RRTM2

if you really want to work with the gadgets, have you considered biomed? it's 2 years for a degree and the machines you could play with then! this is an example of a school - http://www.scc.spokane.edu/?electbiotech ok, here's the respiratory alphabet soup... [color=#231f20]rt is the all-encompassing nickname for respiratory therapists. rrt = registered respiratory therapist. this is a credential awarded by the national board of respiratory care (nbrc). the credential held depends on the exams passed. credentials/exams administered by the nbrc are: [color=#231f20]crt - certified respiratory therapist (entry level credential. every licensed rt is a crt) [color=#231f20]rrt - registered respiratory therapist [color=#231f20]crt-nps or rrt-nps - neonatal/pediatric respiratory care specialist [color=#231f20]cpft - certified pulmonary function technologist [color=#231f20]rpft - registered pulmonary function technologist lrt, rcp, lrtc, lrtr are all titles/acronyms that vary by state licensing agencies. it's usually variations of licensed, respiratory, therapist, care practitioner, certified, registered, etc. i'll post more info if you would like but basically my license as a respiratory care practitioner is issued by california, after schooling approved by caahep & coarc, and testing by the nbrc, which awarded me a credential for a skill level as first a crt, then a rrt. rrt[color=#231f20] sometimes means a higher salary but mostly it seems to mean that you take your career seriously and it looks good on a resume. a lot of the actual education/testing is really out of the rt (at least, my) scope of practice... i.e. swan ganz placement, er assessment/meds/interventions, crashing babies. we don't differentiate much between crt and rrt tasks. you eventually end up where you fit best. ventilators are the most tinkering i do... and it's software/settings tinkering, not putting things together. (you intubate a flash pulmonary edema in er and that's going to be some fancy tinkering to get that person ventilated!). there are other occupations within respiratory - polysomnography (sleep labs) is a growing field. vendor equipment maintenance and in-service. management or teaching (with more education). you already know the home care. there's no getting away from people and their quirks though! if i had known about biomed when i was going back to school that's the way i would have gone.

we use 25ga ABG kits.

one shift with 5 ventilators is 60 hand washings just for vent checks and treatments... plus re-taping, transports and whatever else comes up. my hands are raw after a few days. thanks very much for the suggestions!

#1 – yes (edit: make that a no. daytonite is correct in her post below - it is respiratory alkalosis. sorry! and thanks daytonite!) #2 – no you are correct that it’s a metabolic mechanism, but if hc03 numbers are high is that acidosis or alkalosis? ph is within normal range. so if ph is within normal range then the compensatory mechanism has done its job and fixed the problem. it’s fully compensated. (again, this is just barely in range. ph of 7.46 would be technically out of normal range making it partially compensated. *this is just a technicality for test taking. a ph of 7.45 or 7.46 isn’t going to be much different for an actual pt) this is the mental tool that i keep in mind. alk / acid / alk ph / pc02 / hc03 *ph numbers high = alkalotic pc02 numbers high = acidic hc03 numbers high = alkalotic

This is just an easy way to put a name on it. You really need to know all the information previously mentioned to know what's going on with your patient... to know why their ABG looks this way and what to do about it. ex: pH-7.35, PaCO2-48, and HCO3-27 Think of the mid ranges of normal. pH: 7.40 PC02: 40 HC03: 24 which side of mid range is your ABG? pH moving alkalotic or acidic? PC02 moving alkalotic or acidic? HC03 moving alkalotic or acidic? Which one is moving in the same direction as the pH? That's your active mechanism. Which one is moving opposite of the matching ones? That's your compensatory mechanism. answer... pH: moving towards acidic range PC02: moving towards acidic range HC03: moving towards alkalotic range So respiratory acidosis, compensated (pH is at the lowest end of normal, so it's compensated, but barely. pH 7.34 would make it partially compensated)

hello... RT question... when i see this, let the RN know? thanks! ....and the beat goes on....

i would bring an attorney with me. they may just be gathering facts, but you have rights too, and your attorney will make sure you keep them.

