However in my limited exposure so far, when it comes to pulmonary disease, distress, arrest, intervention and just general maintenance I am rowing the boat alone.  I am asked my opinion on chest x-rays and we have a respiratory driven protocol that pretty much says "whatever the RRT wants, or the CRT wants with the RRT's co-signature" in regard to hygiene and ventilator management.

I had a pretty baptismal day last week.  I had a baby crash 20 minutes after returning from surgery, we had a very familiar episode again where they called ECMO stat, I was the only RRT in the room, managing everything, as the baby begins the most wicked pulmonary hemorrhage on the planet I have to deal with a lot of blood, when the surgeon said "The heart is empty, hurry with the bolus" I wanted to say "If you're looking for it, its all over my hands and arms and all inside the bag-valve".

Immediately following the code (which ended up as a successful ECMO installation with good volumes and saturations (Arterial, %sat, and cerebral ox) and when I left the attending said he predicted the outcome to be a good one) - following the code I was called stat to another one of my patients rooms, where as I am walking in the attending says "we might intubate" and I get the stuff together and then says "lets intubate, right now" so I intubated.  Taped that badboy down, stayed to evaluate all my numbers and make sure he was good.  Then I am called to be "standby" while they did a planned exploration of one of my patients chests at the bedside.

All of these were my assigned patients.  I need to not whine about being "more clinician" because I did not leave the bedside very often all day with these super high acuity patients.

I did all of this 100% alone, I was the sole practitioner, with no one to double-check my decisions.  Even the physician just said "whatever you want to do" insinuating that I am there to worry about the lungs so he doesn't have to.

Respiratory Care week is coming up, are your departments doing anything special for it?

BECOME Series: Physician

How to become a Physician

Step 1: Bachelor of Science in ________

Attend a College/University and graduate with a Bachelor of Science in a field related to medicine in some way: Chemistry, Physics, Biology, and some have a pre-med specific program.

Step 2: Medical College Admission Test

The Medical College Admission Test (MCAT) is a computer-based standardized examination for prospective medical students in the United States and Canada. It is designed to assess problem solving, critical thinking, written analysis, and writing skills in addition to knowledge of scientific concepts and principles.

Step 3: College of Osteopathic Medicine or College of Medicine

Apply and get accepted to a College of Medicine or College of Osteopathic Medicine.

Once you graduate from this school you will receive a Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree.

You are technically a doctor, but you cannot yet practice yet.

Step 4: Internship placement from your college

Step 5: Residency placement 

Placement is based on how good you did in college and your internship

Step 6: Fellowships are optional.

You are now a physician!

Resources to help you on your adventure

• American Association of Colleges of Osteopathic Medicine

This professional pathway is incomplete but the included information is accurate as of May 30, 2012

Last night in the PICU

Respiratory therapists where I am are behind the bed for all major procedures; procedures like bed-side-surgery, or anything requiring conscious sedation.  That is where I was at the beginning of this story, just hanging out behind a bed, every so often saying aloud something about peak pressures on the vent and cerebral oximetry  readings if they began dropping.  After almost two hours of this, its over and everything went amazingly clean and smoothe, the surgeons were joking the whole time and everything was great.

Then I walk out with the surgical team just in time to hear "RT ROOM 99 STAT" on my phone.  So I jog over, room 99 is three rooms from where I was and the surgeon is right behind me.

The attending is shouting orders and this baby is very clearly unconscious, not breathing and more cyanotic than I have ever seen in my life, and I have seen many many deaths (by cardiac arrest secondary to respiratory arrest) in this line of work.  There are two fellows changing out on compressions, another RT that got there before me is bagging and I am setting up all the stuff to intubate.

I have never been so amazed at what I saw next, because I was now at the head of the bed setting everything up for intubation I got a stage-to-audiance point of view and at this point there are over 20 residents, fellows and medical students watching.  The attending takes the scope from me and intubates the baby himself, which I am fine with.  He loves intubating.  The amazing part is still yet to come; remember I had just walked out of a bed-side surgery.  The attending looks up from the baby and mid-command of epinephrine he yells an order for heparin and then yells "Call ECMO stat!" and then its repeated "ECMO has been called stat!" and then the surgeon, that I had just been working with comes into the room, says "Surgery is here" and in less than 1 minute, and I am not exaggerating the scrub-techs had the surgeon in sterile gear with a tool in the first 10 seconds and he was cutting, in the next 50 seconds as if they had done this exact impromptu surgery every day for the last 50 years, had every single box they needed opened in the order the surgeon would need it in the next 50 seconds they had the entire room sterile-fielded, and they even put gear on people that were involved in holding the baby and I watched them dress out the RT while she sat there bagging unable to stop.

