GreyGull

"Sigh"

Our IT people set up some of the most complex technology on the market. They are present in the patient care area to troubleshoot and make sure everything is functioning as well as to TEACH RNs and MDs how to use it. That may definitely be during a code if that is when the technology is being trialed. They or Biomed may also have to help us switch a patient off of a very delicate and expensive piece of equipment if it has failed for some reason. They also make sure we can stay up and running during an emergency such as an earthquake (West) or hurricane (East) with adequate backup. The list is endless to their importance. You may only notice them if your internet password on the computer doesn't work.

You guys tickle me sometimes and I'm the one who is 2 - 3x your age and grew up with the stone tablets. Get over your arrogance. You need computer specialists and the more they know about your job, the easier they can make it.

Define "record a code". In my hospital it has many meanings since we do teaching and have electronic gadgets everywhere. Someone writing events on a piece of paper is just one way and may be done while other methods are also be used to "record a code". 20th century today and maybe the 21st century hopefully by the end of this decade.....

Then allow me to introduce you to the Philips elearning website. Philips bought Respironics who makes many pieces of RT equipment including the Vision. There is a good Vision inservice and NPPV courses along with ETCO2 and other noninvasive monitoring. Registration is free and so are most of the courses. https://theonlinelearningcenter.com/default.aspx The Vision will be under Philips Hospital Respiratory Care. The V60 is the next generation but the module is being updated.

I see someone who is asking questions about the things he is seeing or reading and would like an explanation from those directly involved in patient care. Maybe he does not want to bother those where he works with these questions especially since many of the forums stress they are overstressed and too busy to pee. He might get that but feels an open public forum might be a great place to learn. It is no different than some of us popping on to some of the computer wiz or tech forums to ask a question about some of our gadgets which are probably too intense for us but we must have them and now we turn to those forums and ask what might seem like really stupid questions to those in that specialty. But, fortunately someone always takes time to explain to a mere health care professional how to turn on my new TV set. How many times has someone here picked up the telephone and screamed like it is a life or death situation if a computer expert does not get up to the unit real fast and fix (resuscitate) the technology before the paper order forms must come out of the closet? Bystanders may interpret your voice, words and actions to be a serious event and somebody really important has coded in the nurses' station. Anyone who keeps the technology running in a hospital is definitely part of the team.

That would depend on the disease process (underlying and acute), the plateau pressures, the waveforms of the ventilator and at what stage of the acute or recovery/rehabilitative process the patient is in. ARDS protocols will run from 6- 8 ml/kg (emphasis on plateau pressure as a guide) but will also allow for PEEP to make up the FRC and increase oxygenation. http://www.ardsnet.org/system/files/6mlcardsmall_2008update_final_JULY2008.pdf Specific criteria must also be met for ARDS and a package deal including possibly a buffer might be included for the protocol. In extreme cases paralytics might be used for the patient to tolerate the low VT and high RR. Rehab units (SCI patients) may run from 10 - 20 ml/kg to inprove FRC, lower FiO2 and decrease secretion causing atelectasis and infection. ORs may run high VTs and lower respiratory rates since they rarely will use PEEP. The ICU will then adjust the VT and RR to maintain the same minute volume achieved in the OR.

But then over simplification is why some don't understand ABGs the way they should especially if they are in a position to assess and maybe treat. Over simplification is also why some still use "no more than 2 L for COPD" or toss out something like "hypoxic drive" without of an explanaton thus leaving some patients struggling at 88% and hypoxic. Over simplification is also what has led to the misuse of the term "high flow" and not taking time to explain inspiratory demand. Over simplification has led some to believe BiPAP™ is a life support ventilator and a misunderstanding about the "rate" which is set on it. Over simplification has led some to believe CPAP pushes lung water out. Over simplification can lead to a misunderstanding of all the components of the acid-base and fluid/electrolyte systems. Over simplification has led to a misunderstanding about when to give NaHCO3 for a low pH and when it is total inappropriate. Over simplification has led some to believe a "normal" or "compensated" ABG means everything is okay or "let's wait and see" without realizing it can very much be like "shock" in a compensated stage. The crash and burn might happen very quickly and some just didn't see it coming because of over simplification. Instead of always trying for the simplest approach, dissect the information given and study it thoroughly in pieces. ABGs should come after one has some indepth knowledge of fluids, electrolytes, acid-base, cardiac, circulation, BP and the respiratory components. A well structured approach to Anatomy and Physiology will help with this. Unfortunately ABGs are sometimes included with the respiratory section before some of the other components are covered, thus giving some the impression there no more to the story. The analysis of the ABG then becomes very limited.

