GrannyRRT

I have taken ACLS classes for over 30 years which includes back when the certification actually meant something. On page 70 in the text there is a paragraph about IO. On the website there is a short video. In PALS you might play around with a chicken bone but not to any depth to where you should be doing this on a child without further training by your unit. On the first page of the text it says the course does not certify you for anything and definitely not replace the skills competencies at your hospital. Your ACLS and PALS instructors should be emphasizing this to the class. Epic fail on their part if you leave a class believing you are fully competent to do skills you had not been adequately trained for. Transport team members spend at least a day learning alternative access methods. How do you decide to stick the tibia, humerus or sternum? Not all patients will be unconscious, dead or 20 year olds making tough guy YouTube videos. Do you know how to prep the conscious patient? What about the EJ which is a PIV? I don't see nurses using that site very much and it is in their scope of practice. Part of your assessment is to know if a patient might need a central line or a PICC just like I assess for an art line. People in the ICU shouldn't be without access nor wait until an IO is necessary. I don't think we have ever had to resort to that in any of our ICUs. The NPS and a few doctors have utilized them on the floors and the ED but mostly as teaching examples.

I do not agree that none of them require knowing the diagnosis. Many of the alarm parameters are diagnosis based. If you have a fixed rate pacemaker your alarm settings might be different than a variable rate or regular patient. If the patient is part of the cardiac "mixers" group, you would know to get the parameters. The same for patients on a pulmonary floor or those hooked up to "breathing machines". Some nurses do not always think to pass on this information or even ask the doctor for parameters. This is why I prefer a floor with a good Tele Tech as opposed to a floor with a hodge podge group of RNs or various techs watching the monitors. It is also good to know a little about the patient whose HR is usually at 62 but goes to 98 (which still in normal limits for most alarms) if the patient is easily agitated or on a floor with no SpO2 monitoring but is on hefty O2. The monitor techs can see changes with are not necessarily outside of the alarm settings. I have seen enough Tele Techs get blasted and belittled by RNs for not knowing something even though certain information was never passed on to the Tele Techs. But then, I guess maybe it is sometimes best to just say you only watch the monitors and only report what you are told to. Alarm fatigue is an issue. I have had RNs tell me to set my ventilator alarms way out of the parameters for that type of patient and ventilator or shut off that alarm totally. Others demand the mode be changed to PCV so there are fewer alarms. They also say probably the same thing the Tele Tech told you, "But, I'm here watching the vent (monitor)". I could easily just call these nurses "idiots" also but I would rather explain "why" which might involve taking a few minutes to go into detail about the diagnosis. I don't always have to go into a great amount of detail but I will tell the Tele Tech I have a brittle pulmonary patient in room X and am expecting something to do with the ABC. I also tell them to call me directly if the nurse doesn't respond or in addition to. If we didn't have great Tele Techs, RT and the CCM doctors would be totally against BIPAP, ventilator and most trach patients being on the Tele floors. This would mean a lot of ICU time and beds tied up for otherwise stable patients.

