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 While some of this is outdated, most of it is not.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 For instance, according to the MUST protocol (which is now outdated, and the link is outdated as well), cost estimates nationwide tend to scale into the $17 billion category.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 

The common sense approach to hard luck asthma

A hard luck asthma patient came to see me in the ER last night. She had asthma so bad she actually spent some time at National Jewish recently (she hated the place). Since I was an asthma patient there in 1985 for six months, we had a nice chat.

That aside, after several breathing treatments I found myself standing behind the nurses station. The doctor (Dr. Q1) was concerned by something the patient said to her, which was this: "I gave myself 25 mg of solumedrol 2 days ago, and today I put myself on 80mg. Obviously it didn't work."

The doctor said to me, "She shouldn't be medicating herself like that without a doctor's order."

"Why not," I said. "I used to do that when my asthma was bad every day."

"You used to abuse your medicine?" Her stare was blank.

"Is it abuse?"

"Well yes it's abuse."

"I used to adjust medicine when I was having trouble breathing. If I didn't do things like that I would have ended up in the ER every week of my life. And since I'm not on welfare, I can't afford that. "

"But that's against the asthma guidelines."

"No it's not. The asthma guidelines are guidelines. They also recommend the doctor and patient work together on developing an asthma action plan individualized for the asthma patient. There are some hard luck asthmatics who can be trusted to treat themselves at home. When the said treatment doesn't work, they come to the ER -- like this patient did."

"I don't like that," the ER doc said.

There are many asthma action plans that allow for asthmatics to have a prescription of oral corticosteroids to keep in the medicine cabinet. When the asthma flares up the patient may self medicate and call the doctor.

If it works the patient avoids another expensive hospital visit. If it doesn't, then the patient has someone drive her to the ER, which is exactly what my patient did last night.

I respect Dr. Q1 in that she does a great job with her patients. But her inflexible methodologies of treating patients means that all patients get treated alike, and the ideal therapy for the patient may be overlooked.

Then again, this is the same doctor who believes only doctors are capable of determining what patients need breathing treatments and how often (usually Q1).

A guideline is just a guideline

The Happy Hospitalist wrote a neat post about guidelines from a doctor's perspective. But he reminds us that while a guideline is a good tool, it is just a guideline.

We'll make this RT Cave Rule #15:

RT Cave Rule #15: A guideline is just a guideline. It is not a substitute for experience and common sense. For the most part, that guideline is just a tool.

I've written on this blog about how sometimes asthmatics require a bronchodilator more often than is recommended on guidelines.com. Sure the guideline states that if a rescue inhaler is needed more than 2-3 times a week, your asthma is not controlled. But just because someone uses his inhaler more often, does not always make for uncontrolled asthma.

Look at it this way. What if a person had bad asthma, and used his inhaler 10 or more times in a day. As time goes by he and his doctor eventually find a better medicine routine, and the patient makes a few changes in his life, that allows him to only need to use his MDI 2-3 times a day instead of 10.

This same person is active in the community, and stays physically active. You cannot tell me that this person has uncontrolled asthma.

In fact, this brings us to RT Cave Rule #16:

RT Cave Rule #16: If you have asthma and you do not miss work, and you do not miss school when you are a kid, and you are able to lead a relatively normal life, then your asthma is controlled. That's how we define asthma control. It's not based on how often you use your rescue inhaler.

The same is true of COPD:

RT Cave Rule #17: Whether someone has controlled COPD is not based on how many times a rescue inhaler is used, or how much oxygen the patient is on, but whether or not that patient can continue to be a productive member of society.

Ideally, however, you want your asthma and COPD patients to not need to use their rescue inhalers, but in the real world, many lung patients get short-of-breath when they wake up in the morning, and might need a few puffs. I don't see a problem with that.

I can use myself as an example here. I have asthma. I work out just about every day, and I jog (not walk) four times a week. And I rarely use my inhaler during the day. However, I do use it a few times during the night, most particularly first thing in the morning. And, most important, I have never missed one day of work due to my asthma. I'd consider my life as normal; my asthma stops me from doing nothing.

However, I have had a few people email me and tell me my asthma is not controlled because the asthma guidelines state that if you use your MDI more than twice a week, then your asthma is not controlled. That might be true of most asthmatics, but there are exceptions to every rule that doctors have to be prepared for.

The same can be said of COPD patients. If you measured COPD control based on how often a rescue inhaler is used, then there would be very few COPD patients who have control of their illness. As we learn in RT school, the goal with COPD patients is to help them remain productive members of society.