It was like a scene from fantasia, no scrub-tech attempted to grab the same thing as another one; everything got done in probably the most efficient manner ever to exist.

Then the trouble starts, the surgeon is ready, ECMO has arrived and another surgeon shows up and the other surgeon says "whats up, do you need me?" and the primary surgeon is really upset and says "I dont know what the fuck happened Dan, this is one of my norwoods from last week that was doing fine.  He is struggling to get everything on lock down and yells "Son of a bitch, is ECMO here yet".. "ECMO is here doctor" to which he replies "Fucking say something then, I cannot see you, you have to talk to me, tell me everything because I'm waiting on you."

at this point I am an observer, my the other RT cannot move because they did not tape the tube because they could not confirm past an end-tidal that it was in the right place so she was holding the tube in place while the anesthesiologist maintained ventilation.

I leave and I take her phone from her pocket and have assumed her patients at this point.  I start getting calls on both of my phones now, change the ETT here, advance ETT there, withdraw ETT over there.  "RT TO ROOM 1 for extubation" comes over my phone.  I jog over there and there is a Swahili family with their 3 year old daughter who is trying to shred her ETT out of her throat, 4 nurses are holding her down and the doctor is talking to another doctor at the door.  I come in, and say "are we ready?" and I'm given a big yes so I grab the yawnker, I suction her mouth out, and its full of blood, I drop the cuff and in-line suction.  I announce I'm extubating and its out.   She has an audible stridor that seems to be actually going away and she sounds course, with full-body retractions so I say "she had a leak greater than 20, with obvious issues should we give racemic or what?" The doctor says "lets goto vapotherm and wean her fast" and I said "ok" so then I hook up the vapotherm at 10L, 30% FiO2 and she improves, a little.

I leave and go to check on the other people and to make sure all the therapy is done for my patients and the other RT's patients.  I get a call to "setup oxygen in room 1" so I have them call me and they tell me "The nurse took her off vapotherm and just wants a nasal cannula now"

This is now at 7:45pm, so the RT who got there to assume those patients at 6:45pm said "I will handle that"

at 8:00pm the other RT is relieved and we both walk out together, debriefing from the last 4 hours of hell and go home.

A few things I have learned and you should know.

Mechanical ventilation is an interesting thing, and I have discovered that its being shown that we should have soft music playing for patients who are being ventilated; it improves outcomes[1].  Respiratory therapists as a profession need to expand our practice to being a lot more bed-side and directly involved in the patients outcomes because in our current state, we are struggling to constantly prove our necessity while simultaneously delegating our scope to the bedside clinicians[2].  Oh yeah, and there are only four (4) modes of mechanical ventilation, the rest are all brand-names that represent a strategy within one of those four modes[3]. Lactic acid is a good indicator that the patient is not being ventilated well enough and their work of breathing has increased, in addition to the typical pH balance measurements[4].  I also have far too much free time.

1. Hunter BC, Oliva R, Sahler OJ, Gaisser D, Salipante DM, Arezina CH (2010)  Music therapy as an adjunctive treatment in the management of stress for patients being weaned from mechanical ventilation. ''J Music Ther'' 47 (3):198-219. PMID: 21275332
2. Rose L (2010) Clinical application of ventilator modes: Ventilatory strategies for lung protection. ''Aust Crit Care'' 23 (2):71-80. DOI:10.1016/j.aucc.2010.03.003 PMID:  20378369
3. Preferred Nomenclature for Mechanical Ventilation for Manuscripts Submitted to RESPIRATORY CARE (2011). On the web: AARC.org
4. Marjanović V, Dordević V, Marjanović G (2009) Oxidative stress in patients on mechanical ventilation. ''Med Pregl'' 62 (11-12):578-81. PMID: 20491385

This week has been exhausting.

In the Neonatal Intensive Care Unit I worked pretty hard at evaluating and consulting with the teams working on babies; I would be assigned up to three "pods" which is a fun way of saying "hallways".  Each pod has 6 rooms so I could be assigned 18 patients, with acuity in mind (...of course).  In the Pediatric Intensive Care Unit I am way busier.  I was only assigned 6 patients to "start me off" but 5 of them were being mechanically ventilated and  all of them required therapies.  I had hyperinflation therapy (HIT) on all 5 every 4 hours with an intermittent-percussive-ventilation therapy (IPV) on one of them every 4 hours.  Along with general evaluations, answering questions for nurses and families, and running blood-analysis.  The latter was probably one of the most annoying and time consuming parts of my day.  The respiratory department at this particular hospital is not allowed, isn't given the responsibility of actually drawing the blood, but we are required to analyze it.  I loathe mindless task-oriented "technician" types of things, but there really is an issue of consistency at stake when we are required to plug blood into a machine but we have no idea what has happened to the blood before it got to us.

