RRT2RN2CRNA

@JENHEY- If you need to start making money that's above min wage, then go for sleep cert first, because it's a short course and you can work in that while you're in school for respiratory or nursing. However, sleep is very specialized and unless you work in a large metro area, the job opportunities are limited. Sleep labs are usually 4-8 beds and each tech takes 2-3 patients so you only have 2-3 techs working per night. And it's somewhat of a dead end as far as earnings for a routine sleep tech job. If you can afford to just go straight into an associate's or BS program, I highly recommend Respiratory Therapy to anyone who's looking to get into health care. It's particularly great if not you're quite sold on nursing (at least right away) or don't want to deal with fussy RN program admissions wait lists and all that. It's a great field to work in to get a look at what goes on in all the different units. You will be much more prepared than someone who has never worked in a hospital if you decide to go for nursing school later on. And you can have an idea of what kind of unit you will want to work in. And it can be really fun. On an average day I run between the ER, a few ICUs and the floors. I see every kind of patient. I do boring busy work like nebs, and then I'll go do something more demanding like put an arterial line in or fix an oscillator. I run a lot of crazy machines and it teaches you to be able to logically troubleshoot a situation under pressure. It can be really great *depending on the hospital you choose* (very impt) And who knows? You might like it and not do anything else after. And that's perfectly fine too. P.S. Don't get the wrong impression from these territorial ninnies fighting up top. I work in an academic trauma center in ICU where our nurses love us. And it's mutual. We have different roles that are complimentary. End of story. Anybody blowing it up into some sort of feud for the ages is lacking in either self-esteem or mental faculties. Plus we have a common enemy.... the residents! Let me know if you have more questions- A

or CRT/RRT :)

I think OHSU in Portland has one too. Double check though.

What's your BS in?

I work at Stony Brook, and went to Stony Brook undergrad. I would say hands down that Stony Brook nursing is the most well-respected nursing program on Long Island. Plus you will get the opportunity to do at least some of your clinicals at Stony Brook, which is the only academic Level 1 Trauma Center east of the city. If you can make an impression in critical care clinicals, they may recruit you for the nursing fellowship program and you can go right into ICU without doing med-surg. This is very important if you want to go on to CRNA school. Level 1 trauma experience in CVICU, SICU or MICU is the best thing to have on your resume. It's difficult to get hired into Stony Brook unless you have some sort of "in"- you know someone, or were a really good student. It is, afterall, a state hospital. And it's a *hell* of a lot cheaper than Adelphi. It's a very difficult program though. I highly recommend living on campus. Don't commute; parking is insane and there's more support on campus. Just my 2 cents... Good luck! PS: Look at other schools in addition to Columbia. You're going to want to apply to a few others at least. I've heard mixed reviews, and it is one of the most expensive CRNA programs in the country. I personally think it is overpriced, and there are 10-12 other programs within 5 hours of the city. The Columbia name is great... but most people I've talked to don't care where you went as long as you have the letters "CRNA" after your name. It's not like undergrad, or getting your MBA.

This is always such a can of worms. If I feel like messing with a new MICU resident I'll just say "So can we try pt in room 128 on SIMV?" Some of them totally freak out. (It's very fun.) Honestly, I really don't see what all the fuss is about. I don't see the need to make a unit an "SIMV only" unit or an "A/C only" unit. Every pt is different and I think that we should be able to tweak settings and use all the tools in the vent box when trying to comfortably ventilate a pt. My only rules are that I always use AC when a pt is not going to be taking any kind of spontaneous breaths anyway (anoxic-neuro, totally and completely sedated). Not that SIMV would do any harm, it's just that the basic AC is all that's needed. I always use SIMV with my post-open heart and thoracic patients because I don't want them to possibly stack breaths and created auto-peep as Joeystzj said. Other than that, I think the Physician and RRT should use all the modes and settings and see what works for that particular pt.

You're just having a little freak out. It's just a lot of things at once. Be a sponge.. soak up everything around you. Enjoy your learning process, and embrace the subtle panic that goes on with everything you do right now. Triple check everything. You'll look back a year from now and think about how much you've learned. Take advantage of the support you're receiving. Make sure the people who are helping you know how much you appreciate their kindness.

I would be an organic truffle farmer in New Zealand.

If they are tubed, they have soft restraints on. Period. Even the calmest looking pt who indicates he understands not to pull tubes or lines can pull his tube and cause hurt himself. Sometimes they just suddenly panic, and reason goes out the window. Maybe they cough and feel the vent pressuring or something and they just get a fright. And you know how hard it is to re-tube some of these people? The airway is sometimes very swollen from the trauma, and trying to get a tube down there after a bad self-extubation is difficult. Now you've got a sick patient, with no airway. And he's panicking- so now he's tachy, hypertensive and desatting.... not what you want to see in a pt. If the pt has had open chest or abdominal surgery, we also watch that the pt isn't pulling against the restraints too frequently, because this causes increase in intra-thoracic and abdominal pressures and you can actually pull at internal surgical closures and damage the surgical site. In those cases, they are also sedated heavily enough so they don't pull. And if you're comfortable enough that your pt will be ok even if he happens to self-extubate... you kinda have to think, why is he intubated at all then? You have to make sure though that if the family is coming in to visit, you warn them about the restraints and make sure they understand that it's for the pt's own good and the kind of damage that can be done by self-extubation and pulling out invasive lines. This should also explained before the procedure so they know what to expect after surgery. Usually as long as the pt and family are educated, I've never had them give me a problem. RRT2RN2CRNA

So true! We had a guy last week that we re-named David Blaine. He extubated himself 3 times in 2 days!

