Everything RTs need to know about Sepsis

This post was originally published on January 29, 2008. It is part of the classics of the RT Cave collection. While some of this is outdated, most of it is not.

So, in our quest to become more well rounded therapists, we must now look into another common condition, a condition that is the leading cause of death in critical care units.

For starters, we need to know that is is the leading cause of death in critical care units. Of the 750,000 patients it effects every year, 250,000 will die. These statistics cannot, and are not, being ignored. Hospitals continue to work overtime to create guidelines to help caregivers both recognize and diagnose sepsis so those who have it can get the treatment they need. Likewise, efforts can be made to recognize who is at risk for developing sepsis so it can be prevented.

These statistics have gone pretty much unchanged since the early 1980s. So, even with modern knowledge and technology, hospitals have been unable to break this trend. Yet they are, as noted above, working overtime to do just that.

But there is another side of sepsis that we must look at, and this is the financial side. While the experts will tell you and me that they are working overtime to make changes that improve lives, the bottom line is usually money. And this is the case here as well. For instance, according to the MUST protocol (which is now outdated, and the link is outdated as well), cost estimates nationwide tend to scale into the $17 billion category. I'm not sure what the data is for each individual hospital, but I imagine it's a lot of money, most of which hospitals eat.

So, sepsis is expensive. Actually, we can probably go deeper than this, and say that Medicare probably forced hospitals to look at this. Now, many hospitals had already begun their own research into it, but the government seemed to force their hands, so to speak. I'm not blaming government here, I'm just saying, sepsis kills, it costs a lot of money, and efforts are ongoing to improve upon them.

So, with the hope that hospitals would create sepsis protocols (many are now well beyond a gamut of committee) of their own, the MUST protocol was created to be used as a guideline protocol. According to the protocol itself, most hospitals have not adapted it (although this has changed since the original publication of this article). but I do know that many hospitals are looking into creating their own sepsis protocols (most already have).

So, what is sepsis. It's caused by an injury. Your body is infected by a pathogen, most likely a bacteria. Your immune system recognizes this. T-cells identify them as harmful, and initiates an all out immune response. This ultimately causes cells in the infected area to leak their fluid, and this causes inflammation. This response is necessary to trap pathogens.

Inflammatory mediators are released into the blood stream and sent to the area of infection to cause inflammation. Ironically, sepsis is a pathological process caused by the widespread release of these inflammatory markers into the bloodstream, with or without an initiating infection. When these get to organs, they can injure them, even cause them to fail, resulting in death.

There's a little more to it that what I just described, although it's all a respiratory therapist needs to know.  The basic theory here is early recognition and early treatment can greatly diminish injury, and reduce the death rate from sepsis. This, in turn, can reduce healthcare costs.

(Although, ironically, the costs to individual hospitals rises considerably. This is especially true as they do many procedures automatically on anyone who meets criteria for the sepsis protocol. Medicare will usually be the only one who saves money,and that's usually all that matters.  But I digress.)

Here are the early signs of Sepsis:

A. Suspected Infection

B. Two of the following: Meeting two of these should trigger the sepsis protocol (editors note: This may have changed slightly since then).

1. Temperature greater than 100.4, <96 .8="" li="">
2. Fast heart rate, or greater than 90 beats per minute
3. Fast respiratory rate, or greater than 20 breaths per minute, or a PaCO2 that is elevated above a person's baseline (for this reason, an ABG is usually included in the sepsis protocol. Likewise, a pH that is acidotic can be an early sign of organ failure)
4. <32>High white blood cell count (greater than 12,000 or <4000>10% bands)

C. Systemic blood pressure <90>

D. Lactate greater than 4.0 or elevated LDH

E. Decreased platelets (watch for DIC)

F. Decreased PaO2, or a PaO2 below normal for that patient

G. Altered mental status not due to drugs may signify organ failure.

Here are the signs of Severe Sepsis:

A. Patient receiving antibiotics & needs Vasopressor (this is a dangerous sign).

B. Pt showing signs of organ failure in 2 + systems for <= 24 hrs.
<90>
C. Patient showing signs of Adult Respiratory Distress Syndrome, DIC, or Multi System Organ Failure.

