What

Today I heard on CBC radio that patients are refusing blood transfusions because they don't want to be exposed to the COVID vaccines. My patience for these uniformed people is limited. How can medical professionals combat this kind of ignorance? 

There is a part of me that blames the medical community for the way it handled the pandemic. There were so many confusing guidelines and conflicting information that many people just lost any level of trust or respect for the "experts". 

The pandemic and the reactions of so many people so vigorously campaigning against the vaccine and the public health measures demonstrates the incredible distrust that many people have of science and government. I'm wonder if this may be a global example of how existential fear results in individus grasping to simplistic and conspiracy theory causes of all the problems in the world. Most of us need answers that we can understand and fit our view of the world.

So I am trying to understand these antivaxers and ultraright nationalist but its very difficult when these individuals feel no obligation to consider anyone else's views. In fact they resent me more because my trying to understand them suggests, correctly,  that I think they are either uniformed, idiots, or just simply self serving assholes. Which of course I do.

Al

The Mysteries of Mindmapping Revealed

The term mindmapping is maybe not very helpful as it invokes visions of large machines probing  into our heads trying to find out our innermost naked thoughts. In a way there is some truth to this view, less the machines, and the probing is more self directed but other than that there some obtuse similarities.

Mindmapping or creative capture is simply a way to quickly capture ideas or random thoughts in a way that allows you to grasp, organize, or visualize large complex problems. The traditional way to do this is on paper. A central concept is written in the middle and spiraling ideas or related elements are written randomly around the edges. The desired trends or ideas are then organized to give clarity and direction. This method works well with groups or individuals, with everything from developing advertising promotions to research methodology.

Now what I like is that computers can help us do this. There is a variety of software programs that run on regular computers and all the modern mobile devices. My personal favorites for a desktop / laptop computer is "X Mind" and "Freemind".  Both of these software products are powerful, quick to learn, extremely useful, and best of all, totally free! The tools that I have tried for mobiles have been much less satisfying but there is hope in products like "Big Fat Canvas"  which starts to mimic the pleasure and power of handwriting for mind mapping by offering unlimited zooming and area to freely explore a concept. This is a much different concept than the other computer based models but it offers an insight to where the technology may take us.

Mind mapping software can be a very effective way to manage large complex projects and come to grips with complex tasks. As a writer, teacher, and sometimes manager these tools have worked well for me. I can only suggest that as a computer user you should look into your brain and unleash your total creative capacity by mindmapping your next project or idea. Check them out, it costs you nothing.

Attitudes Matter

Maybe after all these years of teaching I am a little sensitive to the concept of attitudes as I have one as a teacher and so do students.

I tried a little experiment the other day. I asked the class to divide themselves into two groups. The first group I explained were experts in respiratory therapy and were teaching a student about PEEP and how to do PEEP studies on a patient. They were very busy but took the time to demonstrate the procedure, explain it to the student, and show them were the policy and procedure manual was for the procedure so they could study it.

The second group were also RT experts but they were now with the student the very next day and were going to discuss their learning and how help the student understand PEEP studies.

I, as the instructor, was the "student".

So I set it up that the second group were meeting me, the student, and they correctly were trying to determine what I needed to know and what they could help me with. They asked appropriate questions such as; What did you learn yesterday? What is your understanding of PEEP? Can you describe the steps to performing a PEEP study?

To all of these questions I stated that I did not know. That I didn't learn anything from my preceptor. I have no idea how to do or what a PEEP study is.

This is where it gets interesting. The second group, who are taking over the teaching, were quick to point out that the first instructor / preceptors must be a very poor teacher. It was almost unanimous in the group that the Preceptor needed more training and needed to learn how to be a more effective instructor.

