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.

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.

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.

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.