There, that's pretty much all you need to know. These are all things you can learn from a quick assessment, which may entail talking to the patient or family members, talking with doctors and nurses, or simply by looking into the patient's chart. We at the RT Cave think it's always a good idea to look a the patient's laboratory results anyway, if time allows.

From there doctors and nurses use their magic potions to fix the patient. This may entail Activated Protein C, the only drug to show any efficacy in sepsis. It may also entail antibiotics and steroids. It may also include vasopressors to control blood pressure.

Central Venous Catheter administration may be indicated to adjust vasopressors, to monitor fluids, and to determine if a blood transfusion is indicated. These and other therapies may be prescribed just in case it might do something, which is often the issue with administering albuberol for sepsis and heart failure. So, you never know, albuterol might also be indicated for sepsis.

It's nice to know all this, although it comes secondary to whatever our job is at the time. The hardest part about treating patients is getting to the bottom of what's causing their symptoms, and you and I both know a breathing treatment with albuterol is often a top-line option. So, while you're standing there waiting for the treatment to get done, you can do some investigating for the true cause of that shortness of breath, or whatever symptoms you are treating.

Still, I have had times when the true diagnosis eludes even the best nurses and doctors, and in these cases it's nice to have a well rounded RT come into the scene and say, "Hey, maybe this is what the true cause is!"

Edited on July 5, 2016, by John Bottrell 

Everything RTs need to know about Sepsis

This post was originally published on January 29, 2008. It is part of the classics of the RT Cave collection. While some of this is outdated, most of it is not.

So, in our quest to become more well rounded therapists, we must now look into another common condition, a condition that is the leading cause of death in critical care units.

For starters, we need to know that is is the leading cause of death in critical care units. Of the 750,000 patients it effects every year, 250,000 will die. These statistics cannot, and are not, being ignored. Hospitals continue to work overtime to create guidelines to help caregivers both recognize and diagnose sepsis so those who have it can get the treatment they need. Likewise, efforts can be made to recognize who is at risk for developing sepsis so it can be prevented.

These statistics have gone pretty much unchanged since the early 1980s. So, even with modern knowledge and technology, hospitals have been unable to break this trend. Yet they are, as noted above, working overtime to do just that.

But there is another side of sepsis that we must look at, and this is the financial side. While the experts will tell you and me that they are working overtime to make changes that improve lives, the bottom line is usually money. And this is the case here as well. For instance, according to the MUST protocol (which is now outdated, and the link is outdated as well), cost estimates nationwide tend to scale into the $17 billion category. I'm not sure what the data is for each individual hospital, but I imagine it's a lot of money, most of which hospitals eat.

So, sepsis is expensive. Actually, we can probably go deeper than this, and say that Medicare probably forced hospitals to look at this. Now, many hospitals had already begun their own research into it, but the government seemed to force their hands, so to speak. I'm not blaming government here, I'm just saying, sepsis kills, it costs a lot of money, and efforts are ongoing to improve upon them.

So, with the hope that hospitals would create sepsis protocols (many are now well beyond a gamut of committee) of their own, the MUST protocol was created to be used as a guideline protocol. According to the protocol itself, most hospitals have not adapted it (although this has changed since the original publication of this article). but I do know that many hospitals are looking into creating their own sepsis protocols (most already have).

So, what is sepsis. It's caused by an injury. Your body is infected by a pathogen, most likely a bacteria. Your immune system recognizes this. T-cells identify them as harmful, and initiates an all out immune response. This ultimately causes cells in the infected area to leak their fluid, and this causes inflammation. This response is necessary to trap pathogens.

Inflammatory mediators are released into the blood stream and sent to the area of infection to cause inflammation. Ironically, sepsis is a pathological process caused by the widespread release of these inflammatory markers into the bloodstream, with or without an initiating infection. When these get to organs, they can injure them, even cause them to fail, resulting in death.

There's a little more to it that what I just described, although it's all a respiratory therapist needs to know.  The basic theory here is early recognition and early treatment can greatly diminish injury, and reduce the death rate from sepsis. This, in turn, can reduce healthcare costs.

(Although, ironically, the costs to individual hospitals rises considerably. This is especially true as they do many procedures automatically on anyone who meets criteria for the sepsis protocol. Medicare will usually be the only one who saves money,and that's usually all that matters.  But I digress.)