IPAP = ventilation. Higher settings increase the tidal volume, which lowers C02 levels. EPAP isn't exactly PEEP but you can think of it that way. It's a lower amount of positive pressure keeping the lungs open. (or positive pressure for CHF... depending on the application). Usually set at 5 or 6... it won't change much. Like everyone has said... settings change per ABG results. Or pt tolerance. An IPAP of >20 and the pt might as well hang their head out the window going down the track at NASCAR. :)

]I have asthma, so I’ll tell you what helps for me when a bad one hits and I don’t have meds. ]Fresh air]. No smoke, dust or potential allergens. ]Sit]. I’m using all of my accessory muscles to move air so it helps to sit to support my torso with my hands on my knees. ]Sometimes arms above the head will move more air, but it’s tiring. ]Calm]. Very important. I have been scared before and have felt the airway close and the muscles stop working. It’s like the panic locks everything down. Then I realize what I’m doing to myself and calm down. It’s a mental decision… one that isn’t going to be easy for some, or for a kid, so it could be up to a caregiver to keep the calm too. ]Help]. Be proactive in getting help… either the pt to the meds or the meds to the pt. Mind over matter only works for so long with a reactive airway disease. Albuterol can turn the tide in seconds. I’ve never tried the caffeine idea but I will keep it in mind. (Hopefully I won’t be a dope and leave my inhaler at home ever again! But... it happens.) ]Comfort]. Breathing like that is hard sweaty work. A cool towel feels good but also be aware of a potential chill. Depends on the environment. ]I’ve had an attack come on suddenly in a restaurant. Had to rush home with the window open… cool wind blowing in my face… aaaaaahhhhhh! :) ]I’ve been so exhausted from trying to fix it on my own for a week or so, that when I went to the ER, the automatic doors closed on me because I was moving so slow. ]I’ve been in the ER, sitting on a gurney, getting a Tx - got sweaty, tunnel-vision, fell over, and woke up intubated. ]Anyway, I hope this helps.

]I read the link, and I was done with my 2 cents, but then I thought maybe I should say something, just to avoid confusion for someone. ]The definition of Sa02 in the article is true but #4 is a common error... Sa02 is measured blood analysis (ABG) and Sp02 is pulse oximetry. They both use the same principle of light spectrums through hemoglobin, but Sa02 % is not the same as a pulse ox sat %. ]Both are a measurement of hemoglobin 02 saturation affected by arterial 02 content, but t]he definitions, methods and accuracies are different. ]Sp02 can use the 40-50-60/70-80-90 Rule. Assuming normal pH, PC02 and Hb values, saturations of 70%, 80% and 90% are roughly equivalent to Pa02 values of 40, 50, and 60. Or the Minus 30 Rule... depending on what you remember best. Pulse oximetry is only an estimate and a tool. ]Sa02 isn't linear like that... it changes, and the difference is more as hypoxia increases because of the dis-affinity of hemoglobin for 02. Sa02 accurately indicates the changes in hemoglobin saturation and considers the effects of PC02, temp and pH. That's where the Oxygen Dissociation Curve comes in. ]However, it's not a huge difference between Sa02 and Sp02 until Pa02 levels are

]Look up the 'Oxygen Dissociation Curve'. ]Pa02 measures partial pressure of oxygen in the blood (plasma & hemoglobin). ]Sa02 measures the percentage of available hemoglobin actually carrying oxygen. ]So, at normal levels, they are usually about the same numbers but one is a pressure and one is a percentage. ]The Oxygen Dissociation Curve shows the relationship between pressure and percentage. You'll see that at normal ranges they are close because the curve flattens. ]At lower Pa02 levels the gradient changes in relationship to saturation. ]Acidosis and high body temp will also lower Sa02 at the same Pa02 level. ]I hope that helps!

]From Egan's Fundamentals of Respiratory Care: ]cuff pressure - between 20 and 25mmHg, or 25 and 30cmH20

