A day in the life of a
Respiratory Therapist
It’s 6:15 a.m., I am on my way to work. I wonder
what today will bring. That’s the thing about being a respiratory
therapist, you never know what challenges you will face each day.
Report Room: 0645
I just received my assignment for the day. I am to
float between the emergency room, trauma care and the neonatal unit. The
workload in each of those areas is more than one therapist can handle
but there is not enough for two therapists. So I get to bounce from unit
to unit. I am a new graduate, some of the seasoned therapists say,
"looks like you’ll need your running shoes today." I don’t
mind, I enjoy the opportunity to work with a wide variety of patients.
The Neonatal therapist wants me to start in her
unit, the trauma care therapist wants me to start my day in his unit.
They both loose, the ER beeper goes off. Sally is the therapist assigned
to ER. Sally calls down and is told that there is a multiple trauma
enroute to the emergency room. She and I both rush down to the Emergency
Room. The nurse tells us that we are expecting 3 patients, a 38 year old
female, a 42 year old male, and a 12 year old female. Apparently the
victims are a mother, a father and their daughter. They were involved in
a single car roll over on the expressway.
The father, Mr. Richardson, arrives first. He has
splints on both legs, and his right arm. He has multiple cuts and
bruises on his face. The medic states that the patient wasn’t wearing
his safety belt. At the scene it appeared that patient hit the steering
wheel and than was thrown around the inside of the car. He is
unconscious, and has sustained chest injuries. He has an artificial
airway in place and the paramedic is bagging the patient. (We call this
bagging the patient because you squeeze a bag to force air into the
patient’s lungs.)
The medic tells me that it is getting more
difficult to squeeze the bag. The patient’s oxygen monitor is showing
decreased oxygen levels in the blood. The medic is worried that the tube
may have slipped down into one lung. The patient has several rib
fractures. The medic and I are also worried that the patient may have
"blown a lung". The correct medical term for this is a
pneumothorax. (A pneumothorax is a life threatening event, not that this
guy isn’t already in big trouble.) I listen to the patient’s chest
with my stethoscope. He has decreased lung sounds on the left side, the
left side of his chest is not moving. At first I think it might be
simple, the artificial airway may have just slipped down into the right
lung. But while listening to the upper left chest, I feel that
unmistakable "rice krispy" sensation of air under the patient’s
skin. The medic and I immediately alert the trauma surgeon that this
patient needs a chest tube. The trauma surgeon quickly inserts the chest
tube. It becomes much easier to squeeze the bag and the blood oxygen
level has increased to 100% on the patient monitor. The chest surgeon
tells the medic and me "nice catch".
They suspect that this patient may also have
ruptured his spleen. He needs to go to the operating room immediately. I
quickly check the portable oxygen cylinder on the cart to make sure I
have oxygen. I bag the patient while he his transported to operating
room. I hand the patient off to the nurse anesthetist and head back to
ER to see if Sally needs help with the other patients. When I walk in
the ER I hear the screams of the 12 year old coming from the pediatric
trauma suite. To most people screams, are distressing. To respiratory
therapists, screams mean that a patient’s breathing is probably ok. I
peek in and ask if they need any help. They don’t need a therapist at
this time.
I find Sally in trauma suite 2, she is using a bag
to breath for the mom. The mom has minimal external injuries. The medics
said that she was wearing her seat belt. She suffered a head injury
during the roll-over. They want to transport the mom to Cat-Scan.
I run back to the department to get a portable
ventilator (breathing machine) while Sally bags the patient enroute to
Cat-Scan. I arrive first in Cat-Scan. Using the patient’s height and
weight, I determine the ventilator settings. Because of the patient’s
head injury I decide to use a slightly elevated breathing rate.
Breathing faster for a patient gets rid of carbon dioxide. Lower carbon
dioxide levels help decrease pressure with in brain.
Sally brings the patient into the Cat-Scan Room.
One of the new ER residents is with her. I double check my settings with
Sally and the ER resident. The ER resident asks me why I am using a high
rate. I explain the ventilator’s effect on the intracranial pressure.
I am not sure he is going to buy it, when the neurosurgeon arrives and
says "make sure you hyperventilate her a little." We get the
mom set-up on the ventilator and step out of the Cat-Scan room. We are
able to observe the patient through a window in the control room. The
Cat Scan shows that the patient needs immediate surgery to relieve a
small bleed in her brain. Sally bags the patient enroute to the
operating room.