Here are the early signs of Sepsis:

A. Suspected Infection

B. Two of the following: Meeting two of these should trigger the sepsis protocol (editors note: This may have changed slightly since then).

1. Temperature greater than 100.4, <96 .8="" li="">
2. Fast heart rate, or greater than 90 beats per minute
3. Fast respiratory rate, or greater than 20 breaths per minute, or a PaCO2 that is elevated above a person's baseline (for this reason, an ABG is usually included in the sepsis protocol. Likewise, a pH that is acidotic can be an early sign of organ failure)
4. <32>High white blood cell count (greater than 12,000 or <4000>10% bands)

C. Systemic blood pressure <90>

D. Lactate greater than 4.0 or elevated LDH

E. Decreased platelets (watch for DIC)

F. Decreased PaO2, or a PaO2 below normal for that patient

G. Altered mental status not due to drugs may signify organ failure.

Here are the signs of Severe Sepsis:

A. Patient receiving antibiotics & needs Vasopressor (this is a dangerous sign).

B. Pt showing signs of organ failure in 2 + systems for <= 24 hrs.
<90>
C. Patient showing signs of Adult Respiratory Distress Syndrome, DIC, or Multi System Organ Failure.

There, that's pretty much all you need to know. These are all things you can learn from a quick assessment, which may entail talking to the patient or family members, talking with doctors and nurses, or simply by looking into the patient's chart. We at the RT Cave think it's always a good idea to look a the patient's laboratory results anyway, if time allows.

From there doctors and nurses use their magic potions to fix the patient. This may entail Activated Protein C, the only drug to show any efficacy in sepsis. It may also entail antibiotics and steroids. It may also include vasopressors to control blood pressure.

Central Venous Catheter administration may be indicated to adjust vasopressors, to monitor fluids, and to determine if a blood transfusion is indicated. These and other therapies may be prescribed just in case it might do something, which is often the issue with administering albuberol for sepsis and heart failure. So, you never know, albuterol might also be indicated for sepsis.

It's nice to know all this, although it comes secondary to whatever our job is at the time. The hardest part about treating patients is getting to the bottom of what's causing their symptoms, and you and I both know a breathing treatment with albuterol is often a top-line option. So, while you're standing there waiting for the treatment to get done, you can do some investigating for the true cause of that shortness of breath, or whatever symptoms you are treating.

Still, I have had times when the true diagnosis eludes even the best nurses and doctors, and in these cases it's nice to have a well rounded RT come into the scene and say, "Hey, maybe this is what the true cause is!"

Edited on July 5, 2016, by John Bottrell 

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.

No more T-Piece

Remember how we used to hook up intubated patients to a t-piece connected to wide bore tubing and an oxygen source to see if a patient was ready to be weaned? Well T-piece no more.


Most microprosessor ventilators allow for you to place the patient in CPAP, and with minimal pressure support to make up for the resistance of the narrow tubing, you can allow the patient to spontaneously breathe, while also having the advantage of alarms to warn you if the patient stops breathing, or is breathing too fast, or otherwise is pooping out.


Our protocol recommends that we use a pressure support of 5 for ETT less than 8, and 0 for ETT greater than 8 during our spontaneous breathing trials (SBT). T-pieces are no longer recommended and rarely used.


Our anesthesiologists still, on occasion, use T-Pieces to make sure a patient is ready to be extubated. That is the only place T-Pieces are still used at Shoreline Medical.


Does your hospital still use T-Pieces to wean?

guidelines to adjusting ventilator settings

So you're tired of doctors just making up ventilator changes. Here are the recommended AARC guidelines for adjusting ventilator settings. Study these, and impress a doctor or a nurse with your wisdom:

1. PaCo2 greater than 45 (or EtCo2 greater than 50)

• Increase RR
• Increase VT

2. PaCo2 less than 35 (or EtCO2 less than 30)

• Decrease Rate
• Decrease VT

3. PO2 less than 60 (or SpO2 less than 90%)

• Increase FiO2 to 60%
• Increase PEEP
  
• Increase FiO2 to 100%

4. SpO2 greater than 95% (or appropriate oxygenation for patient)

• Reduce FiO2 to 60%
• Reduce PEEP to 5
  

This is to act as a guideline only to assist you in making the appropriate ventilator changes based on invasive ABG results and/ noninvasive EtCO2 and SpO2 monitoring. Of course you'll need to know your patient.

