If you're anything like me, you enjoy a good trauma case or a code. Helping patients with breathing treatments, O2 rounds, ambulation, etc. are all great things-- but there's nothing like the rush you get from an emergent situation.

There are so many factors that go into each individual code situation; sometimes it's hard to keep up. In this blog, I'm going to describe the 4 Critical Life Functions.

• Ventilation
• Oxygenation
• Circulation
• Perfusion

If you have all of these things, great! You're alive and in good shape. If you are missing any one of these things, you're coding!

As we've come to know, ventilation is the exchange of air in and out of our lungs. In an ABG result, our CO2 reading gives us a good gauge of how well our patient is ventilating.

Oxygenation is simply oxygen moving through the blood. PaO2 gives us that reading in an ABG.

Circulation is the blood's movement through the body. Do you have a pulse?

The blood and oxygen feeding the body's tissue is perfusion. Vital assessments such as blood pressure, temperature, and hemodynamics give us a feel for how well the body is perfusing. Blood pressure is obviously the most common test for this in a code situation.

As I said before, if any of these life functions are missing, it must be corrected immediately. Our piece of this mainly lies in the ventilation and oxygenation categories. This is what we are trying to restore when bagging a patient during a code, placing an ET tube, starting mechanical ventilation, etc.

Circulation and perfusion are often corrected through the use of CPR, defibrillation, or pushing cardiac medications.

If you have a patient who is worse for wear, and exhibits none of the basic life functions, the main priority is ventilation. That is why "listen" is  #1 on our list. Oxygenation is number 2; circulation, #3; and perfusion rounds out the list.

Next time you get a chance to observe a code where there are no life functions, watch what is done first.

Intubation usually occurs first (ventilation).

Then bagging the patient will occur after the ET tube is in place (oxygenation).

CPR or defibrillation will occur along with cardiac medications (circulation).

Once those are underway, getting an acceptable blood pressure is next on the agenda (perfusion).

If you can memorize those 4 life functions and the order that they are prioritized, you are well on your way to understanding code situations!

We are all born ordinary. We're all genetically the same, more or less. However, not everyone's intentions and drive are the same.

When I was nearing the end of my stay as a respiratory student at Laurel Business Institute in Uniontown, PA, I felt a particular drive that I had not felt before in my life. I had achieved what I had fought so hard for, and my career was just about to start. I wasn't about to screw it up.

I came to the determination that I would milk my degree for all it's worth. Work in respiratory? YES! Write about it? YES! Nag my supervisors to institute protocols and policies that would give me, the therapist, more leeway when it comes to patient care (and let me help write them)? YES!!!!

Prior to enrolling in respiratory school, I led a less than ordinary life. I flunked out of school and didn't really care. I was content working at a grocery store for minimum wage and hanging out with my friends all the time. Simply put, I was a loser.

The 18 month struggle to make my way through respiratory school was the best thing that ever happened to me.

As you students begin your programs, or end them, I implore you to not settle for ordinary. Sure, ordinary is easy. It's no extra work. No extra hassle. Ordinary is 9-5 and most people will settle for it.

However, ordinary doesn't change things. Ordinary doesn't move people.

Ordinary isn't spending extra time with your patients to help their day along. Ordinary isn't giving up a lunch break to stay ahead of your work. Ordinary doesn't go the extra mile to make a difference, no matter how minor it may seem.

So I ask you, the future of the Respiratory Care world, to be extraordinary. Leave school and resolve to be brilliant in your new career. Who knows...maybe the cure for cystic fibrosis is in the mind of one of you, who otherwise would settle for ordinary.

Extraordinary changes the world.

I was recently accepted into the RT program and very excited, however, I am very nervous about the math portion.  Do you have any suggestion about studying, time management, anything that would be helpful?

Congrats on being accepted! The nervousness is natural, but try your best to discard it. Just study and try you're best, and you'll survive.

The math in particular is intimidating, but it's really NOT THAT BAD. They are simple equations, and although some of them look huge, just take it one step at a time and solve. It's all simple math, and the hardest part is learning the equations and figuring out which part to tackle first.

As for studying, flashcards always worked for me and my fellow classmates. They are invaluable, especially when you need to memorize something.

A site I've come across (by another current student) seems really cool for studying and memorizing things: Study Stack

Really, it seems like a lot, but you have nothing to worry about. As long as you study and apply yourself, you're golden. And always do the best for your patient when you get in the hospital!

If you or your classmates ever need some help or advice or want to offer some helpful tips, don't hesitate to contact me!

Email me at beejayss07@gmail.com and I will help you with your concerns as best as I possibly can. Who knows, your email may be featured on the blog and help fellow students across the nation!

Until next time, keep your nose in the books, and your eyes on the finish line!

People seem to share a lot of the same concerns, and I felt like we needed a refuge for these people; a place where students can gather and work through this oftentimes very difficult career.