It sounds like you did not realize you were getting hired to be part of a PATIENT CARE TEAM. You don't need a college degree to understand a few things beyond the squiggly lines on the monitor and how they pertain to the total care of the patient. No one is asking you to make assumptions. There are concrete reasons and even some speculations already made by the doctor who ordered the patient to be on tele. Your job is to support that reasoning. As you gain experience you will be amazed at what your will learn about people from watching the monitors. You will find other professionals such as RT and PT will want to know what you have been seeing on the monitor. As an RT, I find the Tele Tech to be an invaluable part of the team and to have my back for some of the Pulmonary patients. Our tele is also capable of SpO2 and in some cases ETCO2. I sometimes let them know if I am going to be working with the patient or if I have put them on CPAP/BIPAP/AVAPS or a Continuous Albuterol nebulizer (increased HR or PVCs from K+ drop). The Tele Tech might be told when the patient is on a considerable amount of oxygen. They may document that initiation of therapy in their own notes at least to pass on to the next Tele Tech. We also provided education for OSA not only to the RNs but also to the Tele Techs since they will be directly involved when we initiate the protocol. Some Tele Techs have also told me about patients who have had rhythm changes only at night and have been placed on oxygen by nurses temporarily but still not in our protocol. This is not diagnosing or making an assumption. This is merely reporting observations to possibly initiate the proper care for the patient. What the licensed professionals choose to do with that information reported is on them. Tele Techs may be asked to do extra documentation for certain drug studies. Patients, especially pediatrics, will have notations that their cardiac issues will have SpO2s at a much lower range for normal. You would really have to be very task focused with a "not my job" attitude to not want more information about these conditions. If you see that dx on the charting it should be appropriate to ask for SpO2 parameters. The Tele Tech has also been instrumental in preventing falls. They, of course, do not replace a sitter but they have watched someone's rhythm long enough to know the patient's movements. I sat at the monitors back when post op hearts in the tele wing were on major drips including lidocaine. By 0200, some of them were bat crap crazy. I got to know when someone was about to do something even without a "reportable" rhythm on the monitor. I still take my turn sitting at the monitors in the units and the RT department does the 12 Lead ECGs which we may also report to the Tele Tech to document its existence to correspond to the tele monitor. Even the doctors will rely on the Tele Tech for information or just to know where a patient is since it is not uncommon for nothing to get past the really good Tele Techs who will know where their patients are and their tele boxes. Once the doctors get to know you, you might just find yourself having some very indepth discussions on cardiac issues and rhythm interpretation with them. It is your choice to build on that very minimal training the ECG course gave you to function as a valued part of a patient care team and learn why patients need a Tele Tech or you can just do the task of watching squiggly lines on a monitor.

It used to bother me but now, if the patients are on RT service, I just protocol them to an MDI and wish them well. This was after several times of being paged by RNs who didn't want these patients to miss their RT treatments and would call us to give them their treatments before they went out to smoke. I also tell the nurses to ask the patient if they are interested in Smoking Cessation before putting the RT order in. If they are not interested, no need to take time from patients who are serious about getting better or delay the patient from his or her cigarette or whatever smoke of choice time.

Since you mentioned Echo, is your floor utilizing or attempting to establish order sets for core measures based off the physician diagnosis such as for heart failure? There are also pre and post procedure order sets. Ideally the computer system should be set up for all the individual orders to appear for the physician but some require the orders to be individually entered by the UC or RN or RRT/RPFT.

Field provider? Okay, I didn't go into all of the many different specialty devices we use in the ORs, bronch suites and ICUs because they usually have an RT, CRNA or anesthesiologist at the bedside. We have devices to do bronchs on BIPAP and ventilator patients also. But, these devices are kept in limited access areas since they do require close observation, trained providers and are very expensive because of the specialty label. We also have special ETTs for different purposes and have had them for several decades. I will say many of us are kicking ourselves for not patenting the modified NRM which is now the Panoramic mask. For many years some did cut holes in the NRB to accommodate for various procedures and to monitor ETCO2. For more common use we do have the Oxymizer NC for comfort, ambulation, home care and Pulmonary Rehab where there is a need to spare the portable O2 tank. It is low flow and still expensive. Pilots also use it and aviation was where it had its start. I doubt if an expensive specialty device would be necessary for most EMS patients. Even for CCT, the Paramedics will toss the Oxymask in the trash which we might have at 6 L and place a NRM because "it looks funny" when they do the interfacility transport. This is even after attempts at education and even giving them a case of Oxymask. Some will put a 6 L NC under a Simple Mask or NRM, even for low FiO2 requirements, for more flow instead of using a high flow entrainment device (various venture systems). Others will try to run a regular Nasal Cannula at 15 L/M and miss how a HFNC works or its intended purpose. Change is slow even if something has been around for years. In the hospital we have had to keep the Oxymask also under lock and key because people didn't like its looks and would rip open the package and discard it even though we have been trying to provide education. It is also rare that respiratory equipment vendors are invited to share the latest and greatest with nursing staff. Purchasing and a nurse manager makes the equipment decision based on cheapest for the budget and "what has always been used". I hate moonlighting in hospitals which have O2 devices controlled by nursing in the ED and on the floors. I will say again, in the hospital, if the patient needs an FiO2 of 1, it is time to consider using another device and getting aggressive in treatment. They also will probably have someone specialized in respiratory equipment who has the keys to the cabinet with the cool stuff or the ability to provide other interventions. For now hopefully at least in the urban areas, EMS can get by with NRMs or maybe consider intubation if a patient requires an FiO2 of close to 1. If you have access to a large hospital, you might be able to get an RT, CRNA or Anesthesiologist to show your their airway cart and special equipment room. Chances are a smaller hospital will have a more limited budget but may still have some interesting stuff in their carts. If RT is under nursing, chances are their department will be more limited the exception of the bronchoscopy and endoscopy cart. You might be able to attend a state or national RT conference which usually will have over 300 vendors of specialized RT and anesthesia equipment. Go in as guest nonRT or nonRN so you won't have to pay the expensive conference fees for CEs. You might be able to get in for the student price.