I would check with the sleep lab about ANY medications, OTC or prescription, to see what they do allow. Many machines are now auto titrating (APAP) and many insurances do allow these. Some patients may have this study done in the hospital near the end of their stay. The program card is downloaded and it shows what the patient required t/o the night. You'll be seeing more of this in the future with new protocols in place for hospital admissions and especially those for surgery. The patient can be observed, diagnosed and educated easily. Sending a patient home, waiting for them to see their PCP who may or may not be well versed in sleep apnea and who may not give them the referral to a sleep lab is a hit and miss process with a lot of misses.

I apologize for my lengthy posts. To summarize, sometimes patients are "assumed" to be a COPDer or in exacerbation with sole focus on the respiratory component. The clinical presentation and the ABG iare useful for the inital rescue but as the bedside clinician, the history, duration of overall illness and the acute situation must be considered and how it has affected the respiratory component. If a COPD patient by confirmed diagnosis tells me has have been sick for 3 days, looks clinically stressed but has what some would think is a normal compensated ABG, he might be looking at a ventilator in his future rather than NIV. CO2 narcosis should not be assumed to be just COPD or even too much sedation. Other major issues are missed due to the focus on the pulmonary issue for assessment and treatment and of course the "OMG they have COPD, hold the O2". Understand the difference between the rescue treatment and that which addresses the underlying cause which may not necessarily be pulmonary. Lots of breathing treatments may NOT be the answer either and may harm more than help in some situations. Be careful when assuming all COPD patients need Albuterol and have it distract from what treatments should be done especially in the face of an MI or CVA which are sometimes overlooked. Another issue which should be assessed before any NIV is initiated is a GI problem. You do not want to exacerbate vomiting or any situation where air in the gut with gastric distention or perforation might be a problem. Alcohol intoxication and NIV also do not mix very well but once the ABG is obtained or the patient snores you will usually hear someone yell "BiPAP STAT".

You must monitor the intrinsic or auto PEEP and plateau pressures. High Peak pressures are also just one small part of the story. By knowing the plateau pressure you can make an informed decision about whether it is a problem with secretions, bronchospasm or compliance. http://anesthesia.slu.edu/pdf/plateau.pdf The CXR would be a necessity to determine the strategies for protecting the lungs to achieve the amount of oxygenation required. But then, initiating one of these strategies would come with a package deal of CVP monitoring, fluids, pressors and maybe a buffer depending on the etiology of the lung disease and permissive hypercapnia. I would also still look at the other lab values to determine the correct path for treatment. Stabilizing with a ventilator is just short term or maintenance. It may only buy a little extra time.

The over simplified teaching of ABGs do an injustice to the bedside clinical health professional. Many focus on the disease process of "COPD" without considering the many other pulmonary and non-pulmonary disease processes which are interconnected. Treatment is not going to depend solely on the ABG. The anion and OSM gap must be considered when it comes to acidosis. The other lab data can also help determine if the results of the ABG are an early or later stage and determine the path of care. Sometimes a patient with a low pH can avoid intubation based on this data. We've also extubated patients post operatively with a less than ideal ABG by understanding the other data used for differential diagnoses. Here's a little more detailed ABG interpretation. http://www.thoracic.org/clinical/critical-care/clinical-education/abgs.php http://revisemedicine.com/forum/medical-students/1947-guide-abg-interpretation-medical-students.html For Respiratory Acidosis you may need to determine if it is hypoventilation from: (taken from the above articles) 1. Chronic obstructive pulmonary disease 2. Neuromuscular diseases - e.g. Guillain-Barre syndrome, Myasthenia Gravis, Muscular Dystrophy 3. CNS depression - e.g. drugs (opiates, barbiturates), neurological disorders (trauma, brainstem disorders) Or failure due to V/Q mismatching and hypoemia. 1. Atelectasis 2. Pulmonary edema 3. Pneumonia 4. Pleural effusion 5. Haemo/pneumothorax Some of these you can help correct or influence as a bedside clinician. The support (O2, NIV, ventilator, positioning) offered will depend on the determined underlying disease process and the clinical symptoms determining the amount of "rescue" required. Pulmonary Emboli is also another consideration but the ABG will probably appear as "hyperventilation" initially.