I let this play out in a class as a discussion. As an instructor and preceptor I know this type of scenario often happens.  The class basically went on to describe how preceptors need more training. What I would like to put forward for consideration is were is the responsibility of the learner in this scenario. Why did the students not consider that the student who spent hours with a preceptor reviewing a procedure not be responsible for anything. How can they just state "They didn't teach me anything". Where is the personal responsibility for learning? Also I suspect that if I had been the preceptor spending time with the student and learned how they can offload the responsibility and basically blaming the instructor for their lack of involvement I think I, as their teacher, might be very insulted.

Attitudes matter and I suggest students consider taking responsibility and even if they don't understand or can't recall everything demonstrate a positive attitude by using comments like; I know we reviewed this yesterday but I'm still unclear of how to do the procedure. I'd like to review the policy and procedure again to refresh my mind and learn the procedure better know that I've seen it. Or even try: I know we went over this yesterday but I need more time to learn all the details, can you help me by demonstrating and explaining this again.

This sets up a positive learning environment where preceptors are supported and the needs of the student can be met. I have personally heard many time in the hospital students report to preceptors: They never taught us that! This blames the school and their teachers. Good preceptors know this is not true but you would be surprised at how often we get complaints from preceptors asking us why we don't teach effectively and the student's don't know anything. Informed preceptors know the student is just passing the buck. They now have a poor opinion of that student.

I suggest student demonstrate more responsible and positive attitudes.

Al

My 59th Year

And so I am once again confronted with my yearly reminder of mortality. Death draws closer and I notice the age of those in the obituaries and who's death make the news and I compare my age to theirs. Like all those before me I wonder the eternal questions, how much time do I have? Have I contributed anything to the world? Will anyone notice my passing? Have I been a good man?

On good days I have positive feelings about some elements of my life. On many days I feel that my efforts as an educator have been wasted. Students prefer the more sociable and socially capable members of our Faculty. My idiosyncrasies, over enthusiasm, and insecurities build a subtle but definite barrier between myself and effectiveness.

My true love of the outdoors and exploring the world around me seems selfish and indulgent when I look at so many others who struggle for the basics of life. I feel like a rich spoiled child. Okay maybe not rich.

I love my photographs. They speak to me but they are only my treasure, no one shares my joy of these images. It is like this blog, useful in it's reflective therapeutic exercise. Working my images is like working these words. It lets me pause and gain some perspective and the luxury of remembering.

It is with a true but harsh perspective that I see myself as the selfish, sometimes foolish, man who has been give two great gifts, a wonderful wife and a wonderful daughter. My only contribution to the world should be to help them and love them as best I can. If I can truly love that is enough.

And yet, that said, if I can get in a few more hikes, some sailing, and maybe drink a few more bottles of whisky that would be good too.

I guess there is still more living to do before I die. The glass is after all, half full, and I realize I'm still thirsty.

Al

Arterial Blood Gases

We as respiratory therapists are experts in arterial blood gas procurement and interpretation. This places a burden on students of the profession as their preceptors and instructors expect a high level of understanding and performance with regards to arterial blood gases (ABGs).

An approach that may get a novice started is to work on the initial classification system. To help with this there are many tools but the tradition of using HCO3, bicarbonate, as a basis of interpretation is often problematic in my opinion. An alternative is to focus on the base excess (BE) to guide the classification. Here is a link to my website where these free tools are offered, check out the "Resources for  Clinicians" (http://respiratory-education.usefedora.com/). I have also created a Google Play application that also guides you through the classification and also provides some insight into the pathology or patient conditions that would be potentially consistent with an ABG classification.

This leads me to the next level of ABG interpretation. A practitioner should be aware of how the ABG results aid to the understanding of the patient's condition and treatment plan. Clearly this takes time to develop this level of understanding and students will gain experience by studying cases, a patient's history and clinical situations.

So as a student where does this leave us? Well using the tools and becoming an expert in the mechanics of classification and relating that to pathologies is a good start. My suggestion would be then to work on the application of this knowledge and using one of the most fundamental rules that I believe should always be applied.

Never interpret an ABG without knowledge of the patient's condition and history at the time of the ABG.