For a great review of EtCO2 monitoring check out this post.

For a printable cheat sheet with this information and more, click here.

For a printable cheat sheet for EtCO2 monitoring click here.

Ventilator Delerium should not be overlooked

I don't think this matters so much on day shift, but I think on the night shift we RTs and RNs and doctors when writing orders ought to have more consideration for the amount of sleep our patients get, especially patients in the critical care on a ventilator.

There's this thing called Ventilator Narcosis (Delirium) that I think is way underdiagnosed. In fact, I bet it hardly ever gets diagnosed.

According to the August, 2007, issue of Chest, Ventilator Delirium effects 85% of patients receiving mechanical ventilation, resulting in , "and has been linked to prolonged length of stay, reintubation, higher mortality, and higher costs of care."

Delirium, or cognitive decline, often effects elderly patients who are on narcotics or benzodiazepines and left in a state of coma (or "suspended animation") for lengthy periods of time, thus resulting in a poor quality of sleep.

Or, poor lighting coupled with the above and continued patient agitation resulting in lack of adequate sleep often causes a patient (particularly the elderly) to enter into a state of cognitive decline. This happens even in elderly patients who are in otherwise good physical condition.

Likewise, "recommendations by professional societies have established the importance of delirium monitoring and recommended it as standard practice in ICUs all over the world."

Roger Striker at RTMagazine.com provides a more cons ice definition:

"Delirium, as defined by the DSM-IV, requires an acute disturbance of consciousness with reduced clarity or awareness of the environment (eg, an inability to focus or to sustain or shift attention) and either (1) a new cognitive change (eg, deficits in memory or orientation, or a language disturbance) or (2) a new perceptual disturbance (eg, hallucinations or misinterpretations).2 Delirium frequently develops over hours or days, and fluctuates over time.

One of the major contributing factors is believed to be poorly dosed, or too much, narcotics for the age of the patient. Many experts who study ventilator delirium note that most doctors dose narcotics the same for most patients, when the dose should be adjusted for age and size -- particularly in the elderly.

Along with too much, or poorly dosed narcotics, we hospital staffers add to this problem by constantly irritating the patient.

Think about it though. You would go nuts too if the lights were on in your bedroom all night long, and every two hours someone came in to brush your teeth, and every hour between that someone came in to roll you over, or wipe your bottom, or break the circuit of the vent to give you a breathing treatment or squirt in an MDI, or dump water out of the circuit, or insert a new IV.

There have been studies done on this, and the result to every one I've read the experts conclude that the lights need to be out for at least 8 consecutive hours a night, and interfering with the patient needs to be kept to a complete minimum in order for that patient to get a good nights sleep to prevent Ventilator Narcosis.

However, at Shoreline Medical, we have a protocol that calls for 2 puffs of Ventolin every 6 hours, and a good mouth cleaning every 2 hours, and shifting the patient from side to side every hour. The result here is that the patient never gets more than one hour of consecutive sleep.

Since the average sleep cycle lasts 1.5 hours, one can assume that ventilated patient rarely if ever gets through a cycle. And, the result of lack of enough REM sleep is psychosis.

What has me most concerned is brushing the teeth every 2 hours. I understand that a good mouth cleaning is a great way to prevent ventilator acquired pneumonia, but I think there comes a time you use an amount of common sense and just let the patient miss a few of these mouth cleanings so he can get some sleep.

Some RNs I've talked to agree with me, and they ignore the protocol at night. Some, however (those who do everything by the book), never miss a mouth cleaning. To these individuals, the reasoning "I have to do it because it's protocol," or "I have to do it because the doctor ordered it," supersedes common sense.

I understand that rotating the patient often is a great way to prevent blood clots from forming, although I don't see why a little night time common sense can't prevail to allow the patient to sleep.

I understand why the overhead light needs to be on most of the day to so we can see the patient from the nurses station, but putting on the nightlight for six hours during the night shift is a great way to allow the patient to fall asleep and get some REM.

