Teamwork

Among the best parts of working in the medical profession is teamwork.  I was reminded of this again yesterday as my coworker and I were called upon to a rapid response call.

1.  I was the first out the door, so I headed straight to the room.  My coworker went to get the EKG machine.  Teamwork. 

2.  By the the milieu of panic in he hallway prior to entering the room, I sensed something horrible was occurring in he patient's room, so I asked an aide to get the crash cart, and she said, "It's already in the room."  Teamwork. 

3.  I rushed into the room and RN Reva was standing by the patient.  I approached the bed, placing my hand on the patient's chest to feel her respirations.  As I went for the pulse, Reva said, "There is no pulse, let's start CPR!"  Teamwork.  

4.  I open the airway box and fumble to open it.  As I go to place the mask on the patient, I notice she is vomiting.  The nurse says, "Just bag through it."  It was a subtle reminder that airway comes before making sure the patient doesn't get aspiration pneumonia.  Teamwork.  

5.  Noting now that Reva and  put the patient first and did not have gloves on (Gross!) Dr. Gary tosses each of us a pair, and I quickly slide them over my hands.  As I'm doing so, the head nurse smoothly takes over and provides a few quick breaths.  Teamwork.  

6.  A critical care nurse is now in the room, and observes the AMBU bag is not plugged in.  She quickly makes the switch (thus saving me from future agony) to benefit the patient.  Yes, even the best of us make such oversights in emergent situations.  Teamwork.  

7.  Three doctors are now in the room, three quality nurses, two respiratory therapists, and an aide, so we are well represented, each of us tending to our area of expertise.  My coworker sets up suction and gets an ETT ready without even being asked.  When the doctor says calmly, "Can someone get me a size 8 ETT," it's already being handed to him by my fellow RT.  Teamwork.  

8.  The supervisor taps a young aide on the shoulder and says, "You can take over for CPR now."  The aide confidently jumps on the chest, and thumps like a pro."  I wonder if this was really his first time.  Teamwork. 

I could go on.  I simply cannot imply enough here how much training goes into each person in the room in such situations, and this includes the nurses aides.  As the patient is wheeled to critical care, she is not just placing orders, but rushing to get blankets and other items the nurse needs, and it's just a great feeling.  

Whether we save the life or not in the end, just the feeling of so many people coming together to give the fallen a chance to get back up is simply amazing.  

Narcan is a good drug

Well, we had a post-op patient this evening in the critical care who decided to start paradoxical breathing, and I was called to assess the patient. The general feeling among the array of soldiers in the room at the time was that the patient was going to need intubation.

"Mr. Farnsworth! Mr. Farnsworth!" I shook him by the shoulders and got no response. His audible forced expiratory wheeze was nothing new, as he'd been doing that before his surgery. But the non-responsiveness was.

Tom, my partner in crime, drew the gas and rushed it to lab. The order from Dr. Andersen, I learned, was to call him with the results. I suggested Dr. Anston be called and told to get his butt in here, but I was kindly over-ruled.

"Is the patient possibly over-medicated," I asked quietly.

The nurse said, "Well, he did get a low dose of Morphine and some Ativan, but they were very low doses."

"Well, how about some Narcan?"

Right then Dr. Anderson showed up with my coworker.  The doctor had the ABG, which showed a CO2 of 50.  The doctor said, "Based on these ABGs and the patient's lung sounds, we should do a breathing treatment."

I say, "The patients breathing this way because he's over medicated, don't you think?"

The doctor says, "Sounds like bronchospasm to me."

So, the treatment doesn't do anything, as I suspected.  While giving it I came up with a name for it: Narcanolin.

In the meantime we all just stand around looking at each other, at the monitors, at the patient. The word "Ventilator" circulates the air more than once, as did the question "Is he a DNR?"  A nurse informs us he was a DNR, but the surgery negates that order.

Waiting! Waiting! Waiting!

"There has to be a way we can keep this man off the vent," someone says.

So the nurse and doctor  ponder now what could be wrong with this patient, and of course I already gave the solution -- Narcan.

Finally the internist cooly saunters into the room. "How much Morphine was he given?"

The RN provided the answer.

"Let's try some Narcan."

The patient woke up right away, "How'd the surgery go, doc?" the patient chimed, and smiled.

Hmmm, so maybe the next time the doctor will listen to the lowly RT and save an hour of hymning and hawing.

