BreatheDeep

Well then that's just even more ridiculous! One thing I've noticed is that there's often an inverse relationship between how territorial an RT is and how good of a therapist they are. The strong ones know their own skills and knowledge, know they don't need to defend/justify themselves or their existence to others, and typically get along better with people too (which also leads to less people having or trying to step on their toes anyway). Almost without fail, it's always the trash therapists who blow up whenever an RN does something they "shouldn't have". And usually, because they're trash, they have to hide behind policies and rules to justify their being there, because otherwise in most cases they could completely disappear and no one would notice. I remember once I was getting slammed in our CVICU, so the RN changed our patient over to spontaneous so we could get the weaning going before it was too late. Oh my god! He touched my ventilator!! Super against every rule and policy we have at our hospital. And I didn't actually give a sh*t. Because I trusted him, and he trusted me, and the world somehow kept spinning. Now, when I went to look at the machine I did notice that the settings he picked were crazy wrong, but still, it was fine. I fixed what he did wrong, told him what was incorrect and why, and then we went on and handled business. Because that's how strong clinicians who are good coworkers handle themselves. Anyway...To the point, I'm absolutely insinuating that your RT in question is crazy insecure about something, because there's no logical reason to get so crazy about something so small. As for those supervisors? You should have told them that your qualification to use a BVM was having a pulse and enough brain power to tie your shoes. Then followed that up with a, "if you consider a basic BLS skills to be 'advanced', are you sure you meet those qualifications?"

I think the real monsters here were your supervisors. If an RT wrote you up for bagging a patient (which, by the way, is probably the most absurd thing I've ever heard before, and the person who wrote that complaint should find a new career field), once they saw the complaint they should have thrown it away. Hell, they probably should have filed a complaint against the RT for being so insufferable. The only exception I could see to this would be if the RT's at your facility intubate. I always do the physical bagging prior to intubation so that I can better assess the mouth, airway, chest wall compliance, etc. before I start trying to stick a tube down there. Even then, I'm more than happy to let the nurse take over once I'm comfortable anyway. That whole situation you had to deal with sounds absurd, and your supervisors in particular should never have been upset about you doing something to help keep a coding patient alive. Ridiculous.

You're correct, home care wasn't what prompted this decision from the Boards. This whole decision is the unfortunate sequelae of events stemming from the practices of various SNF/LTAC facilities. The unfortunate truth is that their actions, specifically, encouraging LVN's to act outside of their scope of practice (in particular, making ventilator changes based on their own assessments, and assessing the patients response to those changes), are what caused this to happen. Objectively speaking, the position of the BVNPT and RCB is that LVN's do not receive enough formal education in ventilator management and the necessary related subjects to appropriately assess and manage the machine and the patients physiologic response to it. Of the 15 or so LVN schools who's curriculum's I personally had to assess, a number of them did not cover ventilators in any sort of meaningful depth. The ones that did covered, in totality, about as much information as your average RT school covers in a day. When you consider that in the context of RT's having, on average, 6-8 months worth of dedicated didactic training related to solely to mechanical ventilation, it becomes easier to see why the Boards came to this position. Now, going back to the main point - By these facilities having LVN's act in a function which was legally restricted to only RN's or RCP's, the Board was unfortunately forced to intervene. Either way, the outcome of this intervention, i.e. the letter which started this whole thread, is the logical outcome of what happens when a state agency uncovers widespread misbehavior. It is also a good example of why Board intervention is undesirable - because statewide mandates are blunt instruments, the effects of which always catch innocent people in them. On a personal note, I actually have no problem with LVN's working with ventilators in the home setting. Hell, I've taught family members how to care for vents in the home...so obviously training a nurse to do so wouldn't be an issue. For what it's worth, I thought that an exemption should have been made for home care LVN's who have received the appropriate training. I also suggested that home care companies that are involved with ventilators should be legally required to have an RCP on staff for training/competency/consultancy/oversight. It's kind of perfect actually - because now you have an expert to initially train the nurses, to help maintain their competency, and to be available for them should questions arise while they're in the home. It also would maintain the current workforce without disruptions. Unfortunately, this would require actual legislation and isn't something that any of the boards can mandate. Still, it is something I've been working on. Whether it will actually amount to anything though, that I couldn't tell you.