This is also a very public open forum. The OP expressed a concern for a nurse over something he/she thought he/she withnessed. The OP is also a member of the hospital team even if he does not have RN behind his/her name. The OP's question also seemed to be out of respect for nursing. Since this is a very public forum, how we treat each other and anyone who happens to post BECAUSE it is a nursing forum, forms an opinion by those who might stumble upon this website. This website does appear on several search engines since it covers many different topics. Also, a situation simiar to this is not that uncommon and how we respond is important. In the hospital it is not uncommon for a visitor, family member or patient to ask about something they may have witnessed or overheard. You could have patients, nurses, CNAs, various techs, doctors and visitors who could be shouting, crying or making some type of fuss in a patient care area. Being able to explain a situation without be a real turd is an art as much as it is a valued skill. There are also closed forums where you enter by a professional membership and your real name, title and facility are posted. Those forums rarely if ever have fluff, laid back or snippy posts. They are all busines. This forum is sometimes a delightful change from the all busines attitude and to see newbies get advice from the more experienced.

Since this was a teaching hospital there might be several ways to "record a code". We record the actual code in action to be played back. There are also electronic markers on a computer screen that has all the monitored data sent to it and it takes is someone to press a button on cue. The OP might have been near the monitors where the ECG was printing. We've also had our Computer Technicians standby to limp our equipment along until a better solution is found or the equipment is replaced. They are more than capable of "recording" or ensuring the equipment continues to gather information and sometimes they are the Masters at doing this by knowing the equipment better. Without knowing what actually was said between the MD and RN, it is hard to judge. Since the OP did not actually hear harsh words it could have been anything from comfort to questioning the events and an RN who was shaken by the event for some reason. But, had it been a loud verbal attack to where bystanders noticed, then yes that would be very inappropriate regardless of the title of the person doing or rec'g the verbal attack or "scolding". No such exchange should take place in a patient care area or in view of others.

Is the PA catheter used by Habit Based Medicine or Evidence Based? Because we've always done it like this no longer holds up in Evidence Based Practice. http://anestit.unipa.it/mirror/asa2/practice/pulm/pulm_artery.html Any invasive procedure will now face scutiny and CMS will be taken seriously. These procedures are also no longer the cash cows they once were for physicians. We used to have docs stumbling over themselves for procedures. We used to put in an Arterial Line into every ventilator patient and now we rarely do an ABG unless there are multiple conditions that exist which warrant one.

That is an interesting topic that might deserve a heading all to itself. We will also put DNR patients on NIV if we feel it is a short term situation. Sometimes it is a gamble and the patient doesn't turn around as expected. NIV falls into a gray area of ventilation and it can become just as complex as withdrawing from an ICU ventilator. Here is a decent guideline and questions or info you can use to prepare a family or patient. http://www.palliativedrugs.com/download/091209_combined_Withdrawing_NIV_Draft_Guidelines_Revised231009.pdf

Our bodies also adapt quite well to some objects as evidenced by stents, pacemakers, Blom-Singer valves, IUDs, spinal rods, artificial this and that. However, when it comes to body piercings I wish I could effectively use that argument on some young people. I rarely use saline unless the secretions are really thick or the person does not want a suction catheter introduced usually due to being traumatized. If the secretions are thick enough to require saline I look for a solution to the problem or take it as a sign of something more serious. If you ever get the opportunity to see (bronchoscopy) the carina of patient who has an ETT or trach for any length of time, it is a learning experience and you'll have a new respect for suctioning. The damage done can lead to serious inflammation and even necrosis. Checking the patiency of a trach qshift is advised but that does not mean you have to draw blood doing so. Also, if the patient's trach has an inner cannula, it can tell you alot about the secretions and of course patency. If the patient is a quadriplegic, I encourage a cough with the cough inexsufflator or quad coughing before suctioning. They are probably the most difficult patients to determine a suctioning need just by listening to breath sounds due to the paralysis.