Sure, Mrs. Beady might need to use oxygen 24 hours a day, and may even go through an inhaler every month, but her disease does not stop her from performing the daily routines she has been doing her entire life. She is a productive member of society.

Another example of how guidelines are sometimes misused is with ACLS. We have some doctors here who go by ACLS as though it were the Bible.

The other day, for example, I was bagging this little-old-lady with one hand while holding the mask with the other. There was no problem. Air was going in easy.

Then Dr. Krane decided to hold the mask with her two large hands, and I let go and used two hands to bag the same tidal volume. Air started squirting out the edges of the mask: BLLLLLLLLPPPPPPPP.

I looked through the mask, and saw that poor little old ladies facial features all squeezed together. Air wasn't getting in.

"I think you better ease up a bit," I said.

She said, "ACLS recommends one person hold the mask, and one person bag." Yeah, but this lady was ventilating just fine until you grabbed the mask. Let go!

She did not. She had to live up to those ACLS guidelines to a tee, even if it was to the detriment to the patient. The patients sats dropped suddenly.

Now I was in a predicament, because I certainly didn't want to overrule a doctor when she was standing right next to me. Finally, she let go to grab the ETT, and I pumped in some nice easy breaths real fast, and our patient pinked up just fine.

Our doctors are also particular to doing three Q20 minutes treatments. Or, in Dr. Krane's case, Q1 hour treatments. One day I asked Dr. Krane why she does that, she said, "Because it's in the asthma guidelines."

That's fine and dandy, I thought. But what if that first treatment worked and a second wasn't needed. Do I still need to give a second treatment when that first one worked just fine? The patient's all shaky and jittery from the first, do we have to give a second?

According to her guidelines the answer is yes. According to my RT Cave rule, common sense says no.

This brings me to another RT cave rule #18:

RT Cave #18: While guidelines should always be considered, each patient and each patient situation should be assessed and treated individually. We cannot treat all patients the same, as most guidelines portray.

It all comes down to common sense. Guidelines are only as good as the paper they are written on. While they can be a great tool, common sense is the key.

Here are the lastest recommendations for RSV kids

Thanks to Ventworld.com, I've managed to come up with the latest guidelines on bronchiolitis and RSV as written by National Guidelines Clearinghouse at http://www.guidelines.gov/ and based on all the latest scientific research and studies.

These are not new to us RTs in the RT cave, but this is the first time I've actually been able to find all this information in one place. I guarantee you I will leave this lying around the hospital for everyone to read. Perhaps I can enlighten some people.

I would love it if our pediatricians would read this latest research and opt to change their guidelines, however I will not get my hopes up. Doctors at Shoreline, and those of other small town hospitals in this region, prefer to work with antediluvian research.

First and foremost, RSV SWABS are not recommended. I mention this in bold because we RTs have to do RSV swabs at Shoreline. Do other RT departments get stuck with this job? I have no clue.

Likewise, chest x-rays, cultures, capillary or arterial gases, rapid influenza or other viral studies are not recommended because "these studies are not generally helpful and may result in increased rates of unecessary admission, further testing, and unecessary therapies."

Likewise, chest physiotherapy and cool mist therapy (mist tents) are also not recommended "as they have not been found to be helpful."

Oxygen on these children, according to up to date studies, is only recommended if the SpO2 is "consistently less than 91%," and oxygen should be weaned when the SpO2 is "consistently higher than 94%."

This is what I tried to point out to an ER RN yesterday and she tried to debate me that I was wrong. I was not wrong. However, to give her credit, our policy is to place and keep all kids who are unable to maintain an SpO2 under 95% on oxygen.

And, surprise, that means they get admitted.

Here is the part of the protocol that might just cause some doctors to completely reject these new guidelines, because it's just not possible that Ventolin would have no effect on lungs that sound that bad.

But, the new recommendations regarding Albuterol is that it "not be routinely used" for the treatment of RSV and bronchiolitis. I must note here that I did not add the emphasis.

Look, as we RTs have been saying all along, we have no problem trying a breathing treatment. And these guidelines recommend trying one. But, if there are no observable changes noted as a result, then this therapy should be discontinued.

If a child is suspected of having asthma, or is at high risk of asthma, then lets place the child on prn breathing treatments, and give them as indicated, rather than just because.

Note the following: "Although in some cases bronchiolitis may be a prelude to asthma, in the majority of cases the use of inhalation therapies and other treatments effective for treating bronchospasm charicteristic in asthma will not be efficacious for treating airway edema typical of bronchiolitis."

Take that and smoke it in your peace pipe.

Keep in mind, however, that studies have shown Vaponepherine (Racemic Epinepherine) to have a beneficial effect on some RSV kids. So this provides another option for doctors to trial on these children, and discontinue if it has no observable benefit.