Not necessarily. That would depend upon the situation and why the patient is requiring supplemental oxygen. Drug OD and neuro patients do not always respond as others with a normal unimpaired drive would. DKA would also give an increased rate and depth. Please provide links to the other devices. Since the Oxymask has been out for well over a decade, I am sure there are several devices coming on the market. I know Canada and Europe have been using other devices and they had been awaiting approval in the US. Per the original post, the patient is on 2 L by whatever device. The beauty of the Oxymask is that it functions at 1 L and at 15 L. The actual FiO2 of any device that still allows entrainment of air will fluctuate with patient effort and positioning. If the patient is requiring more than an FiO2 of 0.65 and requires continuous ETCO2 monitoring, it might be time to move on to another device such as a HFNC or even CPAP/BIPAP. I might use the ETCO2 mask for some procedure which requires moderate sedation. Whatever the situation, a high FiO2 mask is only a temporary measure and in the hospital we hopefully can take steps to either provide more support with ventilator assistive devices while also initiating treatment for the cause.

It is an open light weight mask with a shallow cup like piece in the center directing oxygen at the patient. OxyMaskâ„¢ Adult | Medical Supplies | Southmedic This site provides great info. Read the FAQs section and use it as a reference if your facility is interested or finally gets the Oxymask. It has been around for over 10 years. It is great for ER patients because you don't have a tangled mess of different masks. The patient can still be examined, NT or oral suctioned, sip water and be weaned or increased without changing equipment. I love it for broncoscopy_ where I don't have to hold a mask near the patient when the nasal cannula is not enough. It is great for bloody and packed noses aa well as mouth breathers. And, it can be used with a humidifier. But, that part rarely gets mentioned if the facility still has NRB and simple masks around to avoid serious mishaps. It is also available in pedi sizes and with an ETCO2 option.

It is not so much the FiO2 which can cause the harm but the rebreathing of CO2. This will not be noticed by the SpO2 value until it is too late. I am going to be the "2 L" thing has to do with the old training of no more than 2L for COPD patients regardless of device. Because of so much confusion in O2 devices, NRMs and Simples masks ( and even Venti masks) should be banned. The Oxymask is safer.

I am more concerned about someone putting anyone on a NRM at 2 LPM. Even 97% SpO2 on a nonrebreather does not give a clear picture especially if the A-a gradient could be >300 mmHg.

Some home care and LTC trachs are changed q 30 days, q 60 days, q 90 days or q 6 months depending on insurance and protocol. Some LTC facilities stretch out changing special order expensive trachs as long as possible. I prefer to change cuffed trach every 30 days. But ,even hospitals get lax and will not change a due trach because they don't carry that type or no one assumes that responsibility on some floors. DOCTORS may not be willing to refer or may have a difficult time finding an ENT for a state insured patient if it is nonemergent. Cuffed trachs can be difficult to remove sometimes. Experience and a good mentor will guide you in how much force to use. Fenestrated_ trachs will sometimes have tracheal wall tissue snagged in the holes. Depending on the feel of the cannula going in and meds the patient is on as well as a doctor's blessing will determine if I force the trach out. Back when RTS were still in subacutes, I would not allow any Paramedic to attempt to reinsert a trach which I could not get in. This was a very rare situation since I could usually get a smaller one in. But if there was a false Trac or some bizarre anatomy, no digging. If it was an emergency, either myself or the Paramedic could intubate orally. Since this trach was jammed in at the ER, chances are it was not by ENT or RT. The tracheal wall can be damaged as well as the stoma. The ER physician probably saw the blood and thought water in the Shiley cuff would slow the bleeding and they may have even put ice water in the cuff. This is not standard practice but more of an "Oh Sh#t!" reasoning. In the hospital we can use a stoma dilator_ and usually avoid an OR trip to "cut".