As someone who works very closely with the CA RCB, and who was also involved in the negotiations between the RCB and BVNPT, allow me to expand a bit on what this means, and why it happened. Also, just for the record, some of this might be upsetting to some of you. Please keep in mind I'm merely relaying the information as I received it or was involved with it - none of this is my own personal take or beliefs on the matter. First and foremost, a couple people have stated that the RCB was dictating things to the BVNPT. This is not true. The RCB and BVNPT arrived at this decision together, after spending over a year working on it. Even if that wasn't the case (which it was), in California the practice of Respiratory Care and regulation thereof lies solely with the RCB. In practical terms this means the RCB can make unilateral decisions regarding what is/isn't respiratory care, and who gets to practice it (to everyone except the BRN). In reality, the RCB, BRN, and BVNPT all work very amicably together, so this hasn't ever, and shouldn't ever, actually be an issue. Secondly, this ruling came about because it was discovered that in a number of facilities LVN's were performing ventilator assessments beyond data collection, and were manipulating and managing ventilator care based on these assessments. Initially the BVNPT said this was fine, so long it was only basic assessments and interventions being performed, while the RCB said it wasn't. The RCB responded by saying that LVN's lack the necessary educational background to perform such advanced functions within their scope. At this point, the educational standards of RCP's and LVN's were explored, and it was eventually mutually agreed upon that LVN's do in fact lack the educational background in comparison to RCP's to perform functions relating to ventilator management. **A side point, but related. In CA, RN's can, in certain circumstances, provide and bill for certain RT related services. To do so requires them to take additional classes/certifications to be considered a "competent" provider. Competent in this case meaning "above and beyond the skill and knowledge level of a traditional RN". In relation to this ruling, it was determined that LVN's, as they do not possess the same educational background as an RT or RN (which are considered to be equivalent with one another), are not able to adequately be brought to this same level due to the nature of their original nursing education. So, what does this actually mean for LVN's? Well, most importantly, LVN's can still care for mechanically ventilated patients. There's nothing in this statement that says they can't. LVN's can still do the following: Collect assessment data/Basic AssessmentsAdminister medications that do not require manipulation of the vent circuitPatient and family educationOral care and hygiene, including ET/Tracheal suctioningLVN's can not: Change any setting on a ventilator, under any circumstanceChange inner Tracheostomy cannulasReconfigure/manipulate ventilator circuitsTroubleshoot ventilator-related controls or alarmsAssess a patients response to ventilator settings or adjustmentsAssess for placement or place a PMV or trach plugTransport patients receiving mechanical ventilationIn short, LVN's can still care for ventilated patients, but they cannot troubleshoot, assess, or manage the ventilator itself - those practices fall solely within the scope of an RN or RCP. If anyone actually managed to read to the end of this, I hope it was useful for you. I'm also more than willing to answer any questions anyone may have regarding this as well.

