Thursday, November 25, 2010

Trachs

Trachs are nasty things. I don't particularly care for them, but for someone who is facing longterm ventilation (anything greater than 10 days in my hospital) they are actually a good solution. They provide access to the lungs and a stable airway without damaging the cord and trachea. You can ventilate through them, and unlike endotracheal tubes, they don't come out as soon as you discontinue the vent. There is another weaning process you must go through to get rid of the trach. First they must be plugged for a period of time to see if a person can breathe through their upper airway. Sometimes this involves going to a smaller size trach before we start the plugging trials. The end result is to hopefully pull the trach out and have the human resume breathing through the mouth/nose area.


I pulled out a trach today. It was going well until I realized there were still some sutures in place. No wonder the guy looked like he was about to punch me in the face. Ouch. Eventually we worked out that minor detail and the guy got kicked out of the ICU and onto the floors. Seems to be doing fine.

Remember the guy who made me cry on Sunday night? I worked with his wife all day yesterday and today. I thought it might be a bit awkward, but she's super nice. The only thing that really got me was this:

  • I attended a delivery with RT who made me cry. I said I wasn't going to suction because the baby sounded fine, and I was pretty sure we tried not to do that if we didn't have to. He told me that was nonsense and we should suction every baby.
  • I attend a delivery today with RT's wife (also an RT). I asked if we should suction and she told me that that was silly, we are trying not to suction babies anymore. WTF. ARGH. Ok. So I don't, and then the baby is seriously not breathing and the laryngoscope is out and the tube is ready to go in and in walks the pediatrician who says STOP. He walks over, suctions the baby, who starts screaming and everything is fine.  
Also. Today was kind of a gong show. It started at 7:01 (1 minute after report finished) with a stat ABG. At 8:11 we intubated this person who was in Status Epilepticus. At 9:00 we intubated a very old man whose code status is NO CPR, but intubation is ok. Sigh. Life doesn't make sense. And on and on it went. 

Wednesday, November 24, 2010

More Resources - For ECGs

On the request of a reader I have compiled a list of some good resources for ECG interpretation.



Peace out. 

Monday, November 22, 2010

Good Resource for RTs

I was forwarded this link today and I thought it was worth sharing.

- http://www.respiratoryresource.ca -

It has several links to current articles as well as a blog section for updates. There are videos and also the author is starting to set up webinars.

A good resource for any respiratory therapist (student or otherwise) who is trying to stay current and knowledgeable.

Sunday, November 21, 2010

Peon RT is a whiny girl

I just worked 7 straight days. And the last 2 I worked with a therapist that I have never worked with before. I am just setting the stage for a possible emotionally stressed out respiratory therapy student - like on the edge of a breakdown.

First I would just like to say that my last day in the OR was amazing. So amazing that I would definitely consider working in an OR (definitely a busier OR where the RT had a much better role, instead of the stocking stuff monkey) or possibly even training to be an anesthesia assistant. I did 5 intubations on my last day and every single one of them went awesomely.  I loved every moment of it. We had one guy come in for surgery (dental surgery of all things) that had already had two heart valves replaced - and the surgeon did not even think he was a candidate for prophylactic antibiotics. An infection in heart valves pretty much equals certain death. So that was awesome. I went to endless boring c-sections. Boring. I found out that a mango allergy is a possible  indicator for a latex allergy. I had no idea - thank god there were some lost looking nursing students standing around who knew that, so I didn't have to look like an idiot. And I generally dealt with fat people's tongues in the way of my laryngoscope.

Then because of poor scheduling on my part and a desperate need to keep up with the endless amount of hours I have to get in before April, I worked Saturday and Sunday as well. I have been outside in -25 degree Celsius (-13 degree F) every day at 6 AM for a week. I trudge along, dressed warmly on the top (toque, mitts, neck warmer, hoody and winter coat) and very poorly on the bottom (runners - my boots were forgotten at home, and my scrub pants). As a result when I get to work every day my legs feel like flaming burning hell-fire legs. And my ankles turn all red and get a little swollen. I am pretty sure it is frost bite. I usually recover by 8 o'clock rounds.

This weekend I attempted my first art-line. I failed. It was on a guy who had overdosed on anti-freeze. Right, because that is something that you can just drink for a good time. Man that room smelled so bad. He was being watched by security. In their infinite wisdom they sent up what appeared to be a 16 year old girl to watch over this gigantic guy. The fumes coming off of him were making her intoxicated I am pretty sure. Anyway, he didn't even flinch when I repeatedly stabbed him trying to get the line. My preceptor got it right away. 10 minutes later antifreeze guy pulled out his art-line, oh and also his foley catheter. OUCH.