If your hospital is as big as you say it is, I would really like to see that hierarchy line. That's good. But, it does not mean the RNs in your state are restricted from touching ventilators. They do in home care, PACU, transport, LTC and a variety of other situations. So you have not even given up MDIs and nebs to nurses? Even in the ER? You also do all incentive spirometrys? That would be great if all hospitals could do that but it is economically unfeasible to staff for this. You are very incorrect and misinformed about this. Did you know that Michigan has not had licensure that long? Just like many other states until recent years, it used just the NBRC credential. This was probably its first Sunset hearing just like every state has had to have once it obtained licensure. Sunset is way for the profession to show it has benefited from licensure in keeping the public safe and the licensing body being viable financially. Florida was not the first state nor is it the only state to have RT licensure. Texas has and has had RT state licensure for several years. This was its Sunset hearing to see how things were going. Unfortunately, RTs in that state were not ready like other states have been in the past for their Sunset hearings. They had nothing prepared to present and literally got throw for a big loop. Since 1960 RTs have used the NBRC or its predecessor for certifying and only since 1982 has licensure been a reality. Most states were very slow to respond with Hawaii just obtaining licensure in 2011 after a 25 year battle. Vermont has not been licensed that long either and Oregon only got licensure about 14 years ago. Alaska still does not have licensure. You obviously have no idea what has been happening in Texas. I advise you to go to the TSRC FB page for an update. The hearings are still going on and there is a counter bill to the one presented. The first one drawn up was an "ideal" situation and now it comes to compromise. Much of what is being used by the opposition to licensure is coming from RTs who do not want to be state licensed. They feel the NBRC was enough. Nor do they want the education upgrade. The OJT was good enough according to some. We are not fighting politicians. We are fighting other RTs who also have a political agenda and are only too happy to feed the politicians what they want to hear when it comes to budget cuts. This guy has a huge following. In My Opinion : Why Should States License Respiratory Care? Incorrect again. CMS and respiratory both have been around for while. Licensure made use more accountable to the public. I already mentioned the states which just recently obtained licensure. Is that Dr. Isabella Sharpe? State suspends Jacksonville doctor's license | jacksonville.com There are many other more notable doctors who have helped the profession including those who helped initiate the first certifying exams. RTs are not being reimbursed. The nursing homes are eating the costs and having 1 RN per 100 patients and scrimping on whatever resources. Nobody wins here and definitely not the patient. Why the hell were you not fighting to coverage for Medicare B? When we were trying to lobby for more coverage from CMS, many studies were done. Guess what? Not enough RTs supported the bills and nothing happened. Most RTs could care less about LTC. There are still no RTs in most of the LTC and subacutes in California just like many other states. Are you saying there is an RT to show up every morning to take the patient off their ventilator for TC trials and then again at night to put them back on the ventilator? Do you know how ridiculous you sound? You only speak for your hospital. I would like to know how many RTs have been laid off at your facility or if being grossly over budget is why you are working understaffed. News flash! Respiratory Therapy is an Associates degree now. PA has always been an option for many in the allied health professions and even those not in it. The plans for the APRT was also linked to the success of HR 2619 which is no more. Without reimbursement, no go. If the states can not maintain Bachelors programs, no way can a Masters be possible. Why are you not checking facts before typing stuff you may have heard on some lame