It's 6:15 a.m., I am on my way to work. I wonder what today will bring. That's the thing about being a respiratory therapist, you never know what challenges you will face each day.
Report Room: 0645
I just received my assignment for the day. I am to float between the emergency room, trauma care and the neonatal unit. The workload in each of those areas is more than one therapist can handle but there is not enough for two therapists. So I get to bounce from unit to unit. I am a new graduate, some of the seasoned therapists say, "looks like you'll need your running shoes today." I don't mind, I enjoy the opportunity to work with a wide variety of patients.
The Neonatal therapist wants me to start in her unit, the trauma care therapist wants me to start my day in his unit. They both loose, the ER beeper goes off. Sally is the therapist assigned to ER. Sally calls down and is told that there is a multiple trauma en route to the emergency room. She and I both rush down to the Emergency Room. The nurse tells us that we are expecting 3 patients, a 38 year old female, a 42 year old male, and a 12 year old female. Apparently the victims are a mother, a father and their daughter. They were involved in a single car roll over on the expressway.
The father, Mr. Richardson, arrives first. He has splints on both legs, and his right arm. He has multiple cuts and bruises on his face. The medic states that the patient wasn't wearing his safety belt. At the scene it appeared that patient hit the steering wheel and than was thrown around the inside of the car. He is unconscious, and has sustained chest injuries. He has an artificial airway in place and the paramedic is bagging the patient. (We call this bagging the patient because you squeeze a bag to force air into the patient's lungs.)
The medic tells me that it is getting more difficult to squeeze the bag. The patient's oxygen monitor is showing decreased oxygen levels in the blood. The medic is worried that the tube may have slipped down into one lung. The patient has several rib fractures. The medic and I are also worried that the patient may have "blown a lung". The correct medical term for this is a pneumothorax. (A pneumothorax is a life threatening event, not that this guy isn't already in big trouble.) I listen to the patient's chest with my stethoscope. He has decreased lung sounds on the left side, the left side of his chest is not moving. At first I think it might be simple, the artificial airway may have just slipped down into the right lung. But while listening to the upper left chest, I feel that unmistakable "rice krispy" sensation of air under the patient's skin. The medic and I immediately alert the trauma surgeon that this patient needs a chest tube. The trauma surgeon quickly inserts the chest tube. It becomes much easier to squeeze the bag and the blood oxygen level has increased to 100% on the patient monitor. The chest surgeon tells the medic and me "nice catch".
They suspect that this patient may also have ruptured his spleen. He needs to go to the operating room immediately. I quickly check the portable oxygen cylinder on the cart to make sure I have oxygen. I bag the patient while he his transported to operating room. I hand the patient off to the nurse anesthetist and head back to ER to see if Sally needs help with the other patients. When I walk in the ER I hear the screams of the 12 year old coming from the pediatric trauma suite. To most people screams, are distressing. To respiratory therapists, screams mean that a patient's breathing is probably ok. I peek in and ask if they need any help. They don't need a therapist at this time.
I find Sally in trauma suite 2, she is using a bag to breath for the mom. The mom has minimal external injuries. The medics said that she was wearing her seat belt. She suffered a head injury during the roll-over. They want to transport the mom to Cat-Scan.
I run back to the department to get a portable ventilator (breathing machine) while Sally bags the patient en route to Cat-Scan. I arrive first in Cat-Scan. Using the patient's height and weight, I determine the ventilator settings. Because of the patient's head injury I decide to use a slightly elevated breathing rate. Breathing faster for a patient gets rid of carbon dioxide. Lower carbon dioxide levels help decrease pressure with in brain.
Sally brings the patient into the Cat-Scan Room. One of the new ER residents is with her. I double check my settings with Sally and the ER resident. The ER resident asks me why I am using a high rate. I explain the ventilator's effect on the intracranial pressure. I am not sure he is going to buy it, when the neurosurgeon arrives and says "make sure you hyperventilate her a little." We get the mom set-up on the ventilator and step out of the Cat-Scan room. We are able to observe the patient through a window in the control room. The Cat Scan shows that the patient needs immediate surgery to relieve a small bleed in her brain. Sally bags the patient en route to the operating room.
