It is interesting that after almost 20 years we still do not have a standardized approach to PEEP and the level of appropriate PEEP is still controversial.
New advancements in technology give us the ability to easily measure the pressure-volume compliance curve at the bedside and should make for some interesting trials and ventilator manipulations in the next few years. It is therefore imperative that new therapists and students be aware and comfortable with these advancements.
I suggest that knowledge of pressure-volume curves and how they are developed and used should be part of the curriculum for 3rd year students. It is not enough to know about these but to have interactive ventilator labs using advanced lung simulators like the ASL 5000 that can model these dynamic lung conditions of both neonatal and adult patients be utilized. We have the technology and should use it.
Maximal hysteresis: a new method to set positive
end-expiratory pressure in acute lung injury?
J. KOEFOED-NIELSEN
Denmark, 2Department of Anesthesia and Intensive Care, Aarhus University Hospital,
Aalborg, Denmark and 3Department of Radiology, Aarhus University Hospital, Skejby, Denmark
Acta Anaesthesiol Scand 2008; 52: 641–649
Printed in Singapore.
The article above and others like it look at possible technical and clinical challenges to the question of using PEEP and lung compliance curves.
I challenge all of us to keep up our knowledge of the research and technology associated with the evolution of the use of PEEP and clinical measurements of patient lung mechanics.
Wednesday, March 14, 2012
Saturday, March 10, 2012
More than following the rules
My take on ideas set forth by John Steinbeck in the book East of Eden (chapter 24 page 307).
The concept I would like to explore is the difference between the inferences of meaning of “Thou Shalt”, “Thou Shalt Not”, and “Thou Mayest” in terms of both morality and professionalism.
There are many rules developed to guide our actions by society, our religions, and our professional supervisors/administrators. We could do well by following these rules and the concepts of “Thou Shalt” or do as we have strictly been told. These same groups will usually clearly define what we are not to do and thus the concept of “Thou Shalt Not” can be followed. Using the guidelines of “Thou Shalt” and “Thou Shalt Not” can allow us to perform seemingly impeachablely but we can usually find examples of individuals who have done exactly as the rules have both told them to and not to do specific actions and yet their conduct is not exemplary. I can think of examples of politicians who have not broken any laws and have done all their expected duties yet their performance is not what we had expected.
Even if we tried to define every duty and action exactly to have it performed correctly and tried to define absolutely clearly every action we do not want performed we could never word it or write it out clearly enough so that everyone would understand exactly our intentions. I believe the essence of this is at the heart of our legal and justice systems where we have been trying to define our laws for all and yet it is still often unclear when individuals actions actually break these laws.
My point is that for a individual to act morally or professionally they must transcend the limits of “Thou Shalt” and “Thou Shalt Not” and explore the realm of “Thou Mayest”. Thou Mayest in my opinion sets out the expectation that we use our judgment and understanding of the rules established by our authorities to make good judgments in the performance of our duties.
For example as a Respiratory Therapist there are often set times you are expected to see your patients in ICU. Often you are expected to monitor every two hours. This may be a rule and no one could fault you for following it exactly but if you have a patient who requires suctioning more frequently or needs repeated adjustments on the ventilator we may need to show good judgment by being at that patients’ bedside more frequently.
My point is that we as moral and professionals people must exercise our good judgment and move beyond the strictly stated and interpreted rules of conduct to be considered truly moral, and professional. Simply following the letter of the rules and laws is not enough.
Can you truly be a moral man if you only strictly follow the set rules of your religion? Can any interpretation of the rules or laws be clearly and strictly applied to all situations?
Do we believe that a soldier who “Strictly” followed orders and kills innocent people is morally or even legally blameless because he followed orders?
There are several elements that are important: knowledge, judgement, responsibility, and humility that apply to decision and actions that require a greater priority than simply following the rules.