Thankfully most patients don't remember being on a ventilator anyway, even if they appear to be awake and appropriate at the moment. I have asked many patients a day or two after extubation if they remember anything, and a majority of them say, "No. I remember nothing."

Riker notes, "Most trauma patients have no recall of their ICU stay, but slightly more than one third do remember these events; 88 percent of the time, they have fantasies or hallucinations about being in prison and trying to escape."

So, the next time you are taking care of a patient on mechanical ventilation, ventilator psychosis or delirium or cognitive decline should be something for you to consider discussing with the attending physician.

He knew no life without her

She was 91 year old mother, grandmother -- wife. Her hair was ruffled to a degree she never in her adult life ever let anyone see, yet I was seeing it. Her skin was pale, no makeup. Her kith and kin may not even recognize her.

She looked up over the BiPAP mask, the machine that was supposed to give her wet lungs time to heal. Her eyes were circled with signs of anxiety and sleeplessness. In her weary eyes I saw all the years of cooking apple pies, hugs and kisses, and love.

On the other side of the bed, holding her frail hand, was the great man she was married to for 75 years; the only man she had ever loved. If ever there was a sign of soul mates, this was it. A feeling of sorrow rushed through my veins as I couldn't help feeling sorry for him.

Although, in a discussion the day before with this man, he said, "Whatever happens it's what God intends. Whatever happens, we had 75 great years together." He smiled then. There was no smile now. He was somber. The decision was made.

I listened to the sigh of the machine as it assisted her with a breath, and the hiss as she inhaled through the mask; the tubing, the machine's exhalation port. The cycle continued again and again. Yet it was my job now to end it. "It's time for her to go home," her husband said.

A vision of yesterday rocked in my head. Dr. Adams walked into the room, shook the old man's hand. I imagine Dr. Adams was thinking the same thing I was thinking now, that for a 93 year old he looks healthy, perhaps not a day over 80.

The husband said to Adams, "I promised her I wouldn't let her suffer, and she hates that thing. I think it's time to take it off. It's time to let her go."

Dr. Adams sighed, said, "With more time we might be able to nip this thing. We can give her body time to heal."

The old man said, "It's time. Let's just do it."

I unleashed the Velcro straps that supported the mask around her head and lifted the mask off her face. She sighed, smiled, looked up at me, took my hand, held it tight, and lipped, "Thank you."

I held her hand what seemed like five minutes, and then I left the room. It was time for her husband to say goodbye -- her best friend. He did not know life without her. What was he going to do. Would he be able to cope? Those thoughts rushed through my somber mind.

Outside the door I turned and looked back: he had his head on her chest, his hand gently caressing her face. They were together as one. Oblivious of the circumstances, they were happy.

I got busy and never saw him again. At around three in the morning I got a page to call critical care. Instead of calling I walked there, and as soon as I looked into her room I knew what the page was for.

I was happy my patient extubated herself

Okay, yesterday I wrote about the OD patient that we didn't intubate because we gave her Narcan and let her puke all over the ER. Tonight I come to work and an OD patient is on a ventilator.

She is awake and alert and thrashing, but she can't quite get to that ETT with her fingers all stretched out. And the Ativan doesn't work so well because she's used to getting oxycontin. This is turning out to be a miserable night.

I get on the phone with the doc. "Listen, this lady is a mess. She's awake, alert and thrashing at the bit. Can we just extubate her?"

"Not until morning." Click.

That was at 9 p.m. At 7 a.m. I was called to the CCU because, "Your patient just extubated herself."

"Yes," I said.

I took my time getting to the CCU and find two nurses all stressed and holding the ETT in place. The patient is being vocal. "This is awesome. Just yank it."

"Are you sure?"

"Yeah. It should have come out 12 hours ago anyway if the doc wasn't so lazy."

I'm telling you, those nurses were all stressed out. And here I come along all happy because my patient extubated herself.

"Oh, Dr. so and so will be so mad," the RN said.

"Who cares," were my exact words.

Grrrrrr

Nothing like a little Calvin and Hobbes to sum it up for me.

But that headline there about sums up my weekend from hell. And I still have six hours left.