I can highlight the critical nature of this with a simple example, a patient has an ABG with a PaO2 of 85, SO2 of 98%, PaCO2 of 40, pH of 7.40, HCO3 of 24, BE of 0. Often when presented with these ABG values a student will suggest the patient has no immediate problems, then when confronted with the facts that the patient is on a non-rebreathing mask and a respiratory rate of 28 b/min the view of the ABG changes.

Another aspect of an ABG that is often overlooked is an assessment of oxygenation. Examination of the PaO2 and SO2 is only part of the equation, oxygen delivery is the other critical component so hemoglobin and cardiac output are critical and leads to my next rule of ABG assessment.

Never interpret an ABG or the oxygenation status of a patient without knowledge of the hemoglobin and cardiac status of the patient.

With these two simple rules in mind and in practice a novice practitioner of the respiratory arts is well on their way to being an expert. An important aspect of the application of these rules is to always ask for the patient information and provide the critical information when discussing ABGs.

Introduction to Mechanical Ventilation

I have been an instructor of respiratory therapy for many years and the topic of mechanical ventilation is an absolute passion of mine for it is the one area of medicine where we as respiratory therapists should be the absolute experts. This fuels my passion and frustration.

My fortune is that I'm gifted with teaching the course RESP 266 Interventions 1 which includes the introduction of mechanical ventilation along with many other course elements. Thus my first concern is that we have diluted the topic and time we as students spend on the subject. A challenge and an obstacle. In years of teaching I've never heard of a instructor who would not proclaim that the time allotted to his subject is insufficient to do it justice. My goal is to see that justice is done! Regardless of the time.

Okay so what advice would I give to students embarking on this introduction? The answer is to play. Play with the ventilators and the tools supplied for the simple pleasure of discovery. Spend the time to discover the ventilator control interactions in both the lab and at home on your computers. The tools are there, ventilator calculators, examples of control interactions, lab time with ventilators and case studies. Play with all of these with enthusiasm and vigor and you will be rewarded with understanding and insight.

In my view lecture time is wasted time. Hearing about it is one thing experiencing it is the real thing.

My zeal for this topic has driven me to create some learning tools that I hope students will find useful. Years ago it was Virtual Ventilators, now I have distilled the essence of that experience and my teaching to offer videos and a synthesis of control interactions on my website; http://respiratory-education.usefedora.com/. I have to charge for the course "Control Interactions" to recover some of my expenses in development but I believe it is a valuable resource for students.

I guess we will see.

Opinions of Common Humans

Does the common human have anything relevant to say?

In a world where we are constantly exposed to instant information, though I suspect often erroneous or misleading, can the average person have anything but an ill informed opinion? I ask this because I suspect that most of us do not have the time or ability to collate the facts.

Maybe some of us can be knowledgeable about a few areas within our expertise of work or special interests but really how are we to have viable opinions on things like gun control or pipeline construction? Who and where do we turn to for reliable information?

As a common human I feel I can only ask these questions and be skeptical of all the proclaimed experts. My personal experience of financial and political experts is that their analysis is only correct after the facts. How many times have I heard on CBC Radio the financial expert explaining to me that I was paying over $1 / L for gas because of high demand and low supply? Then the next week the price of oil goes down and the price at the pump goes up.

As beacons of hope I take solace in the writings of authors like Malcolm Gladwell and Carl Sagan who seem to grasp the need to focus their genius and give us a glimmer of insight. My problem is I'm not sure how their works alter the course of the world or if anyone of influence is even listening.

Another situation that troubles me is that I seem to be surrounded by individuals who tout that they are entitled to their opinions and that their opinions are as valid as anyone's. Even if it's their believe in an obscure god or that global warming is a myth. No longer does it seem that there needs to be any supporting facts or critical analysis. It now seems like it's enough to just have the opinion? It is often touted, in my little world, that everyone's opinion deserves as much attention and respect as others. Thus the dilemma we face when zealots indignantly demand equal education on creation as evolution because they are both equally valid opinions.