I decide to swing through the cafeteria and pick up a cup of coffee before checking with the therapists handling the neonatal unit and trauma care unit. I just put the lid on my coffee and my pager buzzes me for the neonatal unit. I call Marge, the therapist assigned to the neonatal unit. She says that she heard that we had shipped ER patients off to the operating room. (The informal communication system in health care institutions has amazing speed).
Marge tells me that they are about to start a C-Section on a mom carrying twins in fetal distress. The infants will be at least 8 weeks premature when they are born. She asks me to meet her at the C-Section. We make sure that we have all the necessary resuscitation equipment ready. We also set-up two ventilators in the neonatal triage area. The C-Section is very quick, both infants are in distress. It always amazes me how small these neonates can be. One is a boy at about 2 1/2 pounds, the other is about a 3 pound little girl. They place each infant on an infant warmer. Marge works with the team taking care of the little girl. I work with team taking care of the little boy. The heart rates of both infants are low and we have to gently bag both infants. The little girl pinks-up and begins breathing on her own. They are able to keep her stable by just giving her some oxygen. Marge's team places the girl in an incubator with oxygen and transport her to the nursery.
The baby boy needs to be bagged to keep his heart rate and oxygen level stable. They put an artificial airway (breathing tube) in him. The tube will allow us to place him on a ventilator. We move him to the triage area of the nursery. I determine the proper pressure, rate, and oxygen level on the ventilator and confirm my settings with the neonatologist. We put the infant on the ventilator. It is difficult to keep his oxygen level up.
Premature infants lack a substance in the lung called surfactant. Surfactant helps keep the air sacks in the lung open. One of the wonders of modern medicine is the recent development of artificial surfactant. By administering artificial surfactant we are able to save the lives of many premature infants. The neonatologist feels that the little boy needs surfactant. He draws up 4 cc in a syringe, we place the little boy on his right side, the physician squirts half the surfactant in into the breathing tube. We place the baby back on the breathing machine and turn him on his left side. The neonatologist squirts the other half of surfactant down the breathing tube. We put him back on the ventilator. I immediately begin decreasing the pressure on the breathing machine. I am able to help him breath with 25% less pressure than before the surfactant. I am also able to quickly reduce the oxygen. Over the next hour, we frequently "tweak" the machine's settings up and down to keep up with the changes in the little boy lungs. He slowly stabilizes. Mom and Dad finally get to come in and see him. If things go well, he will probably be breathing by himself tomorrow.
I check with Barry the therapist assigned to the Trauma care unit and ask him if he needs help right away. He says he is keeping up for now but will need help when the two ER patients get out of surgery. I decide to grab a quick bite to eat. At lunch, John one of the therapists working on the cardiopulmonary floor, tells me he is getting swamped. They have had three new patients with chronic lung disease admitted to the floor and they all need treatments. Another patient needs home care evaluation. I tell him that I will help him out until Barry needs me in Trauma care. John asks me to take care the home care evaluation on Mr. Crandall.
Mr. Crandall is a "frequent flyer" like many of our respiratory care patients he was a heavy smoker and also worked industry. He has been admitted three times in the last year due to his chronic bronchitis. We all know Mr. Crandall. In fact he insists that we call him "Bud" not Mr. Crandall. After this morning's events, I am glad John asked me to take care of Bud. It will be nice to work with a patient I can talk to. Bud tells me that he was admitted because he "caught a chest cold" from one of his grandchildren. He always has great stories about Korea, working in the foundry, and his favorite hobby fishing on the Great Lakes.
Bud was admitted so that he could receive antibiotics, oxygen and respiratory therapy treatments. The first few days of his hospital stay he required breathing treatments every couple of hours. We had him breath a mist containing a bronchodilator medicine. A bronchodilator relaxes the muscles along the breathing tubes. He also had a lot of congestion in the right middle portion of this lung. We performed chest physical therapy on that area. Chest physical therapy involves positioning the bed so that his chest is higher than his head. Then we use a percussor or our hands to vibrate the secretions loose in his lungs. Bud is doing much better now. His right lung is nearly clear. We have been able to stop doing the chest physical therapy. He only needs the bronchodilator treatments 4 times a day. The physician has asked us to evaluate Bud for home oxygen and home breathing treatments. The physician would like to discharge Bud this afternoon
I need to determine if he breaths well enough now to use a simple inhaler to take the breathing medicine. I bring a portable lung testing machine to his room. I test Bud's breathing. His lung function is not very good, but it is markedly improved from the day of admission. I decide that he should be able to use an inhaler. I teach him how to assemble the inhaler and the proper technique for using it at home. I measure his lung function again after he uses the inhaler. The inhaler resulted in improvement in his lung function. I leave a note for the physician to write a new prescription for Bud's bronchodilator per inhaler. I also suggest that Bud might be a candidate for pulmonary rehabilitation.
