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Monday, October 25, 2021

As The Dust Settles

The dust from the second COVID surge is settling. Between the sound of bullets reverberating through the air, the war-weary soldiers take time to rest. And that's similar to where I stand as I sit here at work blogging about life on the COVID front lines. As I tell this story, I am going to do so in reverse. And the reason is that I am starting my story while the dust is settling, as opposed to back when the COVID war was raging in full force. 

As the dust settles, we only have a few COVID positives in the hospital. We only have one Ventilator going, and that ventilator is a COVID positive. And we have. a few random COVID-positive patients come into our ER on a daily basis. Yet this is a major improvement from the surge itself. 

Several months ago an RT friend of mine from Indiana texted me. She said the second surge had hit her hospital and it was worse than the first. At that time, it had yet to hit ours. So, I did not see why the second surge would be any worse than the first. But, a few weeks later, the second surge hit us. This surge was called the Delta Surge, mainly because it was said to be the result of the Delta Variant. The Delta Variant is supposed to be a variant of the original COVID virus. Over time, the virus mutated, and this new Variant is said to be more virulent than the first. 

By the start of the second surge, most of the high-risk patients had been vaccinated. By September 2021, almost 90% of people over the age of 65 were vaccinated. So, the second surge was mainly affecting younger people. It was also affecting people who were fully vaccinated. Initially, this was why I thought my friend said the second surge was worst than the first. 

But, then the surge hit us. And it hit hard. And, this time, rather than just dealing with COVID patients, we also had our regular patients. We had 4 COVID vents plus 5-6 COVID patients on high flow nasal cannulas. But, we also had an array of COPD, pneumonia, and CHF patients. And this, I decided, is what she was referring to. The first surge we just had COVID patients. This second surge we had to deal with both COVID and our regular patients. And that made us twice as busy as we were during that first surge. 

Also, during that first surge, we were fully staffed. During the second surge, a staffing shortage was happening. So, to encourage us to work extra shifts, the powers that be were offering us our regular pay plus 30%, or 50%, and even in some cases 100%. For October, the shortage was so intense that they simply decided to offer 100% pay. That, to put it in friendlier terms, is double pay. So I, as with my coworkers, picked up lots of extra hours. And, after a month of this, I was extremely burned out. I was much more burned out than during that first surge. 

And now we still have the incentive to work extra. They are still offering 100%. But, now I am only picking up a few extra hours. I had to stop due to severe burnout. And also it has slowed way down here at work. As noted above, we have a few COVID patients, and we have a few regulars. But, now there is time to sit here and share my story. 


Sunday, October 24, 2021

The State of The Paramedic Profession

Rigs Just Sitting Due To Staffing Shortage
I have this unique view from the head of the bed. And I work on the front lines of this war against COVID-19. And I have this platform that gives me a voice. And I have so badly wanted to share my experiences here. But it's been so busy I have barely had a chance to check-in. But here I am. And this is what I have to say. 

I want to start not by talking about my job, but by talking about the EMT profession. In this war on COVID, they have it pretty bad. And it's not just that there are lots of cases of COVID they have to deal with because COVID really hasn't affected them. Most people with COVID get sick and walk into emergency rooms on their own two feet. And it's later, after they get admitted, and as the disease progresses, that they end up either getting better or taking a turn for the worse. What is ailing EMTs is the post-COVID state of the economy. 

Just like other professions, the EMT/PARAMEDIC profession is facing a severe staffing shortage. You can get into theories about why it is happening. In my humble opinion. one of the main reasons is because the government is paying people to stay home. Another reason is that it is now so easy to get food stamps or other government assistance. So, for this or whatever other reasons, many people are choosing not to go to work. 

So there is a nationwide worker shortage. Nearly every job is short-staffed and looking for workers. Nearly every place you go you can see help wanted signs. And the EMT/PARAMEDIC profession is no different. 

It's so bad that we have patients in the hospital that cannot be transferred to other facilities. And the reason is that there is only one RIG in Shoreline County that is fully staffed. And I had a chance to talk to that crew today. Mr. Paramedic and Mrs. EMT were at my hospital. They said they have the only operational rig in all of Shoreline County. He said we have lots of rigs. But we have no staff to put into them. In fact, he said they are facing such a shortage of staff that if one more person were to quit, they would have to go out of business altogether. 