Now I have just as many ill informed opinions as anyone but I would like to believe that I'm not so foolish as to believe I'm correct. The problem in my view is how is an average human suppose to vote or give input into majorly important issues? How can we build trust in our news and other media sources to give us the information we need? Who can we trust? Is it time for us to give up on the notion that the common human is entitled to contribute to the decision making process of important issues like global warming or the economy? Are politicians even capable of making these decisions?

I doubt that they are, but that's only my opinion.

Android Love

No doubt we all love our electronic toys but for me I'm a little gob smacked at how my Android Tablet, Nexus 7, has taken over my life. It's more than practical it boarders on an obsessive love. The size, the interface, the speed, all add up to a very satisfying experience.

It is a very useful device in that it has replaced my much used note books. I'm using an app, Free notes, that allows me to use one of my favorite tools the pen to quickly capture my handwritten notes. I can easily organize and utilize my notes that were once just jammed into one paper book. There are some foibles and things to get use to but it really gets the job done and I like the pen-tablet interface. It feels good to scribble and the pen feels satisfying smooth on the glass. I suspect this feature will only improve with new generations of devices and I will be lining up to buy one.

Since having the Android I've been experimenting with lots of different apps. And to my surprise I have found several that really work well.  Of course we all need word processing and "Office"  capabilities and there are lots of apps that give us that, I use Office Pro and it works very well. The most satisfying apps that I like to play with are; Big Fat Canvas, Sketch Book, and Sho Do.

Big Fat Canvas allows me to write and zoom unlimitedly on an infinite sized canvas. I use this for mind mapping and brainstorming. It is so cool I find myself doing stuff on it just to play with it. Creatively this is a powerful allies.

Both Sketchbook and Sho Do are drawing apps. Now I am no artist,  but the pen interface seems so natural and fun that I find myself making little sketches and drawings just because it's so fun. Who would have thought that this Android would allow me so much creative freedom.

Because of it's portability and the pen interface the Android has become both a professional and personally effective tool that has opened up new creative blood in me and allowed me to be increasingly organized and effective. I am writing and drawing more while enjoying the experience. Like all love affairs this infatuation may not last but for now I'm loving it.

Why I Blogg:

First and foremost I guess I blogg for egotistical reasons, I like to see my ramblings in print, on the record. It doesn't really matter if anyone reads my blogg, I'd like it if they, did but that's not really why I do it. It's to put myself out there to commit to an idea or opinion. To put my crude writings out there for the world to see my limitations and foibles.

That is all well and good but it is also fun to play with the technology at a time when anyone can publish and have a voice. That is a revolutionary concept that has some very interesting social and political possibilities. It's an amazing time and I'm intrigued by this. Even at this moment I'm creating this on a small android tablet. How cool is that. Mostly I'm a geek.

Another element is the combined idea that I get to vent my frustrations and formulate ideas and by writing get some clarity. Writing forces me to commit to some organization these jumbled ideas and concepts that clutter my mind. It's a fun mental exercise this bogging to the electronic oblivion.

So I guess I do it because it's fun and a good mental exercise that allows me to revel in the technology and geekism and forces me to put myself out there in a very raw and personal way. Revealing my  naked self

Communication:

The variety and speed of change is bewildering for most of us. We all love our new phones and texting has given us a level of immediacy that is addictive. The new challenge as I view it is in management. How do we use these tools to be more effective and efficient?

There are several tools that I believe could dramatically improve group communication efficiency but seem to, in my experience, difficult to implement.  The first is the use of wikis and the other is shared documents. Though many of the individuals that I work with seem to understand the possible benefits, we as a group seem slow to adopt these strategies. The problem seems that we fall back on to the tools we know, email.  I suspect that the very rate of  change and the constant development of new tools makes us all leary of investing the effort in learning how to use a tool that changes constantly and may be obsolete tomorrow. These are valid criticisms as my own recent experiences have prove with implementing the use of Google tools in our program.
The criticism of constant  change is valid. Google has changed the access and applications of shared documents, video chat, and wiki access several times in the last six months.  Now dedicated users see these changes as improvements but occasional users  view this as caious and obstructive. A valid criticism.