social media site? That info would be more credible if you provided a link. But yes the reimbursement issue has given Paramedics a huge boost to launch Community Paramedics to take care of COPD, Asthmatic kids and CHF patients. Why hasn't RT been more proactive before now in preventing readmissions? CMS has tracked the 30 day readmits for many years and just recently started penalizing the hospitals. Why wasn't there a lesson to be learned. Oh wait! There was but RTs failed to support their own bill which could have assisted patients in the outpatient area. There were several reports but it does not matter if no one supports LTC in the legislation. California still does not have RTs in every SNF. They don't have them in all of the big ventilator subacutes. Why aren't you understanding this? This is also true of Washington and Oregon. ++++++++++++++++ Now for a little history about Sunset. As I have stated many times, it is meant as a followup on the regulatory body overseeing a license. It is like an audit. The end result is the Governor of that state signing a bill to continue licensure and have all the necessary changes included. Some states are very prepared and have their legislation drawn up and supported way before the Sunset meeting happens. California just did this recently. Not only did they reposition themselves under a more appropriate agency, they also paved the way for RRT only for entry to come into their statutes. Florida had a huge update in their legislation about 10 years ago. But, it was also a give and take. They no longer are sole proprietors of Respiratory although their scope of practice was clarified which is still strong. But, Paramedics now have a place on NICU/PICU specialty transports and RNs are now more involved with ventilators in transport and LTC. If all of the RTs in Florida are hiding their heads in the sand like you, the next Sunset for Florida may not go as well. I suggest you get more computer skills and keep updated on what is happening around you in RT. Please provide links to support your data. In the meantime here is some reading for you to learn more about Sunset. Illinois is up for Sunset this year -2015. http://www.isrc.org/newsletter/ISRC_eTRACT78_JulyAug2014.pdf This was Hawaii's first bid for licensure in 1986. They finally obtained it in 2011. http://files.hawaii.gov/auditor/Reports/1980-1989/86-10.pdf Since you are interested in California, this was their Sunset report from 2012. http://www.rcb.ca.gov/media_outreach/rcb_sunset_report_12-13.pdf Another good read about California's ongoing struggle in LTC. http://www.rcb.ca.gov/forms_pubs/nlsept04.pdf It does give a good breakdown for the differences in nursing education and RT. Colorado http://www.jerrykopel.com/a/respiratory-therapists.htm Alabama's Sunset will be in October 2016. There are other states but I am running out of time and patience with you. But, I will leave you with some CMS reading. http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=169&ncdver=1&NCAId=169&NcaName=Home+Use+of+Oxygen&IsPopup=y&bc=AAAAAAAAIAAA& A quote from that link: And this was HR 2619 https://c.aarc.org/advocacy/activities/FAQs_HR2619_FINAL_rev3-6-14.pdf Sad to say, there will be no way the Respiratory Therapist will get the APRT going within the next 50+ years. Some RTs already have Bachelors in RT and some have Masters who are at the bedside. But, with no chance of the advanced legislation, they will have very limited opportunities clinically. There will some opportunities in research, education and management. What you heard was about this: http://www.coarc.com/73.html It has never gotten past the draft stages and not there is no reason to proceed. I bet a lot of RTs in Texas working in progressive hospitals thought they had it made also and never bothered to care about the Sunset clause in their licensing statutes. No one should ever be surprised by this nor should they be so unprepared. I suggest you make sure you never lose your job at your current employer where you can stay isolated and unconcerned about anything or anyone else in RT. Let those of us who give a **** continue to fight for more opportunities and a strong future for all in the profession and not just a few.