Patients may have trachs because of their disease process which creates secretions. Due to a weakened state or the advancement of their disease they are no longer able to cough, spit or swallow as others would. They are probably colonized with every bacteria imaginable which will rise occasionally for sputum producing infection. If anybody here has ever had PNA or bronchitis, it may seem like you are coughing up stuff for weeks or months later. Your body is just able to rid itself of the secretions more effectively. You also don't have a plastic hollow tube amplifying the sound of the secretions which may sound like a bucket full but really might be just a tiny but annoying amount that takes effort to clear the tube. The other reason for a trach is chronic aspiration or impaired swallow. These patient will of course end up with more secretions, and infections, as they aspirate their own saliva. Cuffed trachs also do NOT prevent aspiration. They only slow down the inevitable or create one very nasty mess around or on the cuff. This is why some trachs now have subglottic suction ports just like the ETTs which are supposed to prevent VAP. Patients can sometimes be weaned to a small trach and one without a cuff for them to be able to cough up and expel or swallow the secretions in a natural way despite a large piece of plastic. And then there is even a bigger reason for secretions than the trach itself. That is over zealous "really deep" suctioning every two hours whether they need it or not and just because it is a check in the box. Also, the way some are taught is to push the catheter in until you meet resistance and that resistance is tissue which becomes irritated. BE CAREFUL when suctioning. Most humidification systems are inadequate and cold air blowing around a trach can also be just irritating. Using a little donut heater on the top of a bottle or having 10 foot of tubing to lose whatever heat was produced is just not going to do much except irritate especially if the person has any asthma or reactive airway component. There is newer technology available for humidification systems which can prevent some of these issues. When the humidification is inadequate, patients retain secretions regardless of how vigorously you suction and that will lead to an infection and more secretions. Poor patient hydration is also another factor which cause secretions to thickend and put them at risk for infection and more secretions. Finally, there is malpositioning of the trach or excessive movement which created irritation. Care is not given when securing the trach or when turning them or just allowing the humidifier circuit to dangle heavily pulling the trach into a poor fit. The trach then irritates the wall of the trachea. BE CAREFUL of the trach's position. Usually when a patient is in control of his or her own trach or is alert enough to tell his provider to be careful, they will have less secetions. The trach itself gets an undeserved bum rap but then the most efficient trach for preventing colonization was the one made with real silver.

The industry has realized the issues concerning BiPAP™ and has responded with a new generation of technology. BiPAP™ was not intended to be a "ventilator" but some often believe it to be and set the rate as they would for an AC mode. I also agree that CPAP might work well in some situations better especially if one does not understand bilevel or BiPAP™. If the machine does not allow for active breathing with a sophisticated exhalation valve at the higher level, the patient may increase work of breathing. The ABG only gives a limited snap shot. The way we have traditionally taught ABGs leaves a lot to be desired.

The ethics of medicine can become quite involved with many factors to consider. Do we always know that a COPD patient will not wean from a ventilator if they are intubated for an exacerbation with an underlying that might be easily treated or if the required surgery for an unrelated injury or illnes?. Much of their ability to wean will depend greatly on the skill and agressiveness of the practitioners managing their care including RN, RRTs, PTs and physcians. Even before they get to the hospital it may depend on the Paramedics and right now CPAP is still not readily available on the ambulances in the US. The other factors concerning maintenance is lack of insurance or inadequate insurance. Maintenance inhalers are expenive. In the US there is no longer a generic Albuterol inhaler available which could be given out at the community clinic for a couple of dollars. The brand names available for HFA standards can cost up to $65. The LABA and combo inhalers cost between $100 - $300 each and some require at least 2 inhalers of each per month. Combine that with the usual meds which accompany long term illnesses such as HTN and Diabetes, you have a very expensive plate of meds. My own hospital insurance plan does not cover the latest and greatest medications. The Physician can order whatever he or she wants but the insurance will make substitutions. Since insurance would be an issue, very few would get to see a Pulmonologist. They would be dependent on the luck of draw for the expertise of the physician at the clinic or ED. Most will just offer something for a quick fix or what happens to be on the ED formulary without any maintenance plan. An ED physician is in no way the best provider for the care of any long term illness. But, the uninsured may have limited options and with the community based clinics closing, there are very few options. These patients are also still incontrol of their own decisions regardless of advanced directives and those who know extreme shortness of breath will also have a difficult time believing they can be made comfortable to have a peaceful end. Unfortunately in some situations they are correct and unless there are excellent pallative care programs and practitioners available, the COPD patient will die a slow and brutal death in a hospital especially if there is a lack of education about medication administration for comfort. This is where we also find that oxygen does not always just knock out the respiratory drive since a NRB mask at 15 liters would be an ideal way to calm or kill (as some believe) a patient by CO2 narcosis instead of using pain and sedative medications for comfort. Very often some will crank up the O2 instead of the pharmacology which in terminal cases will be futile in offering the relief they need. Again it comes down to understanding hypoxia regardless of the amount of oxygen being administered. Some hospitals will also put these patients through several painful ABGs just to see how short of breath this patient is they have determined to be futile really is. Maybe for some it is still ignorance about the process of death or our reluctance to accept death as health care providers. Again that includes doctors, nurses, RRTs and EMS or any other practitioner who is present at the bedside.