As I see it we as managers and developers must choose our implementation strategies wisely and developers must continue the quest to make access and use seamless and friendly. A major step forward would be developing universal access security coding as no one can remember effectively the dozens of access codes and passwords required with aggressive computer use.

Managers will not only need to be aware and implement these new strategies but they must be leaders in their use. It is not enough to make policy and have students or new employees use these tools, managers need to lead by example.

Program Redesign:

The Respiratory Therapy program redesign continues to be a learning experience for me and I suspect for all the Faculty. What I have learned is that a highly motivated and enthusiastic group can go astray on large complex projects even when all those involved have the best of intentions.

I suspect that the biggest contributing factor was individuals became entrenched with their vision and selective in their evidence to support that vision. This was enhanced by senior management that did not involve themselves and only retained a superficial distant understanding of what was being, brought forward in the design. "The devil is in the details" is an apt quote for this redesign failure.

In my opinion SAIT is not a particularly innovative organization and this often works to their advantage. Knowing what you do and doing it well has been and is a good driving principle and has worked well for SAIT.  So this then leads to my major concern with the redesign. Why would we build a totally unique untried educational model designed and implement by individuals with no educational design expertise? A model built basically on a few individuals personal though limited view of educational concepts with large amounts of imagination. Unique and creative  but conceptually weak and in my opinion flawed. The largest assumptions that the redesign seem to be based on are incorrect. In my opinion these are, that learns will have better understanding and success in a totally integrated course design, that our Learners will be successful with a major part of their learning done as self-directed, and that a major focus of the in-class work should be on soft "professionalism" concepts. In my opinion their is no evidence to support these assertions and like many involved I was bullied by my lack of time and energy to find evidence to refute these concepts. My only evidence that I can easily put forward are the many successful programs at SAIT and other institutions that have more standard design models.

I would like to refute the claim that I am not progressive in my concepts in educational design by pointing out that this redesign is not based on progressive use of technology or educational concepts such as problem based learning or even integrated simulation and lab design.  Both of these elements are limited and reduced in effectiveness in this design so how did we get here? This is a very important question for managers and administrators to ask themselves.

I have my opinions but there have been far to many opinions and we'll meaning speculations already in this project. What we need are rationale approaches based on evidence and informed group concensus. "Too late for that" is an excuse that will plague the Respiratory Program for many years. "Evidenced based" is a concept that many of us discuss but in this case have not implemented.

About PEEP

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.

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.

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.

Modes of Ventilation:

This is a subject near and dear to many a Respiratory Therapist’s heart.  It is what defines our ability to manipulate the mechanical ventilator to a patient’s needs.  The primary need is oxygen delivery to the tissues, removal of carbon dioxide and the maintenance of normal pH.  A tall order when a patient has advance lung disease as with adult respiratory distress syndrome (ARDS).

You have already learned but maybe not mastered the basics of volume and pressure ventilation.  Now we will explore the many subtle nuances of how we can manipulate these two basic elements into the modes we use every day.

The kinds of problems we will look to solve in this course are the key control interactions.  For example in the mode of VC-CMV the ventilator controls are: rate, tidal volume, PEEP, flow, and FiO2.   A typical question we will explore may include a statement like; if you increase the rate what would happen to minute ventilation?  Another question might be what would happen to the I:E ratio when you increased the RR?  What would happen if to the mean airway pressure (Paw) with this increase in RR?

The questions are probably a little intimidating at this time, but by the end of the course you will have explored all these relationships and be more confident.

In class I have been impressed that many of you are considering what does this mean for the patient?  Isn’t that rate too low or minute ventilation too high?  What about those ventilator pressures?  All excellent questions because two elements are critical; maintaining the patient’s ABG’s to meet the clinical goals, and to minimize harm to the patient.  We can never eliminate all the harm we will do to the patient but ultimately the good of keeping them alive outweighs the bad.  We must always try to minimize the damage to the patient. 