Why are people quitting? It's because all these other professions have openings. And you can pretty much pick and choose where you want to work. And you can choose to go places that are offering huge sign-on bonuses and a higher hourly wage. Mrs. EMT said she is making less than what they are paying some people at Mcdonald's. And that means that she is getting paid less than $17 an hour to save lives. How sad! 

I will blog later about the RT staffing shortage and the RN staffing shortage. And I will talk about efforts to keep us from quitting. And efforts to bring in more RTs and RNs. Mr. Paramedic said they were offered one check for high-risk jobs. And they have had none since. And they have had no other incentives to stay. At the same time, RTs and RNs have received bonuses, raises, and retention pay. So, for this reason, many paramedics and EMTs have quit for better-paying jobs that are probably less stressful, such as working at McDonald's. 

So, for now, we have one Rig. We have one ambulance in the entire town of Shoreline, in the entire county of Shoreline. We have a patient that needs to go to Big City Hospital to get rehabilitation. And Mr. Paramedic said they cannot make that transfer. He said doing so would leave Shoreline with no ambulance. So, if they did take that transfer, and there is a call for an ambulance, a rig has to be sent from another town. So, a person could potentially be having a heart attack and no one will arrive on the scene for hours. And that is not good. 

We have had patients in the CCU needing priority one transfer. And we have had to call a helicopter in to take that patient because there are no rigs available. That's kind of a waste of that resource, but we have no other option. The helicopter should be on call for other emergencies. But, here we are using them just for a simple transfer due to a staffing shortage. Of course, there have been times a priority one patient has to stay in our emergency room for hours waiting for an available rig. 

This spotlights the need for ambulance reform. Something MUST be done to give these good people better pay. If anyone deserves it, our Ambulance Crew most certainly does. And if such reform is not done. We may be left with ZERO RIGS. 

Thursday, September 16, 2021

Oxygen Therapy Made Easy: 3rd Edition

If a patient is unable to oxygenate appropriately on room air, supplemental oxygen is indicated. This Course will help you decide what oxygen equipment is available. It will also help you determine how much supplemental oxygen a patient needs.

BASIC DEFINITIONS

Supplemental oxygen: It is when you inhale more oxygen than what is supplied in room air. This can be accomplished by using the various equipment described below.

PaO2: This is the partial pressure of arterial oxygen. It the level of oxygen in your arterial blood. It is obtained by drawing blood from an artery. The normal ranges are as follows:
  • Normal: 80-100
  • Mild Hypoxemia: 60-79
  • Moderate Hypoxemia: 40-59
  • Severe Hypoxemia: 39 or less
SpO2: It's a measure of how saturated hemoglobin are with oxygen. It is essentially a measure of what percentage of the oxygen you inhale makes it to your arterial blood. Normal ranges are as follows.

  • Normal: 95-98%
  • Acceptable: 90% or better, and sometimes 88% or better with some disease conditions.
  • CMS will not pay for home oxygen unless the SpO2 is 88% or lower on room air at rest
  • SpO2 decreases with age, while sleeping, and with some disease processes.

4-5-6-7-8-9-Rule. 

Allows you to use SpO2 to estimate PaO2.

  • SpO2 70% = PO2 of 40 (supplemental oxygen is essential on any patient in this range)
  • SpO2 80% = PO2 of 50 (some COPD patients may live in this range
  • SpO2 90% = PO2 of 60 (This is what you want to maintain for most patients)
Fraction of Inspired Oxygen (FiO2): This is the percent of oxygen a patient is inhaling. Room air FiO2 is 21%. By applying supplemental oxygen, we allow patients to inhale greater than 21% FiO2. In the hospital setting, we have the equipment to allow a person to inhale anywhere from 22-100% FiO2.

Indications for Oxygen Therapy:
  • To correct hypoxemia
  • To reduce oxygen demand on the heart
  • Suspected or acute myocardial infarction (MI)
  • Severe trauma
  • Post anesthesia recovery
How much oxygen does a patient need?