What is highly recommended is suctioning. And, to our surprise, our pediatricians listened to us when we recommended this a couple years back, and now we even have booger be gones.

This only makes sense, considering RSV involves secretions in the airway, mostly from sinus drainage caused by a virus isolated (in 75% of the cases) in the middle ear.

Secretions is what causes the SpO2 to drop in some kids, not bronchospasm. And that is why it is recommended to suction before feedings, as needed and prior to breathing treatments if they are indicated.

These guidlines are so impressive to me I almost wonder if they were written by a respiratory therapist.

The following was noted regarding suctioning:

"Suctioning itself may improve respiratory status such that inhalation therapy is not necessary... Suctioning may improve the delivery of the inhalation therapy" if the treatment is given.

I can't believe I'm actually reading this. This is incredible. We RTs have known this for years, and when doctors find this out, well, they'll probably chant something like, "Well, everybody has their opinion."

Setting up continuous pulse oximeters on children under one-years-old is pretty much standard practice around here. However, new research shows that the use of "continuous oximetry measurement has been associated with increased length of stay of 1.6 days."

And, therefore, it is recommended that the child's SATs be checked occasionally, but not continuously because some doctors use it as the sole criteria for admitting children and for keeping them in the hospital "one more day."

There you have it folks. That's the up to date state of the art recommendations by the worlds top pediatricians of the nations top children's hospitals. But, they must have it wrong, because that's not how we do things at this hospital.

Grumpiness stays in the RT Cave

For whatever reason business really picked up last weekend. That, coupled with the chronic lack of sleep and family life, brought me to work on Thursday night on the edge of insanity.

While I'm normally pretty equanimitous no matter what I'm doing, I grumped to my co-workers as soon as I saw the increased number of patients on the worksheet. I clicked on the worksheet I-con on the computer and deleted all the diagnosis's and put in my own.

Here's what the new worksheet looked like. I've always been a proponent of writing reason for treatment instead of diagnosis, and that's what I did here:

• Post-op Bowel: Just because


• Post-op Bowel: Just because


• COPD: needs


• Liver CA/ sepsis: needs


• Hip Fx: Jealous of room mates treatment


• Asthma: exaggeration of


• Pancreatitis: Had a cough once


• Failure to thrive: Nosocomial COPD


• Pneum/COPD: needs


• Hip FX: Bored, needs attention


• Failure to thrive: had ronchi at admission

"Rick you're grumpy," my co-worker wailed. She was a complacent.

"I'm sorry," I grumbled, "but I'm sick of running around doing these useless breathing treatments when I got patients who need my services. All this crap does is wear me out."

She looked at me stunned. She was surprised at my sudden anger, I could tell. She was knew I enjoyed RT humor, but to complain like this was not normal for me. And, if that's what she was thinking, she was right.

I took a deep breath. "Well, now that I got that off my chest, how about report." That was the end of the outward grumpiness for the most part the rest of the night.

However, when a nurse called me to do a treatment on a CHF patient I had just recently did a treatment on, I was blunt on the phone: "She doesn't need a treatment."

"But," the RN said, "She's short-of-breath and wheezing."

"Did you get her up to the bathroom?" That's the only way she'd get SOB that fast, I knew the type. I know my patients that well.

"Yeah, we got her up to the..."

"Well, that's why she's short-of-breath. All you need to do is let her rest." She's a cardiac patient. She has a weak heart.

"But she's really..."

Right here the professional Rick turned on. I know from experience that all the explaining in the world isn't going to work with this RN. "Hey, I will be right there." I should have just said that in the first place.

Being the consummate professional, I knew that I couldn't let my exhaustion effect my work, and whether the patient was recovered in 2 minutes or not I was going to check on her just to be on the safe side. I think all responsible RTs would do the same.

However, I took my time getting there. I was almost certain she'd be fine with rest, and that she really didn't need a treatment for anything other than an oxygen boost.

When I looked in on the patient she was sleeping comfortably. Even though I believe that if someone is sleeping she's comfortable -- most of the time. I woke her anyway. "Hi Mrs. Dee. I'm sorry to wake you."

"No problem, Rick. How's it going today."

"Wonderful," I lied, and then smiled.

RT Cave Rule #8: A true RT professional never carries a mood into the patient room. It's best to keep it in the RT cave.

"I heard you were winded. Are you feeling better?"

She confirmed she was fine. Then I left the room and hunted down the nurse. I probably could have left it at that, but the political me wanted to make sure things were square with the nurse. After a brief hunt, I found her.