Here is a challenge for you to think about.  Two adult patients with ideal body weights of 70kg are involved in a motor vehicle collision come into ER.   They are both unconscious and require mechanical ventilation.  One is set-up with volume ventilation, the other with pressure control.  Now I challenge you to think about the volume ventilator, what would should the initial settings be?  Initial settings Vt set for normal tidal volume about 8ml/kg or a Vt of 560 or round it to 550ml is set,  Rate 12 bpm, flow 60lpm, FiO2 1.0 because we don’t know anything about their oxygen needs at this time, PEEP of 5 because we think that is a fairly normal physiological level.

Now what about patient #2?  What PC level do we set?  How would or could we know?  We would need to know the patient’s lung compliance to be able to estimate the Vt delivered.  How could we know that?  The answer is I don’t know!  We could guess and set a safe PC level and see what happens and sometimes we do this.  Say PC level of 25, Ti 1.2 sec (longer than an expected TC*5 but we will have to check), Rate 12 bpm seems reasonable, FiO2 1.0, throw in +5 of PEEP just for fun.  Okay but what about our minute ventilation.  Are we meeting the patient’s needs?  With this mode we would need to check the Vt delivered (this would be recorded as the ventilator would measure it for us).  Then we could get an idea if the Vt with this PC level would be enough.  So here I hope I have highlighted one of the dilemmas about choosing a PC mode initially in an emergency situation.  There may be a few breaths or couple of ABG,s required before you can fine tune your ventilator.  Mind you VC may also require fine tuning as patients demands change and are dependent upon many factors.

This brings me to the last point today that is we need to meet the patient’s needs.  This means ventilating to ABG’s.  We use our expertise to fine tune the ventilator to minimize the lung damage caused by pressure, volume, and oxygen.  Generally speaking keep the Pplat less than 30 cmH2O, maintain a PaO2 of at least 60 mmHg (works out to about a SpO2 of 90%)  Thus the art of the RT is born!

See you in class!

Professionalism

This is hot topic for Faculty, Mentors, Employers, and our patients and they all have different elements of professionalism that are important to them and so we as students and working Therapists must be aware and meet their expectations.  This may sound daunting with all the legislation that outlines our professional conduct but in my opinion these legal elements rarely are the factors that cause problems or conflict.  It is the soft hard to define attitudes conduct and behaviors that are often the source of heated concern.

I have often heard individuals proclaim; “how being late is unprofessional and unacceptable behavior!”  Clearly this could be considered as true if the individual is wantonly late and has a casual attitude towards punctuality but is this often true?  In our complex world of public transit, required lining up for everything, and just the general chaos of daily life is it not more often true that being late is often out of our control.  To me stating; "that an individual should just have planned better", is arrogant and makes many unsubstantiated insinuations.  In my personal opinion I sometimes think it could be considered that unreasonable intolerance of behaviors such as lateness could be considered an unprofessional attitude in itself.  But I think we can all see why punctuality is a coveted trait in any profession where interdependence is a major operating factor.  So what can we do to demonstrate professionalism with regards to being on time?   In my opinion I think students can demonstrate professionalism in this regard by clearly  striving to be on time and then acknowledging the problem with the inevitable occurrence of being late occurs.  When late, give apologies first, rationale second, then confirmation of your acceptance of responsibility and finally outline how you will strive to not allow this to happen is all that we can offer and expect.  For acceptance by our colleagues and coworkers we must make sure that this problem is infrequent and genuinely something we will try to resolve.  I think we all know individuals who perhaps have a problem with time management or are often late.  I propose there are two approaches to this problem, if it is truly an attitude and callous disregard for others that is the cause of the problem then strict discipline with clear consequences maybe the solution.  But for those other problematic individuals that are trying their best but still are problematic then maybe we need to look inward for a broader definition of professionalism and look to understanding and tolerance rather than just anger and disgust towards the problematic individual.