Spectrum Health’s protocol calls for maintaining an oxygen saturation of 90% or greater or as specified by a physician. Our COVID-19 oxygen protocol calls for maintaining an oxygen saturation of 88% or greater.

How to determine if oxygen therapy is working:

You know oxygen therapy is working when:
  • SpO2 improves to acceptable levels as determined by protocol or physician
  • Respiratory rate decreases to the normal range.
  • Tidal volume are not erratic
  • Patient notes improved work of breathing
  • Pulse is normal or improving
  • Blood pressure is improved or improving
  • Underlying condition is improving, or whatever occurred to cause the hypoxemia
LOW FLOW OXYGEN DEVICES. These are oxygen devices where room air will be entrained. Because of this, the exact FiO2 cannot be calculated. You can, however, estimate the FiO2. How much FiO2 is delivered to the patient is dependent on:
  • Liter flow set at the flowmeter
  • Respiratory rate and pattern of the patient
  • Equipment reservoir (stores oxygen)
The following are low flow oxygen devices:

1. Nasal Cannula: The nasal cannula is the most common oxygen device used and the most convenient for the patient. A nasal cannula at 2lpm is usually a good place to start.

You may at times need to estimate the FiO2. How do you estimate the FiO2 on a nasal cannula? For every liter per minute, the FiO2 increases by 4% as per the chart below:
  • 1 lpm = 24%
  • 2 lpm = 28%
  • 3 lpm = 32%
  • 4 lpm = 36%
  • 5 lpm = 40%
  •  6 lpm = 44%
The liter flow on a nasal cannula should never exceed 6lpm, as studies show doing so is of no added benefit to the patient. Also note that the prongs of a nasal cannula should face down. A bubbler can be added to humidify the nose to prevent nasal drying and bleeds. This is automatically set up at flows greater than 5lpm, or as ordered by physician. You may also add a bubbler for any patient you think may benefit from it. Setting up and managing nasal cannulas is a shared responsibility of nurses and respiratory therapists.

2. Non-Rebreather Mask (NRB): This is a mask that ideally will bring in 100% Fio2 so long as the liter flow is 15 and there is a good seal between the mask and the patient's face. And all three one-way valves are on the mask to prevent air entrainment. The bag acts as a reservoir for oxygen for storing oxygen. So, when you inhale, you will be getting 100% Fio2.

For legal purposes, however, one flap is always removed just in case the oxygen gets shut off. And therefore the highest FiO2 you can get from an NRB is estimated to be around 75%.

3. Partial Rebreather Mask (PRB): This is basically an NRB with both one-way valves removed from the mask. The estimated FiO2 is 60-65%. Flow should be set at 6-15 LPM. Note: The flow should never be set lower than 6LPM. This is because flows less than this may not be enough to flush CO2 out of the system, and may cause the patients PaCO2 to rise. Now that we have high flow devices, PRBs are rarely indicated today. So, in the 4th edition this section may be deleted. 

3. Intermediary High flow Nasal Cannulas. These allow the patient to inhale flows up to 15 LPM by nasal cannula. The tubing is thicker. They also come with a bubbler to prevent nasal drying and bleeding.

HIGH FLOW OXYGEN DEVICES

These are oxygen delivery devices that meet the inspiratory flow demand of the patient. These devices will allow you to give an exact FiO2 to the patient. Respiratory rate and tidal volume of the patient have no effect on FiO2 delivered.

Ideally, the larger the entrainment port on the device the lower the FiO2, and the smaller the entrainment port the higher the FiO2. A major disadvantage is a mask is required, and this may be a bit more uncomfortable than a nasal cannula.

1. Venturi Mask: These masks are ideal for patients with high respiratory rates. They allow you to deliver anywhere from 28-50% FiO2. These masks have various caps that connect to the mask and oxygen tubing. Each cap has a different color and a different size air entrainment port. Basically, the smaller the entrainment port the higher the FiO2. At most hospitals, each cap will have on them what the FiO2 will be delivered and what flow to set the flowmeter at. The flow can be higher than this. But it must never be lower in order to assure CO2 is being adequately cleared from the mask. These masks are ideal for patients with COPD who are in respiratory distress. The most common settings used are 40% and 50%.

