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!