No worries mate, just want to make sure you're aware. Also, this is the internet, so while you may feel some way its also impossible for anyone else to truly comprehend anything other than the words plainly written on the page. And no, not necessarily it isn't. Where I work we have abundant PCA's, who are essentially just CNA's, who do the majority of ADL related stuff including feeding, cleaning, etc. Not the same everywhere of course, but it's still awesome. The nurses are much happier, and in the ICU it's incredibly useful as it gives them more time to focus on the things they need to do. Even places that don't have PCA/CNA's, a nurses role is still so much larger than cleaning/feeding/etc. They're still the ones responsible for the entire patient, which encompasses so much more than just GI functions. And yes, you're going to find tons of that, no matter where you go. You'll still find doctors and nurses that call you the "respiratory tech". You'll find nurses who think RT is just a 1 year diploma program, or some OJT type of deal. It used to annoy me, but then one day I just kind of realized - why would they have any idea in the first place? Unless they went to RT school, or did their own research, they would have no way of knowing that our educations are, essentially, exactly the same in volume, merely focused in different areas. Likewise, they're similarly not going to be aware of the amount of depth our education covers in regards to cardiopulmonary A&P, pathophysiology, or mechanical ventilation, unless they go out of their way to learn about it. I've gotten crazy looks from nurses before when I tell them I intubate, and needle decompress pneumo's, and insert art and central lines, and run ECMO and IABP's. I just take it in stride. Peoples perceptions are molded around what they see, so honestly, if they only see the RT doing nebs all day what cause would they have to think we did anything else? Just take it in stride and keep moving. If you're particularly motivated turn it into a teaching moment if you can. Otherwise, don't trip about it. Just do your job, study your ass off and be a resource for those around you, and the respect of your peers will come naturally. And if you do that and they're still miserable towards you? Then **** 'em, there's enough misery in this world already, don't add to it. Just work to make your little corner of the universe better than you found it and sleep easy at night.

MykRTstudent, From one RT to another, I would suggest that you be careful with your tone and what you say next time you post. Every nurses scope goes far beyond just bathing and ADL's, which I know you know. And trust me, nobody is more aware of the bullsh*t they have to put with from patients than they are - so no need to remind them of that. Not trying to call you out here, just a reminder that allnurses is their home, so try not to antagonize them is all. In regards to that ICU nurse you taught about vents, I'm sure you were able to teach her plenty, and hopefully she's a better nurse for it. While you were in there, by any chance did you take the opportunity to ask her to teach you about the management of vasoactive drips, sedation and analgesia, or tips for interpreting that patients clinical labwork and chemistry?

Do you want to be a narrow specialist, or a wide ranging generalist? When you're taking care of your patients, do you want to be responsible for them head to toe? Do you want to know about absolutely everything that's going on with them? Or do you only want to be responsible for 1-2 body systems? Do you want to know an enormous amount about 2 systems, and a decent amount about how every other system connects back to the lungs? Do you want to be a specialist? Or a generalist? Wide ranging responsibility or narrow? RN or RT? I can't speak to how RN's view their patients, but I can tell you that as an RT, when I look at a patient it's an "all roads lead to Rome" kind of deal. Except its the lungs everything leads to and not Rome, as it were. When I get a head trauma patient, I'm thinking about neurogenic shock. Stroke patients I'm investigating if there's midbrain/pons involvement. That guy in liver failure, I want to know what his albumin is. The lady with CKD - what's her BUN/Creatinine? Etc., Etc. We RT's tend to see every body system in a "how will this effect the lungs" kind of way. As a nurse, you're less likely to be Sherlock Holmsing everything back to the pulmonary system, instead you take a much more general view, seeing all body systems working in unison. Which sounds more appealing to you? As for opportunity? An ADN will give you more, because being a nurse gives you more opportunity than an RT. As an RT you can work in clinical care. You can get your board certifications to specialize in NICU/Peds, Sleep, PFT, and Adult Critical Care. If you're lucky you'll work at a place with strong protocols allowing you to manage your patients fairly autonomously (for example, physicians don't place RT orders at my hospital. They write for an RT eval, after which we do a full assessment and order whatever's needed. Inhaled bronchodilators and steroids, oxygen, physiotherapy, BiPAP/CPAP, ABG's, and CXR's). You might get to work at a place where the RT's get to do a lot of procedures such as ECMO, IABP, VAD's, CVC's, A-lines, Intubation. Still though, this is all just clinical work. Advancement is usually limited to direct line management. Larger departments will often have an educator/coordinator - but usually just one. Large research facilities often have RT's who do research, but again, a very very small number. You can become a Case Manager, Asthma Educator, Nicotine Counselor, Pulmonary Function technologist or Sleep Therapist...but again, these aren't advancement opportunities so much as lateral moves. As an RN? You can do almost anything, almost anywhere. It's not worth trying to list everything a nurse can do and everywhere a nurse can work, because it's almost endless. You will have far more opportunity than the average RT will. And keep in mind - this is coming from an RT who loves his profession and job and wouldn't ever give it up for any other healthcare career. So...which sounds more appealing to you?