"You called for Mrs. Dee, right?" I said.

"Yeah. She's sleeping now, though," the RN said. This was a very nice nurse, but in the past I've had trouble explaining to her RT facts.

"Uhuh. I woke her up anyway. She's a nice lady."

"Yeah. She was really short-of breath. And she was really wheezy."

"I know," I said. "It was a cardiac wheeze."

She gave me a look I interpreted as the, "you are a prick" look. She was thinking I was just another lazy RT. I know when you're exhausted you see problems that aren't really there, so I considered this and decided I would be best to walk away.

The rest of the night I went from one procedure to the next. You know those nights: every time you sit down the pager goes off. By 4:00 in the morning my eyes are burning and my body felt
like it would melt at any moment. My feet were killing me. All of you guys have been here at some point, or will be. Heck, you city dwellers probably go here every day.

My boss called me. I have no clue why she comes in so early, but she does. I trudged to the RT Cave. "Hey, Boss."

She was blunt: "I saw what you wrote on the treatment sheet, and I changed them for you. If Julie saw those she'd write you up." I could tell she was in a good mood. Hell, why wouldn't she: it was her Friday. She didn't have to work weekends like the rest of us.

"Yeah, I meant to take those off by now, but I just didn't get a chance yet." It was the truth.

"You shouldn't put those on there."

"Who's gonna look at my board? And if they do, they'll learn the truth." I tried to feign a smile, but my face was stayed limp. That's how tired I was.

"You know it's not very professional." She was never shy of saying what was on her mind.

"I don't care," I said. I normally would have said something more professional, but when you're really exhausted your true feelings slip out at times. It was one of those nights. "I'm sick and tired of running around ragged when I shouldn't have to."

"I know," she said calmly, "but you really need to stay professional."

"You're right," I said, and set down at the computer to make my changes. Then I thought what I really wanted to say:

I'll be professional all right. When she writes me up, I'll be real professional in front of the admins and explain to them the truth about what the doctors are making us do. I will. Then they'll really be able to cut back on unecessary costs. It's time one of us spoke up. That's the reason things have gotten so bad is because nobody has the nerve to speak up.

"Was it really so bad," the reasonable part of my mind said, "You love your job."

As all of you RTs know, professionalism is more important than releasing frustration. And that is why we participate in RT humor amongst ourselves. That is our release.

This was a very rare occurrence for me to feel grumpy like this. However, and my point in writing this, is while I felt one way, not one of my patients had a clue I was grumpy. And, hopefully, not one of the nurses did either.

The only people I vented to were fellow RTs. Then, to the best of my ability, I left my grumpiness in the RT Cave. A true consumate professional becomes very good at doing this even in the worst of nights.

The six different types of respiratory therapists

There is much resistance to change inside the RT Cave. After much thought on the matter, I have figured out why. It has everything to do with the six different types of Respiratory Therapists (RTs).

Many RT Caves do not have protocols. I've heard every complaint

Very, very slowly I think doctors are becoming more and more receptive to the benefits of adding respiratory therapy patient driven protocols. In real time seems tortuously slow, but I think in ten or twenty years we might be talking about some major changes in the rolls of RTs.

While this is true, there are still many RTs themselves who don't seem to be receptive to change. This became ever more so apparent to me after reading an excellent column over at Snotjockeys Revisited, "Clinician Resistance to Adopting New Practices".

I agree with her, and have my own experience to add to the mix.

A fellow RT, Dale, is very fun to work with. He's intelligent, a great RT; but he is a constant complainer. He complains in a fun way, but nevertheless he is still a complainer.

"I circled all the indicated treatments on the board," he said the other day in report.

"Um," I said, looking over the list of patients, "there are none circled."

"That's my point," he said, and chuckled.

One day he handed me a list. I looked at it thinking it was serious at first, then I started to laugh. On it was a list of 'olins that he made up. (You can view parts that list at the bottom of this blog)

He said, "I bet that 60% of what we do here is absolutely not indicated."

I'm a firm believer that if you're not having fun with your job what's the point. So we make fun of our job. We make fun of doctors, we make fun of nurses, we joke around during a code. I think that's medical humor, and we do it to maintain our sanity.

I check doctor blogs and nurses blogs, and I see their humor all the time.

But humor is one thing, complaining is another. And complaining with Dale is fun, but most complaining in the RT Cave is simply annoying. I avoid it every chance I get. If I have no choice but to give report to a complainer, I give a quick report and scram.

I used to work with Dale a lot. In fact, I'm glad I had that opportunity to work with him because I learned much and he helped me develop my RT humor. However, I was never going to get anywhere via complaining. Complainers rarely get anything accomplished. But they are abounding in the department.