Rapid Response Teams

Studies show that most people do not have spontaneous heart attacks or strokes or go into sepsis without first showing early signs that something is going on. Therefore, the vigilant nurse or respiratory therapist who picks up on these signs can save a life and prevent a prolonged hospital stay.

In this way, we might prevent a catastrophe we might not even ever get credit for. And that, in my opinion, is the greatest job of working in the medical profession. We like to call it being proactive.

Thus, being proactive is the purpose of Rapid Response Teams. It's about educating nurses and respiratory therapists on what signs and symptoms are worrisome, and when to call the doctor. To learn when to call the doctor, click here.

According to "Respiratory Therapists Play Unique Role on Rapid Response Teams," by Steve Babyak (RRT) in the AARC Times (June 2007), studies performed show the following:

• 66-84% of patients exhibit abnormal signs and symptoms within 6 hours of an arrest, including altered mental status, chest pain, fluctuations in heart rate, respiratory rate and blood pressure, tachypnea (58%), tachycardia (54%), hypotension (46%) and decreased urine output (29%)
• Elevated respiratory rate is an indicator of muscle weakness and fatigue. 54% of patients requiring CPR had at least one documented increase in respiratory rate above 27 breaths per minute within 72 hours of arrest.
• 65% drop in cardiac arrests and 56% decrease in deaths from cardiac arrest following the placement of a medical emergency team (rapid response team)

Babyak notes rapid response teams were first "pioneered" in Australia in 1990 and were found to be so successful (see statistics above) that they quickly found their way to hospitals around the world.
Rapid Response Teams generally consist of one critical care nurse, the nursing supervisor, respiratory therapist, and the patient's nurse. In some hospitals it would also include a physician, yet Shoreline does not have an inhouse physician. So this makes it even more important for us, because it allows us to use our skills to save a patient using the guidelines and policies created for the team.

For instance, we are allowed to do EKGs, ABGS, give certain medications, and even order X-Ray and labs even before the doctor is notified, all in an attempt to get the patient fixed and to prevent the patient from getting worse.

We are also allowed to place patients on oxygen, give beta-agonists, morphine and initiate BiPAP if needed. Actually, we aren't allowed to initiate BiPAP, although some hospitals allow for this.

Another advantage of RRTs is that they decrease the number of patients transferred to critical care, and decrease length of stay. I imagine they also increase patient outcomes and satisfactions.

As a nurse is doing rounds, or the RT is doing his rounds, we assess the patient. If we notice mental changes, vital signs that are critical, low oxygen saturations, altered breathing patterns or cardiac rhythms, changes in blood pressure (too high or too low), or simply if we think something is wrong and don't know what, then we can trigger the team.

Thus, as Babyak writes, rapid response teams are a great "opportunity for respiratory therapists to bring their experience and expertise to a progressive format that is rapidly improving the safety and well-being of the hospitalized patient."

Further reading:

1. Do rapid response teams work?
2. How to know when to call a doctor
3. AARCs Rapid Response Team Page

How to know when to call the doctor

I work for a small hospital, so we don't have a doctor in house during the night. We do have an ER doctor available for emergencies, but he's for emergencies only. So, if you have a patient who "just doesn't look right," we had to set some guidelines for when to call the attending physician.

The following was actually established as part of our rapid response team:

1. Respiratory Status: RR less than 8 or greater than 28, new onset shortness of breath, SpO2 decreased from baseline


2. Change in Heart Rate: Greater than 130 or less than 40, changed by 20% from baseline, change in rythym


3. Change in Level of Consciousness: Lethargic, confused, unresponsive, agitated


4. Change in Blood Pressure: Systolic less than 90 or greater than 170 or changed by 20% from baseline, or undetectable


5. Staff worry: Just doesn't look right, nausea, vomiting, diaphoretic, not sure what is wrong


6. Chest pain: New or recurring


7. Fluid Status: Input is greater than output, Wet lungs, urinary output less than 50cc in 4 hours


8. Temperature: Greater than 104 or less than 96.8, Critical is greater than 106 or less than 91


9. Labs: WBC greater than 12,000 or less than 4,000, Critical WBC is greater than 25,000 or less than 2,500

Of course the above is a guideline only, and is not a replacement for common sense. If you think a breathing treatment is indicated, you don't have to wait for the doctor's permission. Likewise, calling lab, doing an EKG, and ordering any other pertinent test is also allowable.

This policy has been proven effective in preventing the patient from failing. It's being proactive, observing the signs of impending doom, and taking action now.

RRT saves another; new use for Ventolin

Here's an interesting situation. A patient who was admitted several days earlier suddenly has an SpO2 of 72%.