It's one thing to be busy just in ER. It's one thing to be busy just on the patient floors. It's one thing to be busy just in the critical care. But when they are all paging you one after the other all weekend long, it's.... Grrrrrr.

Every person who could posibly have gotten sick this weekend did. I've taken care of everything from sick kids (see my last 2 posts) to adult vents.

Actually, about the only thing I haven't had is a code, but I have had at least five occasions when a patient has come close. And even a code would be better than trudging from one room to the next, from floor to floor to...

Come to think of it. Is there a reason that emergency rooms and critical care units are so far apart in hospitals. That's how it's been at all the hospitals I've worked at.

I think they do it this way to wear out us RTs. I don't think hospital builders think of how far RTs have to walk. No wonder my feet are killing me. I read one place that an RT walks on average 20 miles a day. I bet there's some validity to that.

And, here's another observation, whenever I have a ventilator in the unit (not like they put them anywhere else, but you know what I mean), ER is almost always busy. It's like clockwork. Just as you start a treatment in the unit, ER calls. Then you get to ER, and CCU calls you back.

Then when you sit down to have something to eat, they both call you at the same time, and then you get a third page that a patient on the floor needs (wants) a treatment.

I suppose it wouldn't be so bad if there were two of us, but it's just me. And, for whatever reason, I never call in help. It's not so bad being swamped the first two nights, but by the third night, when things still haven't slowed down, you start to drag your feet.

I'm sure you guys know what I'm talking about.

Now, on the fourth night, I'm... Grrrrr. I'm a freight train coming through, get out of my way. If you order a stupid procedure, I might slip up and tell you what I think. I will try to hold back, but I don't know if I will be able to.

And, if those two RSV kids in ER right now end up getting admitted, I think I might break down and cry.

Okay, so I won't do that. But I could.

That pretty much sums up how I feel right now as the lone night shift RT.

Grrrrr...

Most Drs are patient, but some just intubate

To be fair to the nurses and the doctors in my last post who were eager to intubate the patient who tried to kill herself with a massive amount of a certain drug I can't remember the name of, I did leave one very important key point out. I was suffering from lack of sleep yesterday, and from massive burnout, so you have to cut me some slack here.

When the patient was first transferred to her new bed in CCU she had no gag reflex when I suctioned her airway to remove a massive amount of secretions that had accumulated there. Then she provided no response to the sternal rub. She was out. That, coupled with the fact she was agonal breathing, the nurse and the patient's physician decided the patient should be intubated to protect the airway.

Technically speaking, that was not a bad idea. However, I knew for a fact the patient was not like this an hour before, and that's why I thought maybe there was something else we were missing that might prevent her from needing to be intubated. So I did a blood gas while the nurses called the patient's physician.

When I noticed the gases were not exceptionally well, I called the patient's RN from the laboratory and informed her Dr. Krane should be notified with these ABG results since this was her patient in her, and I told the nurse I'd rush down to ER and show her myself. Then, en route, I decided I would just go up to the CCU to be with the patient, and, lo and behold, when I got up there Dr. Krane was standing alongside the patients bed.

"Holy cow," I said, "How in the world did you know we needed you? And how did you get up here so fast?"

"I was just concerned about the patient," Dr. Krane said, "And I wanted to make sure she was okay for you guys."

"Well, I'm very impressed."

Then she stunned me with this: "Give a breathing treatment."

Oh, come on. Here the patient is crashing and you want to give a breathing treatment? Like a good boy, I set up the treatment and fitted the mask on the patient's face. This ought to cure her of all her ailments.

Then Dr. Krane provided us with some information we did not receive in report. "I just talked to the husband, and he informed us that she (the patient) uses her rescue inhaler 5-8 times per day."

Aha, well, that makes more sense. "Well," I said, "In that case she probably uses it 10-16 times per day, because it's usually double what they say."

"True," she said.

Dr. Krane and I watched over the patient, literally, for the next 30 minutes, and I kept watching the clock and the entry way to the CCU for any signs of the doctor who said he would be here any minute. I prayed he was really late.

As she watched over the patient, eyed the numbers on the monitor which showed a heart rate of 126 but otherwise normal vitals, I wondered if she thought she had overlooked something in ER. Was she sleeping the last 6 hours the patient was down there and too lazy to check in on the patient and the nurses didn't pick up on the fact the patient was failing?