0900
I decide to swing through the cafeteria and pick
up a cup of coffee before checking with the therapists handling the
neonatal unit and trauma care unit. I just put the lid on my coffee and
my pager buzzes me for the neonatal unit. I call Marge, the therapist
assigned to the neonatal unit. She says that she heard that we had
shipped ER patients off to the operating room. (The informal
communication system in health care institutions has amazing speed).
Marge tells me that they are about to start a
C-Section on a mom carrying twins in fetal distress. The infants will be
at least 8 weeks premature when they are born. She asks me to meet her
at the C-Section. We make sure that we have all the necessary
resuscitation equipment ready. We also set-up two ventilators in the
neonatal triage area. The C-Section is very quick, both infants are in
distress. It always amazes me how small these neonates can be. One is a
boy at about 2 ½ pounds, the other is about a 3 pound little girl. They
place each infant on an infant warmer. Marge works with the team taking
care of the little girl. I work with team taking care of the little boy.
The heart rates of both infants are low and we have to gently bag both
infants. The little girl pinks-up and begins breathing on her own. They
are able to keep her stable by just giving her some oxygen. Marge’s
team places the girl in an incubator with oxygen and transport her to
the nursery.
The baby boy needs to be bagged to keep his heart
rate and oxygen level stable. They put an artificial airway (breathing
tube) in him. The tube will allow us to place him on a ventilator. We
move him to the triage area of the nursery. I determine the proper
pressure, rate, and oxygen level on the ventilator and confirm my
settings with the neonatologist. We put the infant on the ventilator. It
is difficult to keep his oxygen level up.
Premature infants lack a substance in the lung
called surfactant. Surfactant helps keep the air sacks in the lung open.
One of the wonders of modern medicine is the recent development of
artificial surfactant. By administering artificial surfactant we are
able to save the lives of many premature infants. The neonatologist
feels that the little boy needs surfactant. He draws up 4 cc in a
syringe, we place the little boy on his right side, the physician
squirts half the surfactant in into the breathing tube. We place the
baby back on the breathing machine and turn him on his left side. The
neonatologist squirts the other half of surfactant down the breathing
tube. We put him back on the ventilator. I immediately begin decreasing
the pressure on the breathing machine. I am able to help him breath with
25% less pressure than before the surfactant. I am also able to quickly
reduce the oxygen. Over the next hour, we frequently "tweak"
the machine’s settings up and down to keep up with the changes in the
little boy lungs. He slowly stabilizes. Mom and Dad finally get to come
in and see him. If things go well, he will probably be breathing by
himself tomorrow.
1200
I check with Barry the therapist assigned to the
Trauma care unit and ask him if he needs help right away. He says he is
keeping up for now but will need help when the two ER patients get out
of surgery. I decide to grab a quick bite to eat. At lunch, John one of
the therapists working on the cardiopulmonary floor, tells me he is
getting swamped. They have had three new patients with chronic lung
disease admitted to the floor and they all need treatments. Another
patient needs home care evaluation. I tell him that I will help him out
until Barry needs me in Trauma care. John asks me to take care the home
care evaluation on Mr. Crandall.
Mr. Crandall is a "frequent flyer" like
many of our respiratory care patients he was a heavy smoker and also
worked industry. He has been admitted three times in the last year due
to his chronic bronchitis. We all know Mr. Crandall. In fact he insists
that we call him "Bud" not Mr. Crandall. After this morning’s
events, I am glad John asked me to take care of Bud. It will be nice to
work with a patient I can talk to. Bud tells me that he was admitted
because he "caught a chest cold" from one of his
grandchildren. He always has great stories about Korea, working in the
foundry, and his favorite hobby fishing on the Great Lakes.
Bud was admitted so that he could receive
antibiotics, oxygen and respiratory therapy treatments. The first few
days of his hospital stay he required breathing treatments every couple
of hours. We had him breath a mist containing a bronchodilator medicine.
A bronchodilator relaxes the muscles along the breathing tubes. He also
had a lot of congestion in the right middle portion of this lung. We
performed chest physical therapy on that area. Chest physical therapy
involves positioning the bed so that his chest is higher than his head.
Then we use a percussor or our hands to vibrate the secretions loose in
his lungs. Bud is doing much better now. His right lung is nearly clear.
We have been able to stop doing the chest physical therapy. He only
needs the bronchodilator treatments 4 times a day. The physician has
asked us to evaluate Bud for home oxygen and home breathing treatments.