Thus, the rapid response team (RRT) is called. Upon entering the room the RT finds the patient in no respiratory distress and he adamantly denies any trouble breathing. The rest of the RRT has now arrived.

By RRT protocol, the RT opted to do an EKG and found that there were changes: elevated ST in various leads. Per RRT protocol, the nursing supervisor orders cardiac enzymes, and the patient's RN rushes to call the doctor.

Hold the phone. After a quick ABG draw the patient was placed on a 75% non-rebreather. The doctor was called, and the patient was promptly transferred to the critical care.

Upon the arrival of the doctor, a breathing treatment was ordered. The RT grumbled about this because he couldn't see a purpose for doing this. What is Ventolin going to do for an MI?" the RT thought. But like a good boy he did his job.

Then a second treatment was ordered. He grumbled to himself, but did the treatment again like a good boy. Then, as both the RT and doctor were standing beside the bed, the doctor says, "Let's get a second EKG."

That's fine. An EKG I can understand.

Lo and behold, this EKG was back to normal. While the underlying cause was still undetermined, it appeared to this humble RT that the EKG changes were due to hypoxia, and the oxygen boost helped the patient.

After examining the EKG, the doctor said, "We better do a another breathing treatment."

What are you thinking, Dr. Mast? What in the world are you thinking? You can't possibly think your frivolous breathing treatment actually...??? NO!. Couldn't be.

Nonetheless, we now have discovered another use for Ventolin:

By some magic power, Albuterol now is capable of dissolving a clot in the coronary arteries and fixing an MI. If Ventolin is not the greatest drug of all time, I don't know what is.

Coronoryolin? MI-olin?

Now, on a side note and being serious again for a moment, the RRT came to the rescue and saved another life. I love it when we RNs and RTs are allowed to use our skills to help someone.

On a similar note, if I had access to a scanner I'd put those EKGs up here for you guys to look at. It was pretty neat seeing the changes on the EKG and then the change back to normal after the heart was oxygenated.

Keystone Project to improve patient outcomes

For a more updated and thorough post about the Keystone Project, Click here.

As I have mentioned before, we at the RT Cave believe it is important for each respiratory therapist to be involved in the entire process of patient care as much as possible, as opposed to simply focusing on the respiratory side of the patient's needs.

The main reasoning for this is that, as we learned in respiratory school, "all the organs of the body combined effect the respiratory system in one way or another." Not only is it important for nurses to pick up on the early signs that a patient is failing, it is the job of the respiratory therapist. After all, we are a team, we are all responsible for taking care of the patient.

Most doctors agree that most people do not go into respiratory failure without showing early signs that this is going to happen. It is our job as part of the hospital team to pick up on these early signs and prevent a patient from getting so bad that he or she has to be moved to the critical care unit (CCU).

And, once in the patient is admitted to the CCU, it is our job, along with the nurses, that we continue to monitor the patient for signs of impending failure, besides treating the patient for the critical issue that landed the patient in the CCU.

According to the MHA Keystone Center, "It is estimated that, "over 5 million people are admitted annually (to the CCU) in the U.S., consuming approximately 30% of acute care costs or $180 billion annually. In addition to consuming health care costs, these patients suffer preventable morbidity and mortality. Previous studies suggest that nearly every one of the 5 million patients admitted to an ICU suffer a potentially life threatening adverse event (emphasis added)."

It was the goal of the Keystone Project make recommendations based on the most up to date research to improve costs and, most important, recommend steps that hospitals can take to improve patient outcomes regarding illnesses that do show early signs. And the project recommends each hospitals voluntarily create its own Keystone Team to implement these recommendations.

One of the early recommendations was to create a rapid response team , which would get nurses and respiratory therapists on the patient floors to be on the look out for early signs, and to call the rapid response team into action, to generate early intervention, and thus to prevent the patient's illness from progressing to the point that a move to the CCU is necessary.

Creating ventilator protocols is another recommendation of the Keystone Project in order for the doctors and the respiratory therapists to begin thinking about weaning the moment the patient is placed on the ventilator. Since we have initiated our ventilator protocol, we have seen patient length of time on a ventilator decline sharply.

The Keystone Team at Shoreline where I work has decided that the next step they want to tackle is creating a Sepsis protocol.