"You saw this patient in ER," she said, "Did you notice she was labored?" Perhaps I'm right.

"No," I said, "She wasn't labored at all. What do you think?"

"Well, I think she's going to be fine with the breathing treatments. I think that she hasn't had her bronchodilator in well over 12 hours, and her body responded to the transfer to the floor by having an excacerbation of asthma." She continued to look at the patient, and only occasionally looked up at me. "I think if we just be patient here we won't need to intubate."

"I really like that idea," I reassured her, as though it mattered what I said.

"What do you think of this doctor," she said. I figured she was referring to Dr. Seamon.

"I don't know Dr. Seamon very well," I said, "But I think he'll want to intubate as soon as he gets here regardless, and he'll want a massive tidal volume like 1000 or something stupid like that." Dr. Krane laughed.

Seriously, while I think she does order some stupid treatments, she is really nice. I didn't always think that way though. I've learned to keep an open mind about people I meet while working, and not take anything they say personally. Many people I talk to can't stand her because she is such a control freak.

"I think she will be fine," she said.

"Well, did she have a gag reflex in ER?" I asked.

"Yes, we tried to put in an oral airway, and she definitely responded."

I hesitated a second, as I didn't want to ask a stupid question, then I decided the heck with it. "Why do you think she's has no gag reflex all of a sudden?"

"I think the (drug she took) has peeked. In ER she was just lying there almost obtunded, but she was comfortably breathing. She was in a deep drug induced sleep."

"How long is that drug supposed to last?"

"I know she does cocaine and other stuff too, but poison control said about 24 hours. We can't know for sure how long it will last, but if we monitor her very closely we should be able to avoid intubation. However, that's my opinion, and I won't have jurisdiction over this patient as soon as Dr, what's his name? gets here."

"Dr. Seamon."

"I thought you guys said he would be here any minute." She smiled.

"That's what he said.

Now, fast forward over what I wrote yesterday to the intubation. As soon as we turned the patient on her back she started fighting. When the anesthesiologist started to insert the tube, the patient fought vigorously and even sat up -- twice.

She was obviously no longer under the deep, dark influence of the drug. And she had an obvious gag reflex. That, coupled with the good repeat ABGs, made me wonder if the patient didn't need to be intubated after all. But Dr. Krane was no longer in control, and I had transferred my beeper to my relief.

While watching all this, and assisting in holding the patient down so she didn't whack some nurse or my fellow RT in the head, I watched as the anesthesiologist drew up a white medication via syringe. These doctor's are very intense on intubating this patient. Are they forgetting to look at the big picture?

I audaciously tossed out an idea, "Um, you guys might want to disagree with me here, but I just wanted to toss this idea out. Since she appears to be responding to your efforts here, do you think we still need to intubate?"

"Oh definitely," Dr. Seamon said without hesitation, "We need to protect the airway."

My coworker, while holding cricoid pressure with one hand and bagging with the other, looked at me with a funny grin and rolled his eyes. We RTs, you know, have no control. And it's not that we don't want to take care of another vent patient, it's more that we wonder if sometimes, just sometimes, hospital staff get over aggressive with some patients.

After a lot of tinkering, finally the patient was intubated, and the airway secure. Dr. Seamon said, "Let's see, I think a tidal volume of 750 should be good, a respiratory rate of 14 and, oh, how about 50% oxygen."

My coworker looked at me, cocked his head and rolled his eyes. I knew exactly what he was thinking. "I calculate a tidal volume of 600 for this patient, and definitely no more."

"Well," Dr. Seamon said, "I learned to go by weight, and this patient weighs 230 pounds."

"No!," my coworker chimed, "We go by size..size definitely. How tall is this lady."

"I was told she's 5 feet 3 inches," I said, "and I calculate 350 to 600 is the tidal volume range based upon our ventilator protocol of 6 to 10 millimeters per kilogram of ideal body weight." There, that should help you out Dave.

"Okay, well, start out at 700 tidal volume then," Dr. Seamon ordered.

Dave rolled his eyes again, and made no effort to hide it from Dr. Seamon.