The physician would like to discharge Bud this afternoon
I need to determine if he breaths well enough now
to use a simple inhaler to take the breathing medicine. I bring a
portable lung testing machine to his room. I test Bud’s breathing. His
lung function is not very good, but it is markedly improved from the day
of admission. I decide that he should be able to use an inhaler. I teach
him how to assemble the inhaler and the proper technique for using it at
home. I measure his lung function again after he uses the inhaler. The
inhaler resulted in improvement in his lung function. I leave a note for
the physician to write a new prescription for Bud’s bronchodilator per
inhaler. I also suggest that Bud might be a candidate for pulmonary
rehabilitation.
Next, I need to determine if Bud needs oxygen at
home. We have a monitor that clips on a patient’s finger and reads the
patient’s oxygen level. I will need to take a reading while he is on
oxygen, then take him off oxygen for 30 minutes and take another
reading. If the level is low, he will need oxygen at home. Although it
is technically simple, you have to be sensitive to the patients needs.
Most patients don’t like the idea of being on oxygen at home. We need
to prepare them for the possibility that they will need to wear oxygen
all the time. My guess is that Bud will need home oxygen. Before
starting the test, Bud and I have a long talk about oxygen at home. I
help him understand why he might need it. I also explain the options of
having portable oxygen. This will allow him to take oxygen on his boat
so he can still go fishing. I take him off the oxygen for thirty minutes
and then recheck his oxygen level. As I expected, Bud will need home
oxygen. I tell him about several home care companies in the area. Bud
elects to use one that his friend uses. I call Wanda, a respiratory
therapist who works for the home care company Bud selected. We arrange
to have the oxygen delivered to his home. I know that Wanda will work
well with Bud and his family on the use of home oxygen. I let Bud know
that everything is all set, he smiles and says, "at least I get to
go home."
1300
My beeper goes off. It is trauma care. I call
Barry, the therapist assigned to trauma care. He says both of this
morning’s accident victims are out of surgery. They will arrive in the
trauma care unit in about 15 minutes. He asks me to bring two
ventilators down to trauma care. When I get to the trauma care unit,
Barry asks me which patient I want. I say that I’ll take Mr.
Richardson, the 42 year old male, that I took care of in ER.
The anesthetist arrives with Mr. Richardson, she
tells me that he was very difficult to ventilate and required high
ventilating pressures. She states "he was a mess inside" and
required a lot of fluids to maintain his blood pressure. I work with the
trauma surgeon to determine appropriate ventilator settings for him.
Because of his chest trauma it is difficult to push air in Mr.
Richardson’s lungs. It is requiring dangerous pressure levels to
breath for him. We are having trouble ventilating him with typical
settings. I consult the trauma surgeon about using a new ventilation
technique. This new technique uses low pressures and prolonged
inspiration to breath for the patient. Since Mr. Richardson’s oxygen
level is so low, the trauma surgeon feels that the new technique is
worth a try. I adjust the ventilator to the new settings, and the blood
oxygen level slowly begins to improve.
Once Mr. Richardson is stable, I check on Mrs.
Richardson. Barry tells me that there was only a small bleed in her
brain. She is already able to squeeze the nurse’s hands and wiggle her
toes. She is stable and should come off the breathing machine soon. The
neurosurgeon stops by and tells me that hyperventilating her prior to
surgery really seem to make a difference. He thanked me for explaining
hyperventilation to the resident.
1430
I help Barry with the rest of his patients in the
trauma care unit, and before I know it, the shift is over. It is time to
give report on Mr. Richardson to the afternoon trauma care therapist.
After finishing trauma care unit report, I head up to the neonatal unit
to check on the twins from this morning. Marge tells me that the little
girl is still doing fine. She has been able to turn down the oxygen and
breathing rate on the little boy’s breathing machine. I tell the
afternoon therapist what I know about the baby boy and Marge fills in
the rest. I head back to the department to punch out.
1535
On my way out to my car, I see Bud’s wife and a
nurse helping Bud into the car. Bud has a portable oxygen cylinder and
is wearing his oxygen. He tells me that they are going to send him to
pulmonary rehabilitation twice a week starting tomorrow. I tell him,
"who knows maybe I’ll see you tomorrow, they might need my help
in the pulmonary rehabilitation area."
On my way home I’m am very tired, and I think
about the day. I think of how I held the breath of life in my hands for
the Richardson's and the twin babies. I think about Bud going home and I
feel great. I do hope I get to work in rehabilitation tomorrow.