I'm not sure what steps we will take, but a few years ago I went to an MSRC conference and one doctor gave a presentation "Everything a respiratory therapist needs to know about Sepsis." And he made us aware that the number one killer in the CCU is sepsis. But people do not get spontaneous sepsis any more than they get spontaneous DIC or ARDS, so it is very important for nurses and RTs to pick up on the early signs.

I couldn't remember everything this doctor said because he went so fast I couldn't keep up with my notes, so as soon as I had a slow night at work I looked this up on the Internet, and was surprised at how much I found.

I found that the MUST protocol was created to make hospital staff aware that sepsis, according to aacnjournals.org, "affects more than 750,000 patients and accounts for more than 215,000 deaths in the United States each year at a cost of $16 billion. Mortality to septic shock has decreased only slightly between 1970 and the late 1990s; it remains the most frequent cause of death in noncardiac intensive care units (emphasis added)."

The MUST protocol makes recommendations in making hospital staff aware of the early signs of sepsis and what to do in the event these signs are prevalent. And while sepsis is not necessarily a respiratory illness, if it progresses, it may result in respiratory failure. Thus, when the RT is present with the patient, or part of the rapid response team, it is essential that he or she knows what the early signs of sepsis are.

While I'm not going to get into the nursing end of sepsis (and you RNs can check out the links above if you are interested), I will address everything that an RT needs to know about Sepsis in the next few days. It's also to know which patients are at risk for Sepsis, ARDS, DIC and PE so they can be closely monitored. At some point in the future I will address all of these as well.

We have met resistance in every step of the way in initiating these protocols, but so far at Shoreline we have managed to create our own rapid response team and a ventilator protocol, and we are currently in the process of creating a sepsis protocol.

While it's not the RTs role to insert catheters, central lines and pulmonary artery catheters, the Keystone Project believes it's the role of every person at the bedside to make sure nurses and doctors are in compliance with infection control techniques to "reduce or eliminate catheter related blood stream infections in ICUs." Since we RTs are often at the bedside, we need to be aware of proper technique.

And, while it's not our role to check sugars, an RT must be one of the team members thinking about this, especially when a patient has sudden mental changes, which may also be an early indicator of sepsis. Does the patient all of a sudden have significant change in respiratory rate, heart rate and blood pressure? Is the patient suddenly filled with Rhonchi or crackles. These are not things to be ignored, as they may be signs of impending failure.

As a respiratory therapist, I like to see the big picture above and beyond my role as an RT. Due to the recommendations of the Kestone Team, I know that it is important to do oral care on a regular basis to prevent VAP (ventilator acquired pneumonia), and to have inline suction as opposed to bag and suction, and to make sure the head of the bead is up 30 degrees, and to make sure the patient is still rotated from side to side even though he or she is on a vent.

And, while it was once recommended not to exceed 20 cwp of cuff pressure in the ETT, , it is now recommended not to let the pressure become anything less than 20. The reason for this is to prevent aspiration and VAP.

I'm not sure if this was a recommendation by Keystone or not, but while I was taught to use 1-15ml/kg ideal body weight when I was in RT school in the mid-199s, it is now recommended to go with a lower tidal volume of 6-10ml/kg ideal body weight to prevent barotrauma. And, in cases of chronic or severe pulmonary illness, it is recommended to start on the low end.

If these things are not being done, it is my responsibility as an RT to either do them, or to at least make sure the nurses or other RTs are doing them.

Not only is is a good idea to generate these teams, and these protocols, but it's also a good idea for respiratory therapists to continue to research, to attend seminars and in services, to stay up to date on all the latest research and recommendations to improving patient care. I think this is necessary even if protocols are not available.

Personally, I don't need a protocol to make me participate in the patient's care this way, but the use of protocols provide RTs with more leeway in what we are allowed to do regarding the patient, especially regarding early intervention. If the patient looks bad now, why not get a quick ABG, EKG and, perhaps, order a STAT x-ray while the nurse is calling the doctor.

When we RTs are called to the patient room to give a breathing treatment, and we observe that the patient is not having bronchospasm but is wet, and then we notice that the IV is running at 500, we would naturally make the RN aware of this. And then we would recommend a diuretic, instead of a bronchodilator.

It's not that the nurses are incapable of finding this out on their own, because they are and they do. But if we are a team, we all must be vigilant all the time. What one of us does not pick up on right away, the other hopefully will.

By keeping up on our research, participating in protocols, and making recommendations that work to benefit the patient, we are not just helping the patient, we are using the skills and education that we have accumulated. This is good for our RT morale.

We are a team, and we must all work together to the benefit of the patient, and to the benefit of ourselves and our institutions.