I laughed audibly. I'm sorry, but I was very tired, as I had been at work 13 hours at this time. Nobody but Dave noticed I was laughing, though. I looked at each person in the room, and they were all intense with their respective tasks.

I couldn't hold it in any longer. I wished Dr. Krane was still here, because she had a clue.

Later, as I was finally giving Dale report, he said, "What the hell tidal volume do you figure for this patient."

"Max 600, but with her asthma I'd go lower."

"Good, because the vent was set at 500, and that's what I used."

"I thought it was cool you showed frustration to Dr. Seamon," I said, "but I had that discussion earlier with him and I didn't care what he said, because he doesn't have vent privileges here, and we have our protocol. I was just doing to set it at what I wanted, and hope the Internist agrees with me when he gets here.

"Right on," he said, and smiled. "I just give up."

We have to keep in mind here, however, that the medical field is an art that is based on science. And there is often more than one right answer. Thus, while I disagreed with this intubation, I could still be wrong.

Fewer Vent paitents is ailing small town RT Caves

It used to be really busy here at Shoreline. In fact, even back two years ago I remember being so busy I didn't even have the time to read a chapter of whatever book I stuffed into my tote bag.

In the past year, however, I feel like I could literally sit here in the RT Cave and write an entire novel -- each night.

About a week ago we had a patient on the ventilator when I arrived. Don't laugh, but I had to actually search for the silence button. And then, that same night, I had to set up a vent. My brain was a little rusty, and I couldn't remember the formula for determining ideal body weight.

Other than that I was in RT Heaven that night; it felt great to be doing real RT work.

But that was one night. The next night we were back to our usual 10 patients, 9-10 of whom giving the treatment was equivalent to having them drink a glass of water for pneumonia.

I saw a recent trends report for Shoreline, and it went something like this: 99 vents set up in2000, 98 set up in 2001, 88 in 2002, 80 in 2003, 84 in 2004, 74 in 2005, 48 in 2006, 24 in 2007.

None the downward trend.

What's the reason for this? Total patient admissions have been consistent, so it's not because people are choosing a different hospital. BiPAP set-ups have been consistent, so it's not because the BiPAP is saving people from going on vents.

Another trend is length of stay on the ventilators, which has dramatically dropped from an average of 100 hours per patient all the way down to 21 hours per patient. This, I believe, can be attributed to a variety of factors, including quality staff, great doctors who are more receptive to protocols, and new microprosessor ventilators.

So, technology can be attributed to some of our decline, but what about the lack of ventilators overall trending down? I have theories here too.

Many of the most critical patients are being shipped to specialty hospitals, i.e. cardiac, neuro, trauma. While we used to take care of more cardiac patients, it doesn't make much sense to keep them here when they can be minutes away from a cardiac doctor.

Not that we still couldn't take care of these patients here. We could.

Likewise, more and more patients are prevented from moving to the critical care floor due to early intervention and treatment. This goes along with improved education, quality of care and increased vigilance regarding patient's showing early signs of problems and nipping them in the bud.

So, now I sit here with seven or eight expensive state of the art ventilators collecting dust in the back closet. I'm prepared to take on an epidemic, and yet here I sit while my skills atrophy.

I've written before on these pages how we have been trying to get protocols, and how the RT leaders are against them more so because they are afraid they will result in less work for us. Well, what better time than the present for them to make their case.

I know from reading other blogs, and talking with other therapists, that we are not alone in this.

This is part of a developing trend for small town hospitals. In fact, it might be the wave of the future. We might never get back to the level of having 100 vents in a year again, even though we are more than equipped to handle it.

The reason I saw these statistics is because the admins are concerned about recruiting RTs here in the future. Are we going to be able to recruit RTs to a hospital when they know they'd just sit around waiting for an emergency to happen, as my main character does in "The RT Cave in the Year 2020."

If you're a young RT fresh out of RT school who wants to keep his skills up, a small town RT cave may not be for you anymore. But trust me when I say that wasn't true two years ago, and it definitely wasn't true when I started here.

Rumor has it the admins are aware of how a high quality area is being underutilized, and are seeking to bring something in to generate some business for us. That in itself is a scary idea, especially if this downward trend is an aberration.