2. Aerosol set-up: These devices will deliver anywhere from 21-100% FiO2. An adjustable air entrainment device sits on top of a water bottle. This is connected to a flowmeter. The entrainment device can be adjusted to the desired FiO2. The desired flow to set the device at a given FiO2 is written on the side of the bottle. Wide bore tubing from the entrainment device is connected to a mask.

These are ideal for patients with tracheotomies. This is because the wide bore tubing connects nicely to trach collars. They are nice because they allow us to easily make sure they are getting adequate humidification and oxygenation.

3. High flow nasal cannula: These are machines that allow us to deliver flows up to 60 LPM. They are connected to heat and humidity so the patient’s nose does not become irritated.

4. CPAP and BiPAP Machines. Home devices allow for oxygen tubing to be bleed into the system. This allows the patient to inhale low amounts of oxygen at home. Hospital devices allow us to deliver anywhere from 21-100% FiO2.

5. Ventilators. These also allow us to deliver 21-100% FiO2.

Thursday, June 3, 2021

RT Tip # 21: If you want to know how useful wisdom is, ask an RT of 20 plus years

So you are an RT student. You have a question.  Perhaps it's a question you need to know for a test. Perhaps it's information you need for your RT or CRT test. Then you need to know the answer for that. 

Yet sometimes I witness RT students asking us RTs questions. Well, actually it happens a lot. And most of the time we have answers. And the reason we have answers is that it's the information we find useful and that we use, at least from time to time. 

But if you ask an RT of 20 plus years a question, and they don't know the answer, it's probably because it doesn't matter. The answer might be useful to help you pass a test or impress someone. But it's not a bit of wisdom needed in the real world. 

Example: 

Student: "What type of a ventilator is this?"

RT of 20 years: "It's a Servi i." 

Student: "No. I mean, is it flow cycled or pressure limited." 

RT of 20 years. "I have no idea. I remember studying those in school. But it's information I forgot as soon as the test was over." 

This information is not important to the typical therapist. It may prove helpful to engineers who are developing such equipment. But it's not helpful in the field of RT work. 

Example #2. 

Student. "When peak pressure and static pressure both increase, what does that mean?"

RT of 20 years: "It means that your compliance has decreased. It means your lungs are stiffer. Severe COVID-19 is a perfect example of this. Their lungs are stiff, and therefore there pressures are higher. This is why we use low tidal volumes and high respiratory rates and are happy with some degree of respiratory acidosis." 

Student. "Wow! I am impressed with your knowledge.

This information is very helpful in the line of RT work. I guarantee there will be one or maybe more questions about peak and static pressures. There may be a question about what it means if they both go up. There may be questions about what happens when the gap between them increases. So, know this wisdom. You will definitely benefit from this wisdom when you are a real RT.

Thursday, April 1, 2021

If you are vaccinated, take off your mask (if you won't get into trouble that is)

Look, I got my vaccine. I was told if I got the vaccine I couldn't get covid. And now people are telling me I need to keep wearing my mask because I could still be a carrier. 

What? This is crazy. Someone just made that up. I understand wearing a mask in the hospital. But why am I wearing a mask when I go to Walmart? There is no reason. Why is the CDC now telling people who got the COVID vaccine that they can now meet with people if they wear their masks and social distance? That is crazy. 

Quite the contrary. If you got your vaccine, you should take off your mask (if doing so won't get you in trouble). Because, as studies out of Israel show, those who have the covid vaccine cannot get and cannot carry the virus. There is your science. 

Biden keeps saying, "Follow the science." Yet the science says take off the mask if you are vaccinated. 

I think Biden could set a good example here. You have so many people refusing to get the vaccine for one reason or another. I think Biden should take off his mask. He should say, "Fear not. If you have the vaccine, take off your mask. You are now able to do all the things you want. Get this economy going again. If you are too stupid to get your vaccine, well then that's your problem. If you get covid, that is your problem. Take off your mask if you have the vaccine and live your life." 

You'd have record numbers of people getting their vaccine. And the economy would skyrocket. But, be it as it is, that won't happen. The leaders of our country love the power that covid gives them. Covid is the new global warming. 