Who does he report to? What is the hierarchy of management in your facility? What type of hospital? Be specific. There are exceptions but I am looking at the experiences of many managers in many states including Florida. I am an RRT with degrees and the alphabet soup. And I am an RRT who is very active in regional, state and national organizations for Respiratory Therapists. It takes more than just sending money to make an organization be successful. Critical Access Hospitals use critical care ventilators. Many CAHs keep some ventilator patients. They do not transfer every intubated patient. There is no requirement for an RT to be present in Critical Access Hospitals to manage a ventilator. This is nationwide with only a few exceptions. PACU RNs, probably right in your own hospital if you work in a hospital, can initiate and wean a critical care ventilator as well as extubate. RNs in some EDs and CVICUs can also manage ventilators especially if they control the iSTAT machine or blood gases. CVICU RNs can wean to extubate also in some places. Incorrect again. Home care nurses can and do shut and turn on home care ventilators. They can also do PSV sprints and return to a rate. RNs can make prescribed ventilator changes. RTs are not covered under Medicare B which means no reimbursement for them and there are not many RTs employed by each DME company. There are just enough for an initial eval and setup along with a few maintenance calls. There is no way one RT can be at the home of 25 ventilator patients each morning. The LTC facilities also do not require an RT to be inhouse. This includes the big facilities with 50+ ventilator patients. The nurses, including LPNs, manage the ventilators with their protocols. They do all the trach changes, both routine and emergent, and provide all medication treatments. .Why isn't your manager actively recruiting the new grads or advertising? Are these openings actually listed? Or, is your manager and hospital using virtual openings to serve a budget purpose? I never said it was strictly Respiratory but we are turning over more of our tasks to nursing and reducing staff in RT across the country. If you actually are a member of your state society and the AARC, you should have been aware of this. Why do I have to keep repeating myself for you to actually read the AARC and state society webpages? Which Sunset? We have had several and more to come. Texas is still processing theirs. It did point out the sad state of membership supporting the profession in that state. What about Michigan? That is still an ongoing struggle and who knows what their next sunset meeting will bring. Indiana? Colorado? California? I personally have not had a bad experience in RT in almost 40 years. But, I am not blind to the problems faced by the profession. I would like the next generation to have a secure future as Respiratory Therapist. But, right now with so many like yourself who live in a sheltered existence and could care less about the direction RT is heading, I don't see a bright future. Take your state of Florida as an example. The latest virtual lobby for HR 5380 only produced 7000 letters from RTs in its support. Florida is proud of that number even though it is pathetic given the total number of RTs in that state. The total number across all the states was bad to say the least. This bill will probably pass but the standard wording in it will allow everyone in almost any profession to get a piece of respiratory as it is not a Respiratory Therapist specific bill. Respiratory Therapy is still not recognized by Medicare B. But, I bet you didn't even know about it even though it has been on the front page of the AARC and the FSRC sites along with email. Did you also know what the death of HR 2619 means to the profession? It is a very sad time for RTs when they fail to see the need to branch out into more opportunities or allow those with a Bachelors degree achieve higher goals in the clinical setting both in and out of the hospital. Your attitude and others like you defeat what Florida has tried to strive for with higher education. This has led to the closing of the Bachelors program at UCF. Due to its history, that was a sad day for RT and it made headlines nationwide. In case you didn't know, UCF is University of Central Florida which is in Orlando. For decades it was a role model for Bachelors programs, as few as they might be, in this country. You need to stop hiding your head in the sand. Whatever problems exist in your hospital needs to be fixed so you can be fully staffed if that is the case. It could be because of the lack of progressive attitudes like yours and full of those who don't want to get involved in the profession, again like you, which is holding the department back from making the necessary changes to make it a great place to work. Some RTs probably prefer to move out of state or start in the RN program rather than work for a really bad department. Florida has dozens of schools and I have not heard of any manager complain in the AARC conversations that they have no applicants. Many are trying to create opportunities to bring in more or keep what they have but are facing many obstacles. Do your homework on what I have mentioned so I don't have to keep repeating myself. Definitely read the AARC website in the legislative section before you choose to reply again. This discussion goes nowhere if you are not informed about the issues. Right now anyone wanting to enter the profession should check out the employment ads in their area and also see how many students are graduating from the RT programs.

For the past 20+ years we have allowed parents to be present when their child codes. But, we will have at least one professional with them to explain everything and remove them if necessary.

I am just saying it is time to put the correct reasoning behind statements like "if you give that old bird 4 L she will stop breathing" and understand not all COPD patients are retainers. The longer you leave a patient in a hypoxic state the more chance of CO2 rising once oxygen is administered. But, you must understand there is a difference between the hypoxic drive and the theory that was initiated in 1950 and circulated as the truth and only truth in nursing and past RT classes. Have you ever heard the expression "chasing gases in the ICU"? Some doctors love to make rapid fire changes on the ventilator per the ABGs. Many COPD patients will "spike up" their PaCO2 once on a vent with adequate oxygenation and then trend down. If you know about pulmonary Vasconstriction, deadspace and V/Q mismatch, you don't make knee jerk changes. The same for metabolic issues. Adjust the ventilator for pH only long enough for other therapies to start correcting and understand the vent is supportive; not the cure. This is also why both the serum CO2 and the PaCO2 needs to be understood.