Technically RT could do it, as usually all forms of vascular access also falls within an RT's scope - with the caveat that it must be related to cardiopulmonary function in some way. For example, I do it all the time after drawing my RT labs (VBG's and lactates most commonly). Although I'm not to sure why you'd specifically be interesting in RT doing this for you? Also, like zoidberg said, you wouldn't so much be delegating (since RT's have their own independent license and scope, and aren't supervised by nor do they work under RN's), as much as just asking them for a favor. That said, its not that big a deal. If you asked I'm sure most would be happy to help. And as for the ones that wouldn't, well, now you've identified a lazy POS you shouldn't rely on anyway - so still kind a win for you yeah?

Have you looked at OSU's new APRT program? They have apparently just received acceptance from the Medical and Nursing faculty for the program. It will be Masters level, the RT's will sit in half of their classes right along-side the NP's (systemic path, pharmacology, physical assessment) and will also have further classes taught by the medical faculty (Diagnostic medicine, ICU management, mechanical circulatory support (IABP, VAD, ECMO, Impellas), procedural skills - Swan/A-line/CVC insertion, chest tubes, tracheostomy, bronchoscopy, intubation, etc. Personally I really like how both the nursing and medicine sides not only accepted them, but opened their doors to the APRT program so that a whole new curriculum won't need to be made. Its a nice fusion of Nursing and Medicine, which is perfect as that's kind of the area where RT's already sit. My own inside political source has told me that California and North Carolina are also looking to push for the APRT after OSU serves as the vanguard (with, it looks like Duke and Loma Linda being the most likely first options for APRT programs), and if all goes well they're also working with the nursing and medical boards to make the APRT truly a collaborative professional who can serve in a specific niche (looks to be shaping up primarily as a direct extender to the pulmonologist in both the clinic and ICU setting, and possibly to CT Surgery/Interventional Cardiology - although that might be more of a pipe-dream, as PA's are already pretty active in that area). For what it's worth the ASA, ACCP, and ATS have all signed off on the APRT and given it their full approval, and the ATS specifically has sent a full letter of support for APRT's to operate in the Pulmonology realm along side Pulmonologists. It will still probably be a good 10+ years before the APRT is really a thing, and there are many mountains to scale first, but getting one program approved already with state legal blessing and physician approval is a huge first step. Definitely exciting times!

I suck at things...real message is below

This goes both ways. Yes, some states have opened sleep up to EMT's and LPN's - typically states with overall weak regulatory environments. In contrast, there are other states where sleep has been moved 100% within the realm of RT. RT has it's own sleep credential, the Sleep Diagnostic Specialist, and in certain states the PRSGT credential has been limited to RT's only. For every state that has RN's giving treatments and weaning ventilators you have another where RT's manage ECMO and IABP's, intubating and inserting central lines. RT has also, finally, formalized the move to a Bachelors entry, which in the works and expected to be live in the 2020's. The key here being that once a Bachelors entry is achieved, this opens up CMS classification as a provider - allowing for independent billing, solving the problem of outpatient RT services. With the ACA also came "incident to" billing for RT services furnished outside the hospital. So even now RT's are authorized to perform therapy in the outpatient setting when a physician is present. Also, in comparison to LPN's and Paramedics - in some places they may "do" more, but RT's licenses are almost always wider in scope Paramedics, and in some states wider than LPN's too. Not to mention than an RT will make more than either of them too.