What's that old saying? "Complainers say more about themselves than the person they're complaining about."

I realized this, and I switched weekends. Now all the complainers work with Dale on the other weekend. The RTs who work on my shift are Jane Sage, a very optimistic, intelligent and fun to work with person. And we have Dee, who happens to be a complacent RT (see list below).

Jane had an epiphany one day, and decided the laid back RTs on our weekend are awesome, and she started referring to us at the "A" team. We called the RTs on the other weekend the "B" team. Once the "B" team got wind of this they decided that they were the New "A" team.

"That's fine," Jane said, "We won't tell them that "A" now stands for Anal and "B" now stands for Better than Anal."

Despite the complainers, we have enough "balance" of different personalities to make things work in our department. You need the complainers so we know of our faults, we need the anal people to make sure we get all our work done, we need the content people to boss around, the laid-back people to ease tensions, and the clowns to make us laugh.

I'd even go as far to say we have a great department. I suppose that means we have good balance. I'm sure the members of this RT Cave are no different than any other.

With this in mind, I created the following list. Based on my experience working with many RTs in the past 10 years, these are the six different types of RTs:

1. The stepping stones: These are the RTs who use the career of RT as a stepping stone to a more illustrious medical profession. In my humble opinion, this is the way to go. What better way to learn about medicine than through the eyes of an RT. I'm serious here.


2. The quitters: These are the RTs who don't like to work. Some "Quitters" take a job of RT because they think it will be an easy job and they won't have to do anything. As soon as they learn what RTs really do, they either quit or are forced out the door.


3. The contents: They are the happy-go-lucky RTs who never complain. They are the RTs you love to give report to because they are always happy. They rarely make any effort at learning new information other than what is required. They usually prefer not to work with critical patients, and when they do they never question doctors and they prefer to be button pushers. Usually, you will see these RTs happily knocking off treatments on the floors.


4. The complainers: This composes probably about 60% of all RTs. These are usually very intelligent people who love the career of respiratory therapy in theory, but hate the reality of it. They are usually well up on all the new technologies, and are very quick to question doctors or offer suggestions. However, while they are not happy, they do nothing to better their career field. After working for a while, they become frustrated and content and they give up. One of the reasons they are so frustrated is that they have decided that they are too old to get another job, or have families which makes changing jobs difficult. Yet, while they complain, they do not support change.


5. The optimists (or learners): These are the RTs who write blogs. They may or may not be more intelligent than complainers, but they love to learn. These are the RTs that consistently do research on the Internet and read magazines. These are the RTs that attend every seminar possible. These are the RTs who write the protocols and make recommendations for new equipment, and then write the policy and procedures for this new equipment. These are the RTs who learn about things like Graphics and educate the rest on how to use them. These are the RTs who make the best of their career even though they know there are a lot of forces working against them. Most important, these are the RTs every one in the department loves to talk to because they are good listeners (they listen because they love to learn). More often than not, they work with the leaders to solve these problems as they occur. They often let other RTs take credit for the work they do. They do this to keep morale in the department high. In essence, the optimists are the strings that keep the department together. A department without optimists does not run very well.


6. The leaders: These RTs, while far and few, take charge and lead. They make changes to the RT Cave and they are resented for it. They make sure everything is stocked. They make sure all the i's are dotted and the t's crossed. They are usually opposed to protocols because they don't want to "rock the boat", but they won't say so openly. They listen to the rants of other RTs, but they usually side with the administration on issues. They question RTs who question the status quo. You might hear them at an RT meeting saying something like, "Don't you think protocols might actually create more work for you guys." When they say things like this, they are catering to the complainers, who will work with them to stymie any change. The leaders do no like change because it goes against their philosophy of "do not rock the boat." It is also important to note that while most leaders are good people with normal home lives, they are often hated and revered at work. Complainers often do not get along with them, and optimists are often seen working with them "for the better of the department."

I can give examples galore, but I'll give just one more.

Even though she had several protocols shot down years earlier, Jane wrote a new and updated ventilator set-up and weaning protocol. The complainers in our department all said it would never be approved by the doctors.

Jane trudged on nonetheless. She had the support of me, another optimist, and Dee, the easy going content on our weekend. Finally, with a bit of luck, the protocol was approved.

With our confidence on high after, Jane and I wrote a breathing treatment protocol we thought might work. We were very proud of our efforts. We thought we'd show it to our co-workers and get their support.

I showed it to Dale first. Surely he'd approve of it since he was the most outspoken RT about useless and not-indicated breathing treatments.

I couldn't have been more wrong.