The partial pressure of CO2 in the atmosphere is .28(ish) and O2 in atmosphere is 160(ish).  When those two values are some of the more important things we're measuring, its not really okay to let blood touch air very much.  I am getting syringes with an entire milliliter of air sitting in a cup of ice for who even knows how long.
Not to mention I have been told "capillary gas is not relative to arterial gas" hundreds of times by other RTs to whom I reply "If the capillary pO2 is 0, would you consider it to be irrelevant?"

Anyway, I digress.

The conditions of the kids in the PICU and the PCVICU are way different than the NICU, its almost like the "If its not congenital, it comes here!" catch-all type of place.  Maybe my problem is time-management, I admittedly suck at that and I have not made a lot of progress in the 2 years during clinical or in the 5 months since I have been practicing.  So maybe that will get better.  So far though, I miss the Pediatric ER and the NICU the most.

Addendum to the Medbuntu concept:
I think that Medbuntu could operate a lot thinner than I even suggested in the first place.  Medbuntu would be the ultra-thin OS that ran apps if it absolutely had to, but running every single other thing through the google-chrome (or modified firefox) would be pretty hot.  With a really cleverly designed "chart" with intuitive designs to make it easy for practitioners to know whats going on and see things that the previous clinician may have forgotten to tell them.

Nurse, please!

I have the utmost respect for nurses, I do - I am actually married to one...  I know RT's get a lot of crap for being so hit-or-miss when it comes to being good or being terrible, and I guess I have just been taught that RN's are in the same boat.

When I ask you during a intermittent positive-pressure ventilation treatment with a duration of 20 minutes, 2 minutes in "Hey, how high should the CVP get before I become concerned?"  she replies "well the normal is 8-10, and he was doing that before the treatment, so he's fine."

Because I am timid and not a complete douche-bag, I decided to just drop it.  However, CVP is the central venous pressure, or right-atrial pressure, normal is 8-12 mmHg and it is measured by a line going directly into the heart and sitting in that spot.  My IPV increases intra-thoracic pressure inherently, its what it does - its how it works, it is therapeutic.  Sometimes the pressures increase other pressures that aren't normally a problem like CVP, ICP and maybe helps mobilize gas in the intestines... but when you're a left-hypoplast post-norwood(sano) and had just had your chest closed 2 hours ago after having an open chest for 3 days, maybe an increased CVP into the low 30's is a red-flag for me to stop my treatment?

Maybe that's something I should know and the nurse shouldn't have to know, but either way - I was embarrassed to have forgotten that very important information from my cardiology classes but then I was put off a bit by this MSN, RN who apparently thinks I am just vibrating the baby and not slamming him with pulsating pressures.

Ubuntu and medicine.

This is a quick thought I wanted to write down, I have been thinking it a lot and I want to make it available to anyone else to see it.

A special version of ubuntu (especially with the unity GUI) that allows connectivity for electronic medical record standardization and communication.

I really wish I could spit the words out to explain what I see when I think of this, but most medical equipment is linux based already and all of the applications we utilize are windows applications that have to communicate with linux machines and a lot of automation is nonexistant because of the work involved.

Medbuntu in my fantasy is a cloud based ubuntu distro that allows admins to user-group and give un-editable UI setups for various users.  Login is keyboard or fingerprint (lots of this in hospitals already) with the unity panel containing every application needed by a nurse, respiratory therapist or physician.

I get so excited about this its not even funny.  Who could make money on this?  Whoever the corporation is that has the capital to get it going, Google is a good idea, to establish everything it would take probably 5 years for a small group of programmers to get everything solid, Google could probably convince a small rural hospital system to let them come in and change everything for free to get everything stabilized and then in the case of Google, they could make money somehow based on using HIPAA approved demographics for advertising, or in the case of anyone else, selling support and insurances.

I would even be excited if microsoft created a windows using my concept for streamlining the process.  There is a lot of stuff that looks incredibly unprofessional (start buttons with dialog boxes with no information?, double clicking the clock for the calendar gives you a not-authorized prompt and not to mention IE6 is like ancient but still used by every hospital in the US.)

thats my idea of the night, enjoy it.

Neonatal ICU over and now its Pediatric ICU time.

I have spent a lot of time thinking about what to write but have come up short every time on actually writing.  I will try not to be spastic in this entry but I don't know if I can help it.