Vents really arent that bad. Air in, air out. That's it. Don't be intimidated. It's just a big scary looking computerized box that regulates how you want the air to go in and how you want it to come out. The more sophisticated the vent, the most options you have. But at the end of the day, it's just like having a robot that bags the pt for you. OK maybe it's sooooo simple. But really most vent-anxiety is easily overcome. The best thing about having a vented pt is that you don't have to worry about them crapping out and getting intubated. They're already tubed. The A and B of the ABCs are covered. Usually, they're also sedated so that's even better! I wish all my patients were intubated all the time. :) If you have a nice RT that works in your unit, catch them during rounds and see if they'll have time later to give you a little overview of the vent. Just say you're new to the hospital and you had different vents at your last job. Most RTs are nice and will help you out- at least enough so that you're not completely freaked out by every beep it makes.

Yes- I always take them off the vent and bag. You can't get good breaths in otherwise. ALSO When you have a pt on a higher level of peep (8+) make sure you have a peep valve on the bag. If you don't know if you have one, ask your RT. If the pt's on a high level of peep and you lose that peep when you take them off the vent, it'll just compound problems with oxygenation.

Yes, it does happen on occasion (Usually on a pt that needs to be sedated more.) Sometimes it's a slow leak if the pt's been gnawing on it off and on. Sometimes they just chomp right through it and the cuff wont hold air at all. I also have had 2 nurses cut or nick the pilot line by mistake when trying to cut tapes re-securing the ETT. (Oops.) Usually you'll know something's up when you get "low volume" alarm on the vent, and see that the exhaled tidal volumes are way lower than they're supposed to be. And you'll hear a big ol leak at the trachea. We (RTs) have pilot line repair patch kits that sometimes can hold you over till the tube is changed. The line has to be bit pretty distal though- you have to be able to get at it. The patch kit looks like a little needle attached to a replacement pilot balloon. (For other RTs on here wondering "how does that work?" I usually take the holey pilot line, pump it up, clamp it with a hemostat. Then I cut the old pilot balloon line cleanly with sharp scissors (distal to the clamp obviously), hold the pilot line with tweezers in my left hand, and then wiggle the needle into the lumen of the pilot line with my right hand. Sometimes it works, sometimes- not so much. I only use it when anesthesia is tied up, and I can't retube righ then bc I'd need drugs pushed.) If I don't need drugs pushed, I will just switch out the tube with tube exchanger or a "bougie" - it's a long thin bendy stick basically that serves as a placeholder. You thread the bougie through down the old tube lumen, keep it there , lift the old tube out from around it- take the old tube out- bougie still in place. Then thread a new tube over the bougie back down the depth it was at before (there are markings on the side of the bougie). Or I just re-tube with a scope. Moral of the story for you: Don't just silence the vent alarm and ignore the situation, or just randomly add air to the cuff. Most vents have alarm logs that will show what you're doing. Listen to the breath sounds and call respiratory so they can properly measure the cuff pressure, and check it out right away before it really affects the pt. Don't be afraid to ask one of the nice RTs how anything works. Most will be happy to chat with you.

In CVICU (post-open heart) I use tapes and change them qshift. I extubate most of my patients there within 24 hours, so it saves money. Plus the nurses are used to them and god forbid I use something newfangled contraption like an ETT holder... I'd never hear the end of it. They would totally freak out lol. Doing up the tapes takes 2 ppl. One to wrestle the tape and one to hold the tube. Once you get used to it- it's not difficult. Tapes get slimy sometimes though if you get a drooler- you might have to change them more frequently. Otherwise we use Hollisters or ETADs in SICU and MICU where pts are intubated longer- sometimes until they are trached. Gotta watch the top lip for breakdown. But usually it's not a problem as long as the vent tubing isnt weighing down the ETT holder. For pts that are pretty wild we have these really expensive holders that have built-in bite blocks and steel teeth clamps that dig into the side of the ETT. I forget who makes them- but they are no joke. You tape those things once and they're not moving anywhere. Great for weaning neuro pts that go on sedation vacation but can't yet protect their airway. Let me know if you have more Qs :)

Danskos. Hands down! They are on the pricey side, about $100 USD a pair. But I have have my first pair almost 3 years now, and I am on my feet 60 hours a week. They are very supportive, and very durable. I have a pair of leather "Professional" clogs and I love them. They get better with age. They take 2-3 weeks to break in. I take mine to the shoe repair place and have them stretch them for a few days. You might want to wear them around the house for a few hours at a time. But once you break them in- you don't even feel them. You can find them online, and Ebay.