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 blog about Respiratory Care by a Respiratory Therapist
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.
- 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
- 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
- Preferred Nomenclature for Mechanical Ventilation for Manuscripts Submitted to RESPIRATORY CARE (2011). On the web: AARC.org
- 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.
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.
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.
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.
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.
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