My hands are chemically burned from using that alcohol hand sanitizer for 7 straight days. Multiple times. They are all red, and then I would forget about this and squirt more sanitizer on them. Oh the burning. The burning. It's a toss up though - I have a patient who is MRSA positive. I am more concerned with making sure I burn all of that off me, than having comfortable hands - or any skin at all.

So I survive all weekend. I am working with this guy who I have never worked with before, and I thought I was being a really good sport and doing everything he wanted me to. I was extra cheerful and asked lots of questions. His one negative comment to me at the end of the day was that I am not very good at taking constructive criticism. I know this is actually not true because I have been told on many occasions that this is one of my strengths - responding well to constructive criticism. But how do you respond to something like that? I asked him what he meant, and he said that I was displaying it right now. By asking questions? I think maybe he was confusing my asking for clarification with challenging him. Anyway - we had a long conversation about it. Where he said I was quick to respond to criticism, when I should just be quiet? I am not sure. I responded the way any overtired and hormonal girl would. With tears. Awesome. Someone tells me I do not respond well to criticism and I start crying. Way to prove his point... Total downer.

Luckily I came home to some chili one of my room mates had made. It helped a bit. Then my other room mate came home and offered me some special lotion for my hands. When I was rubbing it in I noticed it smelled quite a lot like urine. Like a lot. Key ingredient is UREA. Next time I'll save a step and pee directly on my hands.


Friday, November 19, 2010

Anaesthetist's hymn

Recommended to me by the anesthetist I was working with all day - after I commented on the important job of moving the bed up and down.


Thursday, November 18, 2010

RSI meets its match.

I finally got my intubation signed off, as well as my LMA insertion. I wasn't too concerned about my LMA insertion -because who cares. Who ever uses those things except in the OR? Anyway, I decided to be pushy today and really ask for it to be signed off, because I didn't want to be all panicked tomorrow. First case this morning I asked my favorite anesthetist to sign it off and he did it! Granted it was a very smooth intubation. Nearly perfect.

Later in the day I asked another anesthetist if I could accompany her and she said yes, but I had better be quick because this one was an RSI intubation. I immediately told her I probably shouldn't be involved in this - but she laughed at me and said she was sure I would do just fine. So we went in, the patient was drugged, I put the laryngoscope in her mouth - and saw nothing. I started to panic but I've done this a few times now, landmarked and voila - a little lift and there were the cords! I put the tube in and that was that. I have never felt so amazing in my life. The anesthetist said she could tell when I finally got my view because my whole demeanour. That was a good end to my week in the OR - too bad I have to go back tomorrow.

Most idiotic things I have been asked in the operation room this week:

  • "Do you know what this is?" Question asked by RN who was trying to quiz me while pointing to the ... baby warmer. Uh yes. I know what that is. Awesome.
  • "Did you turn that on?" Question asked by anesthetist after realizing the sevo had been left on in the room. Uh no. I did not touch your anesthetic gas.
  • "Is there anyone around who can do this ECG" Yes - in fact it is the only thing I am good at. 

Tuesday, November 16, 2010

Intubate Intubate LMA

I did 2 successful intubations today and 1 LMA insertion. It was very strange, the anesthetist inserted the LMA fully inflated. The prior one I had worked with put it in deflated and then inflated it. It is so hard keeping track of all of these.

One girl that I intubated had very terrible teeth, I was so sure I was going to knock one of them out. Also, she had the highest pain tolerance ever. The Dr completely effed up the IV which went interstitial - and the girl didn't even blink. Sadly though, her entire arms were hacked up with obviously self-inflicted ones.
My second intubation was a bust. It should have been the easiest thing ever, big open mouth and perfect airway. The surgeon was hovering over me and telling me to remember this lady had children while I was intubating. I think he made me nervous. So I blew it.
The last one was a lady with no teeth. This made things excessively easy. Laryngoscope in - bam. Tube in - bam.  Bam bam.

I got to watch a pretty interesting thyroid lobectomy surgery. I watched this for a few reasons -

  • it is an interesting and disgusting surgery near the airway
  • it took a long time so I wasn't forced to do other boring OR things during this time
  • afterward we had to check and make sure the vocal cords were still working because they were so close to the laryngeal nerve. 
The downside was that I missed out on the inservice about the brand new ECG machines. Later in the day I got to use it anyway, and as it turns out it's not rocket science.

I am still working with the VERY annoyingly odd girl. Who is now getting married to her cheating bf, and maybe selling her puppy. Who pukes in the car. This came up in conversation, even though it didn't fit into the conversation. That being said, she is a very good teacher, and mostly patient. I have to remember that she is only 23. Which is bizarre. And weird. 

So. About the yoga. I have mastered one yoga move. I call it "Unconscious RT student laying on yoga mat."

Monday, November 15, 2010

Quote of the day.