Rapid Response Teams are awesome

I thinkRapid Response Teams are really cool.

I can't even count how many times I've had a patient who doesn't look good to me or the nurses, only for the nurse to call the doctor and the doctor say, "Mumble, mumble, mumble... Give 20 of Lasix, mumble, mumble, mumble."

Click.

That's okay sometimes, but I know there have been many times we've stressed out the rest of the night about the patient, especially if the lasix didn't work. Sometimes these patients end up in the CCU and we saw it coming.

Now if a patient doesn't look good the nurse pages the RRT and an RT, a CCU nurse and the RN supervisor go STAT to the patient's room. We assess the patient and perform procedures and tests we feel are appropriate.

Tonight I had such a call. The patient was sitting on the edge of the bed, arms spread across the bedside table, paradoxically breathing. I arrived and took charge.

"It looks like she's wet." I said before I even assessed the patient. After doing this job for so many years you become good at observations. However, a full assessment would be needed.

"That's what I was thinking." The nurse, Abba, was setting the pulse ox probe on the patient's finger. The sat read 86%. "Her blood pressure is also way high."

Peering up at the monitor, the BP read 192/124. I reached for my handy dandy stethescope and took a quick listen. Happy, the nurses supervisor, and a second nurse arrived and were now standing by my side.

"What do you think? Wet?" Abba asked. She was a good nurse. I had her trained well. A less worthy nurse would have said, "We need a treatment," without further assessment. This was working out just perfect. The way it should be done.

"Yep." I said.

"I think we should do an EKG, ABG and perhaps a treatment." Wow. It feels good using my brain.. A rush of joy filled my veins. Man, it feels so good to use my skills..

I paused a moment. I looked at the patient. Her head was now bowed between her arms so the back of her head stared at the ceiling. It's a miserable feeling not being able to breath. I understood completely.

I paused, however, because I wanted to make sure I wasn't overstepping my bounds. I didn't want to do a bunch of procedures that were not necessary. Rather, I didn't want the nurses in the room to think I was on a power trip like the Air-Flight nurse the other night. I looked at Happy. "Do you agree?"

"Oh, definitely," she said.

As per protocol, the doctor was called before the tests were completed. As I arrived back at the nurses station after running my ABG, the nurse set the phone on the receiver and peered over at me. "He said, 'Mumble, mumble, mumble, give her 20 of Lasix, mumble, mumble, mumble.'"

"As expected," I said, smiling.

"I told him that we did the treatment and the ABG, and he slammed the phone in my ear." She smiled as though she had expected as much. "I guess he doesn't care. So I'll write the order for those."

I said, "Hey, that's fine, because at least now we don't have to stress out about not knowing what her status is. We got all the test results done before the doctor was called. How many times do you sit and worry about a patient the doctor appears not to care about?"

"Not any more," she said, " But I'm glad we did the EKG at least, because her blood pressure is still in the 190s. He didn't seem to care at all about that. And I told him we did the ABGs and he still hung up the phone in my ear. It was almost as though he was annoyed that I even called."

"Well, perhaps we overstepped our bounds a bit. But I think it's great that we have this team. And I think we should always call the RRT before the doctor is called on these patients so we can do the tests we think are needed that the doctor won't order."

"I absolutely agree. I mean, we are the ones at the patient's bedside. We see right up close how the patient is doing, how she feels. The doctor just wants to get off the phone so he can get back to bed."

"Well, to be fair not all doctors are like that, but that one is."

I checked on the patient. She was snuggled under the blankets and the head of the bed was all the way down, a sure sign she was fine now. Despite that, I said, "Mrs. Beer, are you feeling better."

She nodded, turned to look at me, "Yes."

"Did the treatment work for you?"

"Yeah, I'm still a little short of breath, but I feel much more comfortable."

I know you guys are saying: "Why the hell did you give the breathing treatment when you figured the patient was wet? If a doctor did that you'd complain about it."

True. But sometimes pulmonary edema can cause bronchospasm, and sometimes a treatment can help treat that symptom. What I hate is when the treatment is ordered Q4 after the fact, when they are no longer needed. I have no problem trying one treatment.

I checked on her a few times the rest of the noc shift and she was sleeping comfortably each time, which meant the doctor was right on this one.

The patient gave us no further trouble, which was a good thing, because a half hour after I was finished with her, "SIGNAL ONE in CCU!" railed across the overhead speakers.

It was one busy night. But one in which I used my skills. It was awesome.