So, here we are: with my new blog and a brand new Student Center!

The classroom setting can often times be stressful and bits of knowledge fall through the cracks. It's a perfectly normal and common thing, experienced by everyone at one point or another. One of the first things I am venturing to do is write a new series entitled "Respiratory Made Easy." Don't let the title fool you, the column will not be magic. You may not automatically understand the great mysteries of the respiratory world by reading it. The blog will, however, endeavor to take some difficult aspects of our profession and break them down to an easier-to-understand level.

In the comments section below, you can post questions, thoughts, or maybe even an easier way to go about that week's subject. The idea is that it is an open forum for you students to get help; a place where you can take a deep breathe, and sort through all of the mounds of information thrown at you on a daily basis.

Much like in my last blog The (Respiratory) Graduate, I will continue to center on giving advice. I encourage anyone who has a question, concern, thought, idea, etc. to email me at beejayss07@gmail.com...and your email will be addressed.

I will be posting some of these correspondences in the new blog. Who knows, maybe your question is the same question someone across the county has. Maybe your concerns are shared by somebody 2 miles away or 200 miles away.

If you are a student and stumble across this, by all mean, please pass it along to your fellow peers. If you're a teacher reading this, pass it along to your class. The idea is to create a community of SRT's and get them to becoming RRT's!

So, I hope you all enjoy the changes being made, and will continue to support ADVANCE and our new Student Center!

Take Care,

B.J. Smith

I would like to encourage any students who read this blog to contact me. As I said, I enjoy helping people, and not just patients. Maybe John's inquiries will answer some questions of fellow students, but if not, ask me. My email is beejayss07@gmail.com.

***

I am currently in my last semester to become an RT and was wondering if you can answer a few of my questions. First off, I wanted to say excellent blog and keep up the good work. I told most of my classmates about it and they all visit now.

I do my clinicals at a community medical center with some discouraging therapists who have nothing but bad things to say about docs and the profession. Any input?

Also, I am very nervous about taking the test. I currently have the Kettering exam book and have been studying for the past four months with it. What kind of info was on the exam when you took it? This is going to be the worst exam of my life, and like you, I will be jumping for joy when I pass it.

One more thing: I have only been in two codes before. Do you have any tips on how to not let your nerves get the best of you?

***

My response:

Congrats on making it into your last semester. That is no easy task! Also, thank you for the kind words on the blog. Sometimes it's hard to share personal thoughts and feelings in the profession, but if the blog is helping students, it makes it all worth it.

As far as doctors go, it's a mixed bag. I've met some really great docs who will allow you to do your thing and consider your input as a therapist. (Some will even let you take care of the respiratory aspect yourself.) Then, there are some that are not that pleasant.

I've found that the younger docs are the ones to go to when you need something. They are more compassionate and open-minded to your opinion. Sometimes, the older docs, or "old dogs," are set in their ways. However, NEVER let a doctor make you feel discouraged. As long as you have the best interest of your patient in mind, you'll never go wrong. And many people don't believe it, but I've seen it a lot: RT's know more about the lungs than doctors do. So never feel out of line to give your expert opinion, even if you are a young therapist.

With the test, you are doing everything right. Just study the Kettering book. It's a great program and they really know how to prepare students to take that test. I know it's nerve-wracking, but that's the nature of it. There's nothing I can tell you that will take away that feeling. Just get a good night's rest and know that everything you need to know is already in your head. Take your time, don't rush -- you'll have no problem passing the exam.

Codes are a scary thing sometimes. The best thing to do is just breathe, and take it one step at a time. The more you do, the more comfortable you'll become. Just always look out for your patient's well-being. Also, maybe look into getting your ACLS certification; that will make you more comfortable in a code situation.

It's a really great profession, yet like everything, it is what you make of it. But I can tell you that it is incredibly rewarding to make a difference in someone's life, or to even save a life.

Take care, and good luck with everything.

--BJ

After quizzing me with some trick questions, I suppose the therapist I was shadowing felt comfortable allowing me into a patient's room alone. My objective was to go into this relatively young man's room and have him use his incentive spirometer. Easy task, right? At the time, this singular request was my Mt. Everest. (Just so you know, it's OK to laugh. I'm smiling and cringing as I write this.)

I walked into the man's room, and he was relaxing with his wife. The guy looked in pretty good shape and seemed in good spirits. Now, I don't remember the exact wordage, but I know it went something like this:

"Hi, ummm, (insert patient name here), ahhhh, do you have a spirometer?" I asked, continuously looking at the paper with the his name and room number.

"Yeah, sure," the patient responded.

***NOTE: Students, never refer to an incentive spirometer as a "spirometer." With most patients, you will get the "deer-in-the-headlights" look. Acceptable names for the IS include "breathing device," "clear noise maker," or "that sucking thingy." Or, you could always just use my method: find the IS and hand it to them. Back to the embarrassment ...