This quote comes from a three year old girl who reportedly shoved something up her nose... And that was actually true - I saw it. There was an unidentified foreign body up there. Anyway. Quote, "My mommy hit my dad and cut his face. Then my daddy went away." Moments before she drifted away under the influence of sevoflurane.

I intubated twice today which was a nice confidence booster for me, since I thought I would assuredly fail. The OR is still boring as all hell though. Only 4 days to go.

Sunday, November 14, 2010

Back to the OR

I am back in the OR for a week starting tomorrow. I am not too impressed about it. I am now wishing I had just sucked it up back in July and got it over with. BLERG.

Also - my back is still SO sore from my super huge wipe-out. I am considering taking up yoga, which is something that has always made me internally rage (yes yoga makes me mad. I know it's weird - ok.)

I just finished working on a case study regarding COPD exacerbation. Now I am the one who is exacerbated. or is that exasperated. It took forever, and I find it a little frustrating to work 40+ hours a week (and by work I mean professionally volunteer) and still have to hand in assignments. When will I be making money!? When can I stop churning out these damn assignments.

Tuesday, November 9, 2010

Toaster Strudels vs BLES

What do toaster strudels and BLES have in common. Not too much.

For those that are unsure BLES is the variant of artificial surfactant we use up here for premature baby lungs. We intubate and then squirt some BLES down the tube. It is honestly a miracle drug improving lung compliance literally overnight. 

And toaster strudels. Pillsbury's answer to the poptart (which in my opinion is bland, dry and gross). I bought a box and have been eating them as a treat on my days off. When they are in the toaster you can hear the oil popping and sizzling. Every time after I eat them I get sick to my stomach. But they are so damn delicious. 

Ok. That aside, I was thinking the other day, as I warmed the frozen icing from my strudel box that this was really good practice for me. BLES needs to be warmed from freezing in your hands before you squirt it down the baby's tube. Just like the icing. 

And there you go - I have tied it all together. I must have been really tired on the day I was thinking of that.



Sunday, November 7, 2010

I am Greasy.

I did it. I knew I would eff up this stupid clock thing. So I set my phone back an hour. And then sometime in the night it set itself back another hour. So I woke up at 5.15 (pretend 5.15) and was feeling extra rested and headed to the shower. On the way to the bathroom I happened to look at a clock on one of our walls that hadn't been tampered with. 7.15. OMG OMG OMG. That meant it was really 6.15 and I had to leave in 5 minutes. This was bad on so many levels.

  1. When I work 3 days in a row I generally don't wash my hair on the second day. Just so I can sleep an extra little bit. So two days without hair washing. Gross. And greasy. 
  2. I take a LONG time to get ready in the morning, and believe me it is not because I am paying special attention to my hair and make up. I just seem to be one of those people that operates at a slower speed in the morning. So my waking up time today was actually at someone's bedside while I was doing my assessment on them. 
  3. Breakfast.
  4. Lunch
  5. and Dinner. 

In my 5 minutes of getting ready time, I got dressed, brushed my hair, threw some food in a bag and still left 5 minutes late. And then I drove to the hospital even though it is only 4 blocks away and takes 7 minutes to walk there. 

My preceptor just lets me do all of the assessments and gases in the ICU now. Which I LOVE. Of course he is nearby. And OF COURSE I can't make any vent changes without him actually directing me, but unless I am totally out to lunch he usually lets me make the decisions! I love it! I finally feel like I am hitting my groove. Unfortunately... my brain only has room for so many skills, and now that I am getting good at this critical care business my ABG skill is really plummeting. Thank god in the ICU most patients have arterial lines in. Easy gases 101. 

My patients in the ICU are suffering from major oxygenation issues right now. Both have a PaO2/FiO2 ration of less than 60. That truly SUCKS. As such both are currently being ventilated on ARDSnet protocols. Seriously their gases are nearly identical - they should be room mates. 

One of them self extubated today. This started a chain reaction of chaos. First we were paged to ICU stat, which we were sure meant that he was coding. So we ran as fast as humanly possible. On the way there I passed a wet floor sign, and just in front of me my preceptor lost his footing, but caught it and kept running. I was right behind him and totally bit it on the wet floor, landing flat on my back. He turns around and asks, "are you ok." I replied, "Go on without me." I got up, totally fine but just a bit sore and finished the race to the ICU. So Mr. Extubation was fully restrained, and fully sedated when this happened with no witnesses. I wish I could have seen this. Man, that has seriously got to hurt when you rip a fully inflated ETT cuff through your vocal cords. Anyway, re-intubation took place even though I got yelled at for being too slow with the tube. Seriously, you can't rush quality work. Someone needs to check the cuff, and get the lube ready. 

This was not the first time I got yelled at by that Dr today. Earlier we were cardioverting a ventilated patient and I suggested there was maybe not room for me between the ventilator and the bed - you know, without being electrocuted. She lost it. I am a woman in medicine and I should be prepared to do what it takes, even if it means climbing under the bed. In the end the bed got pulled out so I would fit. I am terrified of being electrocuted during a cardioversion. Surely stimulating a vagal response would be a more reliable method. 