I discovered the other day that our facility is doing research on continuous epinephrine in situations with exacerbation of asthma in our emergency department.  I discovered this after searching pubmed and uptodate for hours for supporting research, to ultimately ask and find out it is a research trial in emergency treatment.  I couldn't help but feel excited that I had been involved in a cutting edge and possibly "ground breaking" development of asthma management in pediatrics.  With all of that said, it feels very awkward that continuous epinephrine (not racemic epinephrine) is just now being researched, I will admit the person who told me may have been wrong and there is another reason we do it.

Anyway, the NICU has been amazing and I am one of the only therapists in my group that thought so.  I like how involved I am as a therapist in the treatment and evaluation-of-progress in the NICU population.

I was actually asked for recommendations by a few physicians.  I really enjoyed the side-by-side position I have as a therapist in the NICU and the treatment of the babies.  As therapists we care much more about the "Why" we do something instead of just "How" to do it, which I think is a fundamental issue with the future of the profession... Why is a therapists job, How is a technicians jobs; what do you want to be? I enjoy being a therapist.

My first day in the PICU was pretty much an overview of protocols and equipment and a general orientation to the units.  We have something like 115 beds in the PICU, and we had 90something in the NICU so its going to be pretty intense...

I will definitely miss the NICU, ultimately I still don't know where I want to be primarily, maybe an ED and NICU therapist.  Though at this facility after a year I have to pick just one and become a primary therapist in that specialty.  I am very lucky to work at a facility like this, considering almost every other facility doesn't have specialties, but instead just forces therapists to do everything with only staffing in mind instead of capabilities.

You'll hear from me again soon.

Tampa in November? I am considering it.

A short blurb...

I have been really thinking about this a lot.  The AARC had assigned a task force for a thing called "Transitioning the Respiratory Therapist workforce for 2015 and beyond"  where they held three conferences between 2008 and 2010.  They decided a lot of things and one of those things was that the CoARC needed to abandon the AS and AAS credentialing of Respiratory Programs and only credential BS degrees.

I originally agreed with this, because it makes sense; a BSRT means that you are more prepared than an ASRT, right?  Probably not, actually.  There has been no difference in the clinical judgement abilities of AS vs BS new graduates that I have seen, but with a BS we do have more opportunity for advancement through management; which is cool.

I have decided the change needs to be in the ability of an RT to climb a clinical ladder.  There needs to be a Masters degree and a Doctorate degree available to an RT, where there currently is not.

I propose these additional program developments available to RT's

Masters of Science in Cardiopulmonary Medicine
"Pulmonology Associate" or "Pulmonology Physician's Assistant"
* Credentialed by the CoARC and the AAPA
You would become a credentialed PA by the AAPA, and the school would be accredited by both the CoARC and the AAPA.  Prerequisit would be a requirement to hold a BS and be a Registered Respiratory Therapist.
The scope of practice and prescriptionary allowance would be the same as a PA.

Doctorate in the Philosophy of Cardiopulmonary Medicine
This would not require additional credentialing other than the normal PhD program requirements.
The idea behind this would be a Philosophy in Pulmonology allowing for Research Scientist work or the ability to be a highly educated, educator.

Creating a clinical ladder would help the field a great deal and stop people from leaving to join other ladders that have better growth options.

Respiratory Therapy is a very unique profession, we are an interventionist like no other and cannot really be compared to any other profession without a great deal of exception.

NICU week 2

I have been in the Neonatal Intensive Care Unit (Level 4, Research Medical Center) for two weeks now.  Tomorrow is my last day of the two week run.  I will be here for two more weeks and then I move to the Pediatric Intensive Care Unit, I dont know what level - whatever the highest level is probably...

I have had only around 30 total patients with around 8 needing real therapy over the course of the two weeks, but even that load is pretty heavy considering the acuity.

I don't know how I am going to write about the cases specifically, I am attempting to stay as anonymous as possible, but when I know everything about the patients and apparently I think the world revolves around me; I can't help but feel obvious about who I am talking about.

This is something I suppose I will have to have someone read as a 3rd party before publishing to this blog.

In the most general of terms, hopefully I will get brave and get more specific later; I have managed some jet ventilators, some nitric oxide therapies, oscillators and a lot of conventional ventilators.  I have bagged a 500g baby and have gotten really good at a task im sure is overlooked, the capillary blood gas (CBG).  The CBG is so humdrum its almost not even worth mentioning when asked what you've been doing for the last hour, but as a new therapist, I can't help but get excited when I fill my vial without any errors.