I am using this example of problematic punctuality as an example of how we as professionals may need to set standards of conduct and behavior but also how truly professional behaviors force us to be tolerant and understanding when viewing the conduct and actions of others.

What do you think?

Week Four, Module 3, and Assignment 1

Well it’s hard to keep up a serious interest in blogging when so few of the class are reading this stuff but I hope to reward those of you reading it now!

I would like to give you few who do check this out a little heads up about next week.  The next chapters on Ventilator Classification are a real slog for students.  I’ve got some worksheets and a few things to try and keep us on track but it really pays to read ahead.  What seems to be the biggest obstacle is the new vocabulary we need to develop so that we can start to understand the performance aspects of mechanical ventilators.  Once this is established we can start our discussions about the modes of ventilation and some of the nuances of ventilating specific patients and adjusting the ventilator to meet their needs.

The essence of this next module is so that we can understand table 42-2, Specifications for some of the modes.  In this table we need to understand all the headings such as; Breathing Pattern, Control Type, Trigger, Limit, and Cycle.  Once these terms are understood we can begin to define the characteristics and unique aspects of each mode of ventilation.

The assignment for this course is actually a virtual laboratory experiment where you will derive the relationship of all ventilator controls for three common modes of ventilation.  For the assignment you will use the virtual ventilator models that I have derived for you.  These are useful because they allow you to control the ventilator and patient parameters, see the resulting outputs without being tangled up in alarms, and ventilator specific controls.  The input and outputs are clearly established in this assignment.  I test regularly and deeply on this subject matter.  It is an expectation that you understand the controls and the interactions. 

An example question would be; In the mode of VC-CMV if the patient’s compliance decreased what would happen to the Ti (inspiratory time) would it, go up, go down, or stay the same?  After completing the assignment you will be able to answer this question.  I hope you find the assignment challenging, fun, and worthwhile.


Please complete this form (click here for RESP 220 Feedback) and give me some feedback about the class.  All input into this form are anonymous.


Thank you

First Week of Classes

Wow our first week of classes is already over and I’m a little concerned because I had to start off with the dreaded “Blood Gas Introduction”.  Please be assured that this is an introduction to orient us to basic ABG values and the classification terminology.  You will notice there is no Power Point and few official notes except for the worksheets.  This is because ABG’s are part of mechanical ventilation in that we use the ABG’s as a guide to manage the patient.

That said; this next section on indications for mechanical ventilation is important and interesting.  Egans chapter 41 is some good reading and all the critical elements of the course are captured there.  Sometimes students comment that they are uncomfortable when Instructors mention different pathologies that cause respiratory failure.  I can totally empathize with you as pathology is a huge area of study and not yet something you have studied in detail.  The course survival mechanism for this is to look at the table 41-2 page 956 and maybe write out a very brief description for some of the basic pathologies.  I know this is work but a quick “Google” search or a “Wikipedia” search can give you all the basic info you need.  Some of the first pathologies you may be interested in and I tend to use in class are; adult respiratory distress syndrome (ARDS), chronic obstructive pulmonary disease (COPD), asthma, and pulmonary infections / pneumonia.  Remember you can always ask in class for me to describe the pathology but it’s hard to grasp my one sentence descriptions delivered off the cuff and on the fly.

My method of using worksheets and in-class exercises I hope works for you.  Notice that I will really emphasize key elements when making presentations and you may wish to focus on this when it comes time for review.

I really enjoy the sidebar discussions and questions in class so please speak up!

Al

Class Preparations

Even though I am kind of an old guy with a fake knee I still think I know what it's like to be a student.  For instance I understand and believe that the question; "What's on the exam?" is totally legitimate.  In my courses I try to make if very clear what will be on the exam.  Maybe not the exact specific questions but I try to leave little doubt about what content is relevant.  For instance in this course you will absolutely need to now normal ABG values, causes of respiratory failure (table 41-2 Egans) and the physiological indicators for ventilatory support (table 41-3 Egans) for a start.  Questions on these will be on the quizzes and exams!