"So what do you think?" I said after he stared at it for several long minutes, grunting and sighing often.

"Well," he paused while staring off, then spoke slowly, "The biggest offenders will still abuse the system. If it does anything it will just create more work."

"Okay," I said. I made no effort to change his mind. I walked away. No point in beating a dead horse.

Jane brought up the protocol at a department meeting. Gary, the department head and quintessential RT leader, said: "It is possible you might just be creating more work for yourselves by doing this."

He may be right; he may be wrong. Either way, Jane and I keep moving forward. And that's easier to do now that we know about the six different types of RTs.

RT to RN, BA in RRT: is it worth it?

I had a discussion with my coworker, Tom, who is working here while still attending school. Tom said he wanted to go on to get an RN and then proceed to getting a BA in nursing and perhaps move up even higher.

You have to realize that Tom is my age, and he has a wife and kids and bills and debt just like all of us hard working RTs.

"I told my teacher that I thought this would make me more marketable," Tom said.

Tom said his RT teacher tried to explain to him his options from a different angle.

He said, "He told me that an RN is basically on the same level, or same playing field, as an RT. And going on to get a BA in nursing isn't any different from going on to get a BA in respiratory. "

His teacher told him he'd be better off getting his RRT and moving on to getting his bachelors, rather than spending the extra time getting an RN. He'd save two years of his life and lots of extra money.

And from there he'd still have the benefits of increased pay, and an increased opportunity of moving up the ladder.

I agreed with Tom's teacher on everything here except the idea of an RT going on to getting a BA. There is no increased pay for BA's in this part of the state. It might work to help him move up the ladder, but there are a very limited number of RT department head jobs available. Would it be worth the investment?

"Besides," I added, "our boss doesn't have a bachelors degree."

"Good point."

"And do you think that piece of paper is going to make our boss a better leader? Do you think it would make him smarter?"

"No," Tom said.

"Well, it would make him smarter, but it wouldn't make him necessarily a better boss. Yeah it might help him get hired, but if he doesn't have what it takes to head this department, he certainly isn't going to be hired, regardless of what papers he has."

"True."

"So, technically speaking, is it worth sacrificing the two years to get a RT bachelors? I'm not convinced. I'm not trying to talk you out of doing this either. I'm just saying: is it worth it? "

"They do pay extra for BA's at some hospitals," he said.

"You'd have to move. Is that what you want to do?"

"I'm thinking about it."

We spent some time on Google trying to find advantages to an RT BA, but failed to find anything before we gave up.

Now, for an RN to get a BA is another story. There are a ton more opportunities on that side of the isle.

Another reason Tom said he wanted to go on to be an RN from RT is he could use his RT skills and he could be hired as a nurse and could fill in as an RT on occasion.

His teacher told him there really is no added benefit to having both an RT and an RN degree because you can only concentrate on one or the other, and whichever one you are doing you will forget what you know about the other.

That sounds veritable to me.

I can think of some really good reasons for someone going from an RT to an RN, and I think the experiences gained while being an RT will very much so make that person a much better nurse, especially when it comes to respiratory patients. For one thing, they certainly won't be calling for treatments on people who don't need them, unless their mindset changes that much.

Not only that, but there would be a pay raise, considering RNs make better money; and there are more jobs available.

However, I can think of no reason why someone who is an RN would want to become an RT, unless they work at a small hospital and they want to watch more TV. But trust me, while you may see me watching TV from time to time, I do my fair share of running. In fact, I think most RNs will agree that when I'm busy, I may be busier than a busy nurse.

Why would an RN want to take a pay cut? Why would an RN want to go from a job with many opportunities even within the hospital, to one where there are only a few RTs in the entire county?

That is, unless you are miserable as an RN and you think you'd enjoy sucking snot far better than wiping butts.

He also talked about being a physician's assistant. His teacher told him he'd be far better off taking the RN route if he were going to do that. But that's a lot of schooling, especially considering he still has to go through the RN program to do that.

Whew, he's gonna be real tired of school if he gets through all that, and very much in debt. But considering he has a wife and kids to support, he's probably better off just working as an RT.

That's my opinion. I think he should stick with what he has already committed himself to. Then, later on, if he's financially stable and still wants to be an RN, he can study instead of watching TV at night while getting paid as an RT.

But that's just my opinion, and I've been prone to be wrong from time to time.

Albuterol is a bronchodilator and nothing more

Some of the posts on this site, including my list of 'olins on the bottom of the page, are my humble attempts to make a humorous account of why doctors order Albuterol on patients having absolutely no signs of bronchospasm.