Thursday, March 25, 2021

I am not an anti-masker. In fact, quite the contrary

I had a friend challenge me recently. He asked me if I had changed my views on being an anti-masker. And I said, "When did I say I was an anti-masker? I never said it! Find anywhere in my blog or Facebook page or anywhere where I said I was an anti-masker." 

Of course, he couldn't. Because I never said it. All I did was challenge the premise. All I did was ask questions. All I did was question the CDC which said, on its website, that masks prevent covid. And I still ask that question. How can they say that masks prevent. It would be fine if they said, "The premise is that if you wear a mask, it may help reduce your risk for getting covid." 

That would be fine by me. But to say they prevent is poppycock. And I'm talking about surgical masks. They do not prevent. And, of course, my friend came back to me. He said, "They have worn surgical masks in surgery for years because they prevent the spread of disease." 

And I said, "That is not why they wear surgical masks in surgeries. lol. The reason people wear surgical masks in surgery is to help reduce the spread of germs from the nurses and surgeons to the patients. It's in case they cough or sneeze. It's to keep the patient safe." 

But even that did not satiate my friend's haste to judge and cast me as an anti-masker. He was persistent and continues to nag me to this day. And I never really understood this until I watched CNN one day. And then I figured it out. I'm not saying everyone on CNN thinks masks prevent. But, the session I watched, all the people were pro-masker in a way that they believe if everyone wore a mask then we could end covid. 

And even that is not true. If everyone wore a mask, we would slow the spread for a while. But as soon as people started wearing masks again, covid would come back. A virus takes the course it takes. They run their course. 

I will give you a good example tomorrow. In the meantime, I encourage people to wear a mask until 2 weeks after the covid vaccine. Once you are vaccinated, there is not a reason to wear your mask anymore. If you still have to wear a mask, then what is the point of getting the vaccine? More on. this the days to come.  And I will also offer evidence. 

Tuesday, March 23, 2021

Science -VS- Scientism

Medicine is an art that is based on science. Art basically means you take the wisdom you have and use it to help your individual patient. And since every patient is different, how to help individual patients will be different. 

Science is a part of medicine that seems to be confusing for some. I walk around town and I see these signs that say, "We believe in science." Or, "Thank You Science." And I can't help but think these people do not know what science is. 

Those signs say something about our country's cult of scientism. What is scientism: It's an excessive belief in the power of scientific knowledge and techniques.

I can give you some examples.
  1. Asthma is a nervous disorder
  2. The hypoxic drive theory is true
  3. The earth is flat.
  4. The earth is the center of the universe.
  5. Global cooling is caused by man.
  6. Global warming is caused by man
  7. Climate change is caused by man
  8. Masks prevent the spread of COVID-19
  9. Vaccinated people can still spread the disease they were vaccinated against.
These are all examples of theories that have become truths to some people. The truth is that some of these theories have been proven false, while others are still being studied. 

Scientism is blindly believing in a theory that is created by science so much so that you forget what science really is. 

So what is science?

Science, by its nature, is an argument. It's debate. It’s controversy. It is attempting to disprove or prove a theory. Science is not blindly adhering to one theory.

Science gives you the scientific method. It gives you ways to do unbiased studies of theories. And from there they either prove or disprove them. And, for the record, science can never be fully proved. For example, how do you prove global warming is caused by man when the climate has been warming and cooling naturally for 4.5 billion years now.  So, the only proof of the global warming theory is computer modulated data. And computer modulated data is only as good as the data entered into it. And, which, there isn't much data, considering we have been studying our climate for less than 150 years. So, there really is no way to prove man-made global warming. We should respect a theory, perhaps, But to worship it seems folly.

Science is never fully settled. It is constantly being verified, challenged, and debated. 

And, furthermore, science is not up to a consensus. So many times you hear people talking about science as though it were up for a vote. I often hear people saying, "Since 99% of scientists believe in global warming, that makes it so." 

No. That is not how it works. Science either is or is not. It is not up to a vote or a consensus. You could have 100% of scientists say they believe in global warming, that does not make it so. The same with any other theory you have out there.