]Honestly, I think you might want to think about moving on. ]Are there are other places to work now that you have some experience to back you? Have you considered acute care instead of a sub-acute/rehab type facility? ]I can see the value of a group meeting with administration but I think you're fighting the corporate monster there. ]I'm an RT too... just for a few years now too. I work in a faith-based Trauma Level ll hospital, and I won't say the loads are cake but they aren't dangerous either. Floors are 12-15 Pts with Txs; ICU is 5-7 vents with maybe a BiPAP, HHN, or a trauma Pt added during the shift. There is usually time to do your job thoroughly and also deal with the things that come up... be that a Rapid Response, a trauma, a Code, a trip to CT, extra ABGs/EKGs, or helping out with a Pt. The tasks that equal good Pt care, not just good time management. ]I realize you probably care about your Pts, especially long term vent dependant ones, and worry about their care if you weren't there. Leaving them would naturally evoke some guilty feelings on your part. But honestly, they will likely find another RT just out of school again who will be conscientious but unaware of the employment options who will pick up where you left off. ]I love being in ICU, keeping my Pts clean, the vents stable, helping out with basic Pt care. I know it's only assisting compared to what the RNs do, and the knowledge they use (not kissing a$$ here... I really do know and appreciate the skills. If I was younger I'd probably get my RN) but I feel like I'm contributing to someone's well-being, plus helping my coworkers. It's job satisfaction compared to honed time management skills. ]Another benefit is that I'm always adding to my knowledge of acute care. I had a vent last night... ICB, shift to the right, a Swan-Ganz, ventriculostomy, an IV pole that looked like a bunch of grapes. I only had the vent... the RN had all of that to manage. But it is sooooo much more interesting. ]Feel free to PM if you like. I read this site all the time because I learn so much... but I do feel like I'm butting in where I don't belong so I don't post much. ]Good Luck whatever you decide!

We were told in our orientation that Press Gainey scores would be used by insurance providers and Medicare as a tool when they negotiate payments. Lower scores = lower payments to that hospital. It's always about the $$.

wow, did this turn into something! it's only a crummy little pulse ox. j ultimately i do think that it's the hospital's responsibility to supply the equipment we need to care for the pts. but here in the real world... i got tired of borrowing a unit or rushing to get to work early so i could get one before they were all gone. another rt and i used to just trade as we gave each other report. it's a pita so, yes, i now have my own fingertip pulse ox. it's a nonin onyx ll model 9550 and i treasure it. onyx ll model 9500 works just as well. i looked at ebay but ended up getting it from a medical supply company for the same price. i've adapted a thin pet leash to attach it to my waistband. it's been cut to the length i need to reach a pt, but short enough to not touch the floor when it's out of my pocket. i have it this way because i never put it back in my pocket until i've cleaned it. there are very nice pet leashes out there now... flowers, patterns, etc., and they are washable too. i change the batteries every other shift, but i use it 50 times a shift. biomed has approved it; checked once a year. our er has used a fingertip model for years. it's fast, it's easy to use, only one part touches the pt, it's light... it was an all-around good investment for me. as far as calibration, liability, cleanliness & competency issues... my fingertip model, our rt department's hand held units with a sensor on the end of a wire, and the table top models, are not calibrated. calibration means set value ranges that are measured and verified. biomed makes sure there are no power issues, the alarms work and that it actually reads something that looks right, and that's it. as to the liability of trusting a machine - it's general practice to verify anything that seems at odds with our observation of the pt, plus no pulse ox unit is ever to be trusted with a sat reading below 80. what could happen? an erroneously acceptable sat reading on a pt with no other indications of distress, and the pt crashes? it's not likely that a sat would be the only indication. an unacceptable reading would be verified. if a nosocomial infection can be traced to a dirty pulse ox, as opposed to a dirty stethoscope, or bp cuff, or no alcohol swab use, or pillow fell on the floor, or, or... dirty shoes! j individual ethics and practices don't change with the equipment. as far as i know, no one is checked out and signed off on the hand held units or on continuous/table top model pulse ox units. pulse oxs are pretty simple. it's not an iv pump, a swan-ganz monitor, or a balloon pump... items that could actually malfunction to the detriment of a pt. a hand held pulse ox is a battery powered light sensor with an led display. it isn't high tech. it works or it doesn't, no troubleshooting required. a laser pointer is more dangerous. i think the pts are competent with it after the first time. yes, we ask repeatedly for the hospital to supply units for us. our department is 45 rts. we need 10 units per shift. we have 6. meanwhile, as it goes through the budget committees and funding to get a few more at a time, my 50 checks a shift x the 3-6 months it takes to go through to purchase the units, remain a p i t a for me. that's why i have my own. there are always trade offs with budget negotiations. i will accept only 3 new pulse oxs a year instead of 10 (which really only replaces the broken/missing ones) to have an adequate supply of the best microprocessor ventilators available (at >$10k ea). a sat reading is a useful indication of condition but it never saved a life, but nitric oxide and bilevel ventilation sure has. i think our manager is fighting the good fight for both the rts and the pts. so, yes, in a perfect world we'd have everything we need, but in a perfect world we wouldn't need hospitals and somebody would be bringing me margaritas on the beach.