RT Cave Rule #5: There is only one purpose for bronchodilators, and that is to treat shortness-of-breath due to bronchospasm

In no way do I think I am smarter than a doctor, for they have knowledge in far more areas than I will ever imagine to have. It is their job, after all, to fix patients. And, when they order therapies I disagree with, I will still do them without complaining.

I have to say, however, that this is difficult not to complain when I know a treatment is not indicated, especially considering I have been using Albuterol since it was invented in the 1980s, and before that I used Alupent, and never once used either one for anything other than SOB due to asthma. In this way, I have over 30 years of bronchodilator experience.

Likewise, I have given many breathing treatments to patient in the hospital the past 12 years as a registered respiratory therapist, and have seen first hand for whom they have a beneficial effect and for whom they have no effect.

Plus I believe my opinion is in concordance with nearly every other RT on the planet.

If you are an RT or suffer from diseases like Asthma or COPD, you know how wonderful a drug Albuterol is. I can tell you from personal experience it's a life saver. In fact, without the drug I'd probably would have died many years ago.

And that brings up my next point. Bronchodilators of the past, such as Alupent and Bronchosol, did have some bad side effects. Alupent was proven to be a great bronchodilator, but had the side effect of making the heart thump. I remember abusing it when I was a kid and fearing that I might now wake up in the morning.

Alupent was a good drug in it's time, and was used for many years, but in 1987 a new refined bronchodilator was invented that was proven to have very little effect on the cardiac muscle, and thus rarely causes the heart to thump or increase. I'm not saying it never does, but very rarely, and usually only when it's given in huge quantities all at one time.

I can tell you from my personal experience as a "Rescue Inhaler Abuser" that I have gone through an entire inhaler in a day and still not had my heart thump like it used to when I used Alupent. Now, I wouldn't recommend using that much Albuterol outside the hospital setting, but my point is that Albuterol is that safe.

When patients come into the hospital, and you are having bronchospasm, we quite often give you an aerosol of Albuterol. If that aerosol doesn't do the job, we have been known to give as many as 10 in a row back to back to back. Again, I wouldn't recommend doing this at home, but I bet many of you chronic asthma and COPD patients have at one point or another. Hey, back me up here.

Now, understanding how quickly and magically Albuterol can get an asthmatic or COPD patient breathing easy, and considering how safe it is, many doctors choose to try it for other respiratory illnesses, even illnesses that are not bronchospasm in nature

I find that some doctors order Albuterol because a patient is short-of-breath because of pneumonia (fluid in alveoli), atelectasis (collapsed alveoli), pleural effusion (fluid in lung) and pneumothorax (collapsed lung) . All of these diseases are in the alveolar sacks, and the aerosol particle of Albuterol are too large to deposit in the alveoli, and thus have no effect there.

If, however, a patient has a bronchospasm component to their disease with any of the diseases listed in the last paragraph, then I'd recommend Albuterol. But if there is not bronchospasm, then it has no benefit to the patient.

Other diseases that Albuterol does not benefit that it is often prescribed for are: Croup, upper airway congestion or excess secretions, CHF, pulmonary edema, post-operative, obesity, cancer and many more.

Let's tackle croup. The harsh inspiratory noise kids make with this illness is because their throats become swollen. The key word here is throat. There are other medications that might help here, but not a bronchodilator. Hence, Albuterol is a bronchodilator, not a throat dilator.

Chronic Heart Failure (CHF) causes fluid to build up in the lungs called pulmonary edema. This does not occur in the bronchioles, but outside them. When this fluid overload causes the pressure inside the lungs to build up, this can cause the fluid to in effect squeeze the bronchioles and causing a wheeze. This is called a cardiac wheeze. Yes, it does cause the bronchioles to tighten, but, since the cause is outside the bronchioles and not inside, Albuterol will not work to solve this problem. This patient will need diuretics like Lasix.

Nonetheless, a cardiac wheeze is very often confused as a bronchospastic wheeze, and treated like bronchospasm.

Many times in the hospital setting I give a breathing treatment the same time a nurse is giving Lasix. The patient is severely SOB. My treatment has no effect on the patient's WOB. But, an hour later when the Lasix has worked, the patient is no longer SOB. Since the patient actually participated in taking the treatment, he or she often thinks the treatment is what eventually solved the SOB.

So, what happens the next time we get a CHF patient? The doctor orders Albuterol back to back to back to back until the Lasix works. Can you see how I can easily make comedy out of this.

Cancer will not be absorbed and broken up by a bronchodilator, nor will it absorb a pleural effusion, nor re inflate a collapsed lung (that's what a chest tube is for). Even if it did get down into the alveoli, it will not remove fluid in the alveolar sacks caused by pneumonia.