The concept I would like to explore is the difference between the inferences of meaning of “Thou Shalt”, “Thou Shalt Not”, and “Thou Mayest” in terms of both morality and professionalism.
There are many rules developed to guide our actions by society, our religions, and our professional supervisors/administrators. We could do well by following these rules and the concepts of “Thou Shalt” or do as we have strictly been told. These same groups will usually clearly define what we are not to do and thus the concept of “Thou Shalt Not” can be followed. Using the guidelines of “Thou Shalt” and “Thou Shalt Not” can allow us to perform seemingly impeachablely but we can usually find examples of individuals who have done exactly as the rules have both told them to and not to do specific actions and yet their conduct is not exemplary. I can think of examples of politicians who have not broken any laws and have done all their expected duties yet their performance is not what we had expected.
Even if we tried to define every duty and action exactly to have it performed correctly and tried to define absolutely clearly every action we do not want performed we could never word it or write it out clearly enough so that everyone would understand exactly our intentions. I believe the essence of this is at the heart of our legal and justice systems where we have been trying to define our laws for all and yet it is still often unclear when individuals actions actually break these laws.
My point is that for a individual to act morally or professionally they must transcend the limits of “Thou Shalt” and “Thou Shalt Not” and explore the realm of “Thou Mayest”. Thou Mayest in my opinion sets out the expectation that we use our judgment and understanding of the rules established by our authorities to make good judgments in the performance of our duties.
For example as a Respiratory Therapist there are often set times you are expected to see your patients in ICU. Often you are expected to monitor every two hours. This may be a rule and no one could fault you for following it exactly but if you have a patient who requires suctioning more frequently or needs repeated adjustments on the ventilator we may need to show good judgment by being at that patients’ bedside more frequently.
My point is that we as moral and professionals people must exercise our good judgment and move beyond the strictly stated and interpreted rules of conduct to be considered truly moral, and professional. Simply following the letter of the rules and laws is not enough.
Can you truly be a moral man if you only strictly follow the set rules of your religion? Can any interpretation of the rules or laws be clearly and strictly applied to all situations?
Do we believe that a soldier who “Strictly” followed orders and kills innocent people is morally or even legally blameless because he followed orders?
There are several elements that are important: knowledge, judgement, responsibility, and humility that apply to decision and actions that require a greater priority than simply following the rules.
Going Paperless
I have to do a lot of reading and I like that about my job and modern life that there is lots to read. It does however drive me crazy that I usually, like most people I suspect, end up printing hundreds and hundreds of pages of text. Why is it that, in this age, that so many of us need to still print materials before reading them? Why do we not simply view them on our computers?
Well I have a theory about that. It’s because 99% of the materials I read are still formatted for printing, not for viewing. For example many of the scientific articles I read are medical or related to respiratory therapy. These are all formatted for print but I usually get them via electronic distribution as PDF files. So the columns that look so nice on the printed page do not display well on a computer. Why is that? Why do we not start formatting our written work for electronic display?
An example of this is that we are still driven to produce 8X11 written works that will be electronic distributed and displayed on wide screen monitors. Now most of us do not use multiple columns when writing but many published works do.
It is a pain in the mouse to have to scroll up and down and across to read a multiple column article on a computer screen. So we have to start demanding either that the format of the articles change or we change the format of our computer screens.
As I write this I have my large 27inch screen standing on its’ side in portrait view. This allows me to view an entire page of a published article without having to scroll all around. The large format makes the print readable from a comfortable distance. Also I notice that this may be one of the very few advantages I can see to the new tablet computers.
I think it is easier for us to accept flipping our computer screens on their sides rather than change the format of the written page but I do like PDFs that are formatted for viewing on computer screens instead of printing. I also like dark background and light print for viewing on a computer.
My goal is to go electronic; we need to stop wasting paper and trees. We need to stop printing 20 page quizzes for students and let them do their quizzes on the computer or some other electronic gadget like a tablet. Put a stop to the madness and let’s go paperless.
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