Here is a link to their prerequisite requirements: Program Details Looks the same as most programs: English, Math, Psych, and Communication + the sciences with Anatomy and Physiology I & II, General Chemistry, and Microbiology. It seems they use a points scale too for admissions. Most RT programs have the same or almost the same prereqs as the RN programs in the same schools with the exception of a physics requirement, so if you're good to go for nursing you should be good to go for RT as well. Interestingly enough though, it appears Mt. Hood's RT program doesn't require physics. Most RT programs require that, but without it that would be one less class you'd have to worry about. Although, as an RT myself I would strongly recommend taking it if you're able to. Everything in RT (ventilators, BiPAP's, oxygen delivery, hemodynamics, ECMO, IABP) is heavy on the physics and not having a physics class puts you at a pretty severe disadvantage in regards to the depth of comprehension required for your boards and for clinical practice. It's not required, and you can always learn as you go - it's just a lot harder is all. Either way, good luck in whichever path you choose. Feel free to PM me if you have any other RT related questions.

So I know this thread is a few months old at this point, but on the off chance you look at it again I figured I'd also give some RT insight on the whole urine output and PEEP thing. There were some good answers but one which was missed. Muscle cells in the atria release atrial natriuretic peptide in response to blood volume (specifically triggered by atrial stretch -- so they are occasionally referred to as "atrial stretch receptors"). In essence when your right atrial volume is high ANP is released. ANP has the opposite effect of aldosterone in that ANP stimulates sodium loss, or urination. Now, say you have a patient on the ventilator. Their PIP is 40, MAP is 26, and PEEP is 15. That's a lot of intrathoracic pressure yes? So you are going to have decreased venous return, but at the same time your right atrial volume will be less. In part from the pressure exerted on the IVC and SVC (though this one is not as important), but also simply due to the pressure the lungs will be exerting on the atria. This combination of increased pressure and lower IVC filling/return will lower the amount of atrial stretch/filling. Lower atrial filling = lower ANP production which = further depressed urine output!

Yeah, my facility is a hot mess. Lab does all our lab draws as well - in fact they are the only department which even carries butterfly needles. Except they decided they didn't like doing stat labs (usually lactates, but sometimes VBG's and Chemistry too) because they're not routine timed studies so it throws off their workflow. So the solution is to just have RT do it of course... Then comes some clipboard wielding tyrants who probably saw that we already draw from other indwelling lines...so this basically must be the same thing right? Whatever. If it's what the overlords demand then so be it. But I'm not going to go down or let my department (or patients!) suffer because of some bean counter - If this is my new job (without any extra pay you understand) then I'm still going to do it well. Or I will, as soon as I learn how to =(

Drawing blood sounds simple enough right? I'm sure it is and all...except that I'm an RT and not an RN. Short backstory: RT has our own blood gas, chemistry, and co-oximetery machines in my hospital. As such RT recently took over processing all stat Chemistry and Lactate's plus VBG's as we have a 2-3min turnaround time vs. 1+ hour for the lab. This includes drawing them ourselves. Since we already insert/maintain A-lines and are allowed to draw off of PA and central/PICC lines we were also granted the ability to draw off PIV's if possible instead of performing a venipuncture. Now the problems. My experience with venipuncture was "follow phlebotomy around and get 3 successful sticks and you're good to go". I also had no training in drawing off of PIV's - this includes in the policy the ability the pause/restart running infusions [Only fluids, only in certain circumstances, and only after conferring with the RN first] so we may draw from that site. Last time I learned about IV's and IV pumps was years ago in RT school. Fabulous start right? I have probably a million questions but let me see if I can narrow it down to just a handful. -When drawing off of an IV what should my thought process be as far as gauge size? Should I only attempt to draw off of 18G's? What about vein size? Also, should I flush the line with saline first to check the lines integrity before drawing? -When it comes to IV's with running solutions I've been told I can pause the pump, wait a couple minutes, waste and draw my labs, and then restart the pump. I've also been told to never draw labs from any line which has been actively running electrolytes. Who's correct here? -I'm straight garbage at successfully puncturing a vein. I can hit an artery anywhere anytime, but veins elude me always. Any tips? -Any other advice you can think of or educational resources would be greatly appreciated. Thanks!