Vent Checks are okay, but I wish that there was a system in place for recommending a ventilator change.  In acute situations, we are allowed (RRT only) to use clinical judgement to change ventilator settings to fit the need of the moment, but for general care when everything is fine except maybe a blood gas tweak, it would be nice to have a place to submit a suggestion for physicians to view when they round.

Giving report is hard when some receiving therapists want to know nothing really, and some want to act like the clinicians we're supposed to be.  I have started to give a full clinician report every time and just deal with the eye-rolling.  I can't get in trouble for being too-informative, at least thats my mantra for the week.

I know this was choppy but I wanted to log something.

Talk to you soon.

a month in acute care

I recently completed a month rotation through general care / acute care.  In pediatric respiratory therapy this means I spent every day working with Cystic Fibrosis patients.  Respiratory Therapy with a Cystic Fibrosis (CF) patient is a big workload.  While admitted to a hospital, a CF patient receives respiratory therapy 4 times (QID) a day.  Each segment of therapy requires around 60 minutes of constant therapy and atention to the patient.  Meaning if therapy is given appropriately, a single therapist can not take more than three CF patients during a 12 hour shift.

Treatments are just like I learned in school, except we have some additional rules that I probably just forgot.  Typically a regimen goes like this: Albuterol MDI or nebulized,  wait 10 minutes for proper peak onset, administer hypertonic saline (percentage is different per patient, but 7% is standard for most kids) and then administer 30 minutes of chest percussion.  Vest therapy can be substituted for manual percussion and in both every 5 or 10 minutes stop the treatment to get good strong huff coughs to help mobilize the secretions even more.  After percussion, Pulmozyme (Dornase Alfa) is given and then any add-on steroid treatments.

Other than CF kids, I had a series of nasotracheal suctioning and a lot of PRN treatments.  Acute Care in pediatrics is incredibly busy, though even being so busy - I don't have any remarkable stories, other than I made friends with my CF kids and their families, it would be hard not to.  I spend at minimum 3 hours with them every day and if the kid is a handful even more.

I started the Neonatal Intensive Care Unit last week, I hope to include some cool stories about that soon!

my interview for a PRN

this is a placeholder for an incoming post.

My first two weeks.

I have been debating on whether or not to write this. I decided that I don't know what my ultimate medium will be but I should try to pen some of the experiences I have recently and my perspective as a Respiratory Therapist.

Another preface is that I became a Registered Respiratory Therapist with the NBRC in May of 2011, so any reference that makes it sound like I have been a therapist for hundreds of years is simply assumption or a perspective from how it seems from where I am standing. I also became a state licensed and nationally registered EMT-I in 2003, so my point of view about EMT related stuff might slip in and that's where that comes from.

First, I will preface this entire blog with how optimistic I currently am about this profession. I realize how big the hill is in front of all of the entire profession as far as getting respect for doing what I am doing. I say that now so I don't have to continually repeat it in future entries.

I also think that it should be a change in the feeling of self-importance by therapists. I don't mean to be super cocky or anything, but be confident in the fact that a Respiratory Therapist is a necessary part of the team. The history of our profession may technically begin in the 60's, but our real profession milestones are somewhere in the 1990's and then again in the early 2000's.

We seem to have had a major influx of people who love trauma and emergency situations and that's great, sort of. Respiratory Therapy was pitched to me as a profession with a lot of application in a plethora of medical institutions, and I still believe it does.

The most embarrassing thing about Respiratory Therapy is the lack of acknowledgement and even understanding of the profession and its administration and history by even the practitioners in it. Have you ever looked at the wikipedia.org page for Respiratory Therapy? It is awful, its full of weird phrasing and horrible explanations of what we do. In the introduction paragraph it says something along the lines of "...respiratory therapists are an important part of the hospital code team and are in charge of oxygen delivery and give nebulizers"

While that is technically true, its like saying this about Nursing "Nurses are important parts of the code team and are in charge of giving patients blankets and reminding them to take their blood pressure medicine"

Saying "Code Team" might not be, but feels intensely uncomfortably improper. Not all emergency response teams are called "Code Teams" and maybe its just that I don't like how elementary the language portrays respiratory therapy.

I was referred to as a technician more than once recently and it bothers me. Its not just that people think the T means technician instead of therapist, but the fact that their opinion of the knowledge and ability of a therapist causes their brain to say technician instead of therapist is what needs to be confronted and corrected instead of simply trying to get them to say the correct word. People don't accidentally say Physical Technician when talking about Physical Therapy and why? You might just feel like its not the right word, and that might be because you have never heard technician used in that place, but I think its a little deeper then that.

There is nothing wrong with the word technician, but it changes the definition of what we do as clinicians.

I think I will try to split up my posts so that they aren't so scattered seeming.