Notice I'm giving a little plug to promote the fact that reading the text is good and starting off with reading Chapter 41 of Egans would be a very good idea.

Our first week will not be an idle one.  We will be getting into the material very quickly, see the course map from D2L for details.

One uncomfortable element at the beginning of the course is that we do a very brief introduction to ABG interpretation.  We need this background information but your ANPH 221 course is really where you will be learning the bulk of ABG interpretation.  ABG interpretation is a critical concept and will be tested in both courses and used frequently in all your courses.  The reason I say it's uncomfortable is that ABG interpretation is a very deep subject that we will only briefly touch on and learn how to do basic classification using a table method.

In class the first week we will also have a little review of the history of mechanical ventilation.  This is really just a nice introduction to the meat of the first module which is the "Indications for Mechanical Ventilation".  There will be not questions on quizzes or exams about the history of mechanical ventilation.  The quizzes and exams will be inundated with questions about the indications for mechanical ventilation.  I make it clear that the students must totally understand the numbers and elements of information contained in Table 41-3 of Egans (Physiological Indicators for Ventilatory Support) and this material will be part of quizzes and exams for the entire course, and even future courses in mechanical ventilation.  So I guess I'm trying to tell you a good place to get started.

Many class days I will have worksheets for you to do.  Some class time will be given for these but often they are completed at home.  Worksheets are reviewed in class and the answers are not published.  I have found that if I publish the answer sheets students are less likely to work on them and wait for the answers.  I do not publish the answers.  You will need to ask questions in class or review the material in the text and with other students to ensure you have the correct answers.

Okay enough for one sessions.

Al

Solution, Solutions

Okay; one of the first things you will learn about me as an instructor is that I often answer my own questions.  This is often true but not always.  Don't give me any grief if I don't occasionally provide the answers and you have to check with your classmates or the confirm your work with the texts.  I do answer questions in class at any time on any assignment.

Okay back to our problem.

There really are two solutions.  The first, as we often must do in medicine, we have to make some assumptions.  The assumption we are going to make is that the patients' compliance is linear.  This is seldom true but often true enough for the range of ventilating volumes and pressures we are using with most patients.  Like all assumptions you need to be cognoscente of making it and realize that it may not apply or alter your observations at the bedside.

Okay with that said, we now assume a constant lung compliance for the patient.  The present "C" (compliance) of the patient is 25ml/cmH2O.  Now we know the equation for calculating is; C= volume / pressure.  Using this equation we can solve for the change in pressures with the increased volume.  I like to set this up as a proportion;

present C 25 = Change in volume 800ml  /  unknown new pressure in lungs X

Cross multiply to solve for the unknown pressures X; so now

unknown pressure X = 800ml / 25 ml/cmH2O

X = 32 cmH2O

So this pressure, 32cmH2O is the expected increase in pressure that would result from increasing the lung volume from FRC (functional residual capacity) with an additional 800ml.  You can think of it as inflating a stiff balloon with 800ml of volume.

Now let us consider the second answer, what if the lung compliance is not linear?  How would this affect our estimation?  It is possibly a valid answer to say that the exact pressures could not be calculated without measuring the dynamic compliance of the lungs.  We will discuss and demonstrate this in class.  So if the actual lung compliance of the patient at the higher volume is lower, then our calculated pressure would be low.  The actual pressures in the patients' lungs would be higher than calculated.

If the actual patients' lung compliance is higher at the larger volume, and this can be true, then our calculated pressures would be high.  The actual lung pressures would be lower than our calculated value.

Comments or questions let me know below.

Added Later: Graph of idealized lung compliance, lower zone = low compliance with alveolar collapse, middle zone =best compliance with open lung, upper zone = low compliance due to alveoli over inflation.

Al