Next, I need to determine if Bud needs oxygen at home. We have a monitor that clips on a patient's finger and reads the patient's oxygen level. I will need to take a reading while he is on oxygen, then take him off oxygen for 30 minutes and take another reading. If the level is low, he will need oxygen at home. Although it is technically simple, you have to be sensitive to the patients needs. Most patients don't like the idea of being on oxygen at home. We need to prepare them for the possibility that they will need to wear oxygen all the time. My guess is that Bud will need home oxygen. Before starting the test, Bud and I have a long talk about oxygen at home. I help him understand why he might need it. I also explain the options of having portable oxygen. This will allow him to take oxygen on his boat so he can still go fishing. I take him off the oxygen for thirty minutes and then recheck his oxygen level. As I expected, Bud will need home oxygen. I tell him about several home care companies in the area. Bud elects to use one that his friend uses. I call Wanda, a respiratory therapist who works for the home care company Bud selected. We arrange to have the oxygen delivered to his home. I know that Wanda will work well with Bud and his family on the use of home oxygen. I let Bud know that everything is all set, he smiles and says, "at least I get to go home."
My beeper goes off. It is trauma care. I call Barry, the therapist assigned to trauma care. He says both of this morning's accident victims are out of surgery. They will arrive in the trauma care unit in about 15 minutes. He asks me to bring two ventilators down to trauma care. When I get to the trauma care unit, Barry asks me which patient I want. I say that I'll take Mr. Richardson, the 42 year old male, that I took care of in ER.
The anesthetist arrives with Mr. Richardson, she tells me that he was very difficult to ventilate and required high ventilating pressures. She states "he was a mess inside" and required a lot of fluids to maintain his blood pressure. I work with the trauma surgeon to determine appropriate ventilator settings for him. Because of his chest trauma it is difficult to push air in Mr. Richardson's lungs. It is requiring dangerous pressure levels to breath for him. We are having trouble ventilating him with typical settings. I consult the trauma surgeon about using a new ventilation technique. This new technique uses low pressures and prolonged inspiration to breath for the patient. Since Mr. Richardson's oxygen level is so low, the trauma surgeon feels that the new technique is worth a try. I adjust the ventilator to the new settings, and the blood oxygen level slowly begins to improve.
Once Mr. Richardson is stable, I check on Mrs. Richardson. Barry tells me that there was only a small bleed in her brain. She is already able to squeeze the nurse's hands and wiggle her toes. She is stable and should come off the breathing machine soon. The neurosurgeon stops by and tells me that hyperventilating her prior to surgery really seem to make a difference. He thanked me for explaining hyperventilation to the resident.
I help Barry with the rest of his patients in the trauma care unit, and before I know it, the shift is over. It is time to give report on Mr. Richardson to the afternoon trauma care therapist. After finishing trauma care unit report, I head up to the neonatal unit to check on the twins from this morning. Marge tells me that the little girl is still doing fine. She has been able to turn down the oxygen and breathing rate on the little boy's breathing machine. I tell the afternoon therapist what I know about the baby boy and Marge fills in the rest. I head back to the department to punch out.
On my way out to my car, I see Bud's wife and a nurse helping Bud into the car. Bud has a portable oxygen cylinder and is wearing his oxygen. He tells me that they are going to send him to pulmonary rehabilitation twice a week starting tomorrow. I tell him, "who knows maybe I'll see you tomorrow, they might need my help in the pulmonary rehabilitation area."
On my way home I'm am very tired, and I think about the day. I think of how I held the breath of life in my hands for the Richardson's and the twin babies. I think about Bud going home and I feel great. I do hope I get to work in rehabilitation tomorrow.