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.