Now hopefully by you reading this you understand RT humor. Since doctors use Albuterol for all these diseases, we RTs (me in particular) have a choice between grumbling and griping about it, or making humor of it. We at Shoreline Hospital choose to make humor, and thus our list of 'olins came to be.

One of the reasons I made this post was because I've received more than one emails or comments from patients who wondered if I was being serious or funny when I wrote "Xoponex now a humidifier." I will confess: I was being facetious.

While Dr. Krane is a brilliant doctor, and while I enjoy working with her, and while I have no problem trying one Albuterol treatment with patients with croup just to see if it works, it is not a humidifier. In fact: Albuterol given via nebulizer treatment is a mist.

Just so you know, any post on this site where I'm using RT humor will be labeled on the bottom as "RT humor" or "funny."

Again, I am in no way proposing that RTs know more about the human body than doctors, but we are the experts in the hospital on the respiratory system -- that's all we do. We study respiratory, we learn respiratory, we learn the other systems as they pertain to respiratory, we keep people alive with our respiratory machines, we sleep respiratory, we breath respiratory. We give breathing treatments all day long, and we see how they work first hand. Doctors can only order them. And, when they do, we have to give them. We have no choice.

Now, if you are a medical staff at a hospital other than an RT, or if you are a patient viewing RT sites like RT Cave, it is important that you know that there really is only one true purpose for Albuterol, and that is to treat shortness-of-breath due to bronchospasm.

To determine if someone is having bronhospasm, it requires an assessment of lungsounds and/or a quick review of the patients history, which usually can be provided by the patient. Most of the time, true bronchospasm is very obvious.

In the insert inside the Albuterol inhaler or aerosol solution you will find an insert. Go ahead and pull it out if you have access to one. On that packet it says: Indication: "(Albuterol) is indicated for the treatment and prevention of bronchospasm in adults and children under 12 years of age and older with reversible obstructive airway disease." (emphasis added)

It is a a fact, proven by much research, that Albuterol is a medications that becomes a particle size of 5 microns and fits perfectly into the size 0.5 micron bronchioles of the lungs to relieve bronchospasm. Five microns is too big to go into the alveoli level (which is 0.1 to 0.2 microns wide) and too large to deposit in the throat (although some of them will deposit there).

It is not a cure for any disease. It will only resolve the symptom of bronchospasm. This is my humble personal and professional opinion. And as long as doctors continue to abuse this most wonderful drug, we will continue our effort at bronchodilator reform. And while we may never get it, we will continue our feeble effort at RT humor here at the RT Cave.

I encourage you to challenge me.

Here is a great column that might explain it better than me.

This article describes what bronchospasm is.

Here's a basic definition of bronchospasm.What are bronchodilators?

Here's how to check if a bronchodilator is indicated.

The indications for Albuterol are listed right here. If you're really bored you can read the whole thing.

Boring study on the particle size of bronchodilator. I just don't want you to think I'm making this stuff up.

Considerations for readiness to wean

Here are some things to consider when determining if an intubated patient is ready for a weaning trial.

1. Awake and alert

2. Able to follow commands

3. Spontaneously breathing

4. Adequate cough

5. Pain controlled

6. No obvious signs of respiratory distress

7. Little to no anxiety

8. FiO2 equal or less than 40

9. PEEP 5 or less

10. Temperature equal to or less than 100.4

11. Hemodynamically stable

• No Dopamine infusion greater than 5 mc/kg
• Systolic BP
• Pulse >50

12. ABGs normal for patient

13. A-a gradient less than 300

14. a-A ratio greater than 50%

15. PaO2/FiO2 greater than 150-200

16. Underlying condition resolved

17. Chest X-Ray improving

18. Adequately nourished (Albumin >2.5)

19. Electrolytes stable (CA, Mg, K)

20. Secretions thin and minimal

21. Adequate Hemoglobin (>8-10)

22. Adequate Hematocrit (>25% or baseline)

23. Absence of bowel problems (diarrhea, constipation, ileus)?

24. Weaning parameters within normal limits:

• NIF greater than 20
• VC >10ml/kg IBW (2*VT)
• VE less than 10- 5ml/kg IBW
• VC double VT
• RR less than thirty 30
• RSBI (VT/RR) less than 100

25. PS must be at patients weaning level:

• PS = Static minus PEEP
• Normal PS usually at least<=10

26. P0.1 = or less than 4.2.

27.   P0.1 > 4.2 is "associated with failure to become liberated from the ventilator... If under 4.2, weaning was successful 78% of the time."  (reference is Vent world)