All complaints aside - I really like working with this Dr. She speaks her mind, and truly has compassion for the patients even though she doesn't always show it. And she can be a very good teacher - but she never can remember my name. Oh well, she has months and months to learn it. 

And then... just when the fun was almost over (you know 5 pm - the time when the real fun starts). Code blue. Code blue. More running - but I was more cautious now, what with the previous injury. We coded a PEA for 15 minutes before the Dr. called it. What is a day in the ICU without at least one death. Seriously.


Helpful advice for next time - from Occupational Safety

Saturday, November 6, 2010

Airway TV

Just sharing this site I found by Smiths Medical. They have a variety of airway videos, that are generally pretty basic, but some are informative.

http://www.smiths-medical.com/education-resources/videos/airway/index.html

Also, my preceptor and myself fell victim to a false accusation which was kind of annoying. We were just entering the NICU, when (purely by coincidence) the oxygen blender on the transport isolette in their entry way started loudly alarming. We recognized that annoying screech immediately and tried to stop it as fast as we could. In the mean time, a nurse came over and informed us that a nurse in their unit suffers from MS and the sound really puts her over the edge. I'm really sorry for this lady and whatever medical problem she has.. but seriously - I don't like the sound of the blender alarm any more than the next person. And don't you think if we were going to intentionally make an alarm go off for a prolonged period of time, we would perhaps take the equipment out of the nursery!? I snapped at the nurse and tried to explain the situation. We were just innocent bystanders. What had happened is that they leave both the air and oxygen tanks on, and one had a leak. When it ran dry, then the alarm started. Actually pretty lucky.

My preceptor was performing an auger suction (a deep suction through the nose) on an awake patient in the ICU. The patient is having trouble clearing his secretions (and also badly wants cigarettes and a beer). We are really trying to keep him from being intubated again, and thus the deep suctioning. Also, as an added bonus, the patient was in a-fib when my preceptor started this suction, and the vagal response totally cardioverted him to a normal sinus rhythm. Good work.

Welcome daylight savings time (or I guess it is really good- bye daylight savings time) and hello extra hour of sleep. This is going to end badly - I am either going to be an hour late or early for work - I just know it.

Friday, November 5, 2010

Smurf Lice

First things first. I have been rewarded for my incessant snarky-ness. (snarkiness? whatever). Please recall incident involving vacutainers. I did some research and printed some stuff out for the manager to peruse. They have since approached lab with the goal of changing protocol (based on what another hospital in Canada is doing) to using an ABG syringe when the lab pulls a venous gas for us to run. It only makes sense. Air filled tubes screw up O2, CO2 and therefore also pH. Lab is pissed. They say if that is what we want we should just do art pokes. I say screw lab - why don't they just train and certify us to do venous pokes and we will be more than happy to do them all the time. Seriously. Oh anyway - the point of that was that I was rewarded with a "Patient Safety Week" water bottle. Of my very own.

And then I got pissed off at lab again today when they insisted on having a 5 ml waste syringe drawn off of our artline before the blood filled their actual little test tubes. I had already drawn my art sample, and didn't do their waste syringe. It is totally unnecessary and totally dated policy. There is no need for a waste syringe with a VAMP system. We don't use them anymore. Neither should they.

This morning I extubated all on my own for the first time. Unfortunately the excitement was dampened by the fact I had to have every piece of PPE on possible. Mask. Gown. Hair thingy. Little booties. And of course the ever-present gloves. Yes - a query lice, query bedbugs room. OMG. I am still itchy. I swear to god I have lice and bedbugs now. Disgusting. They even had double sided tape all around the doorway to prevent creepy crawly things from exiting. By the end of the day the precaution was lifted, but I still feel disgusting.

The girls covering emergency called me down to see something "cool." What they thought was peripheral cyanosis though, was really just blue paint... On the hands and around the mouth. Weird. But you can't fake methemaglobinemia. Not like you can fake acrocyanosis anyway.

I love this website - I heart guts. Plush lungs make great baby gifts everyone.

Tuesday, November 2, 2010

Vacutainer News Flash

Vacutainers are not actual literal vacuums. There is actual air inside of them.

I may or may not have gotten into a little bit of a tiff with the ICU nurses over this. Per them - vacutainers are a vacuum which contain no air.

Right - because actual vacuums suddenly magically exist on earth. OMG.


For your info. Vacutainers are just blood collection containers. They usually have an additive (ie heparin) to prevent clotting. Air is evacuated from them in order to created negative pressure, which aids in withdrawing blood from very low pressure veins. There are varying "strengths" of vacutainers depending on how much air has been withdrawn.