wikipedia? i must agree with gilarrt about a non-rebreathing mask being a low flow device. in the hospital we utilize many other devices that are considered flow by the true defiinition by delivery of inspiratory flow demand. there is also confusion between high flow and high fio2. a high flow device can deliver 24% oxygen at a high flow rate to meet demand. here are more reliable references: administration of oxygen oxygen delivery devices

When a patient is ready to be extubated the air hunger hopefully will not be there causing them to struggle. Whatever even such as a TBI hopefully will have improved which was causing them to have altered mental status and combative. How many times have you aborted an SBT during a vacation sedation due to aggitation? Why do you think wrist restraints are used when a patient is first intubated? Ever see a patient try to extubate themselves because the tube annoyed them? Patients will even tell you later it felt like they were choking because they could not expel the secretions either internal of the ETT or external at the glottic area. No, patients don't always take to a ventilator like a fish to water and many feel like they are going under water. This is why we spend over $40k - $60k per ventilator with the latest and greatest technology available. But, not all hospitals have that and must be creative to get a patient in synch with the machine. Not all have the fancy ETTs either.

Hurricane spray can be extremely effective if used properly. Lido 4% with an atomizer can be effective and so could a 30 minute nebulizer if you have time. We could also use Jackson forceps and a cotton ball to give a direct hit to the nerves depending on intubation method such as a moderately sedated or awake patient and a fiberoptic scope. Every patient is assessed for the most appropriate approach since what may work for one will not work for another. It will also depend on the method used for intubation. In our ICUs and EDs we have several devices to facilitate intubation. We also have to think about the patient for post intubation and what type of ventilator they will be on. Some of the very worst scenarios involve those who are short sighted and only prepared for the intubation. Much damage can occur in the minutes after that when inadequate preparation is done to keep the patient from struggling. Nasal intubation can create problems within 24 hours for some patients which is why it has not been recommended for over 15 years or at least as long as we have been getting serious about VAP which might be more like 25 years.

I have continued to lived in SF for many years by choice even though I could easily move somewhere else. I know the economic stressors. However, I do not believe being cautious when commuting, walking my former neighborhood (the Mission) or being aware of one's surrounding including those at work make me living in fear or prejudice. But yes, I have known fear first hand and I also know the meaning of the word prejudice first hand. None of what you describe comes close. I also don't go through life with blinders on and oblivious to what is going on or in denial either. Being an active part of the community to help those who aren't making the same wage as you and who know prejudice, fear and hardship first hand gives you a closer look at diversity and issues that are still present in our society and they will not go away with your insults toward those who have learned some valuable life lessons. For the topic, money isn't always everything but it sure helps with the choices you can make.

48? I don't live in fear but I don't invite danger into my life unnecessarily. It seems you have not learned the difference yet. However, Tibourn and Walnut Creek are nice areas to consider. If I were to move either would be a nice option. A few facts of life for you. When you have a family to raise you look for security and safety. That includes your neighborhood and job. You look for a good place for your kids to get an education without carrying a weapon to school. You may not find all of these things but you do not want to intentionally put your family or yourself in danger. You may not have worked to where you noticed a mother cry for your young son killed by the stupidity of the streets and hear her words of wishing she could have moved away or have provided more for her kids. Some parents don't care. But some do. I sincerely hope you won't force your wife, girlfriend or children to throw caution to the wind just because you do. A parent should not have to bury their children. If you are working in some aspect of health care, you may have the opportunity to understand all of this someday. You also don't want to be cocky and ignorant of a situation to where you get your co-workers injured. Be safe and not stupid. You might live as long as I have and enjoy a long great career with a healthy and financially stable retirement.