The patient picked up his IS. I then instructed him on its use. After all, I am a respiratory professional here. "Ummmm, could you, um, blow into that for me ... a, uhh, few times ... please?"

***NOTE: You do not "blow into" a spirometer. I repeat, the IS is a "sucky thing," not a "blowy thing." Epic failure on my part.

"Sure" the patient said, paying no attention to my ignorance and doing the procedure correctly.

"Thank you!" I replied, immediately bolting out of the door into the hallway.

I had conquered my Mt. Everest. I spoke to a patient, misinformed him on a very basic procedure, and essentially made a fool of myself ... AND I WAS PROUD!

I felt like a rock star driving home that day. It's funny to look back on that moment now. If you had told me all the things I would experience in the next two years, I probably would've curled up in the fetal position in the corner and cried myself to sleep.

The experiences are many (joyous, tragic, depressing, hopeful), and some may be bigger than others, but they are all cumulative. Those few foolish words I said to that man embarrassed the heck out of me, but I could always talk to patients after that day with no hesitation.

Students, enjoy your embarrassments. Therapists, enjoy looking back to them. It's why you are who you are today.

Until next time,
--B.J.

All throughout school, multiple therapists told me that I will learn more in my first year of actually doing the job than I did in the whole of my schooling. This is 100 percent true. While in school, you still have that label of being a "student" to fall back on; it's almost like a get out of jail free card. You can hide behind it, or discard it and actually try to do the job. Let's face it, once school is done and over with, that "card" is taken away.

Being thrust into patient care is a staggering experience. Unfortunately, I've seen and heard about peers crumbling beneath it, or even worse, never even attempting it. But the dedicated find a way to rise above it, regardless of circumstance. These are the people who change lives. A quick message to new grads and students -- be one of these people.

I've met (and lost) some wonderful people along the way. In the grand scope of things, I'm still in my infancy to this profession. But all the while, my experiences and interactions with patients and staff alike make the "newbieness" a little harder to spot.

I'm happy to be able to say that I love this job even more than I did when I started. It's really a blessing. And although the last few months have separated me from this wonderful thing I worked hard for, it's all building on the inside. These last few months have made me more excited and motivated than ever to pursue this profession and excel in it.

My sincere hope is that this blog finds you with the same kind of happiness and drive to make a change in the lives of your patients. It's been a wild year, and here's to another.

Thank you to all my readers. I appreciate your support and comments through the last year. Respiratory veterans and students alike, take a moment and realize all the opportunities that are standing right in front of you. It's a wonderful thing, ain't it?

-BJ

She said how nervous she felt (something she's quite prone to). "You'll be fine," I said, as usual. I've repeated those same three words since she first got this job. She questions her training, and her self-confidence is waning.

"The only difference between nursing and respiratory is the specialization--you're a broader focus of the patient overall, and we focus intensely on a few areas," I stated. "So, our experiences aren't all the different."

She agreed.

"I understand you're scared and nervous," I said. "I was too my first day."

"You never show it," she retorted.

"Eventually, you just stop being scared," I said. "I don't think about it. When it comes down to it, when you need it most, you'll know what to do. The patients need you, and it really just mostly comes down to being a decent human being.

"The wall of self-confidence is a front," I explained. "In reality, you won't know everything. But do the best for your patient. If you can say that, then I'll tell you right now that you'll be a phenomenal nurse. You have nothing to worry about. Just enjoy the ride."

I like to think she believed me, and maybe I put some of that burden to rest.

--B.J.

One therapist at this facility drove two hours to work each way to gain this experience. (He lived right next to a community hospital.) This is the type of dedication and focus I'd like to display at my next job. I'm really looking to prove myself the minute someone gives me the chance.

Things seem to be stretched thin all over. Most facilities in Southwestern Pennsylvania have holds on hiring, and a few hospitals have closed or are on the verge of closing. I'm not sure if this is the case in other states, but such is the economy. People cannot afford health care, so they simply don't come to the hospital. Low patient census across the board is what's ailing this area.

So, that's an update. Still looking. Expecting nothing, hoping for everything. Times are dark. Gotta keep your eyes bright and your heart open.

Oh, one last thing. There's a comment on my last blog that I'd like to address. Life is too short to be spending time at a job that you're not madly in love with. Patient care, saving lives--this stuff makes my life beautiful.

I'm sure some other therapists (or health care workers) can attest to the same thing. Still, at that, it's not for everyone. If the paycheck is the only thing you regard in your chosen profession, it's time for a new job. Life is too important and too quick to settle.

-B.J.

Being unemployed seemed like a blessing in disguise at first. I mean, who wouldn't want to receive an unemployment check to stay home and catch up on the little odds and ends that accumulate when you are on a strict, busy schedule of day and night shifts?

Sure, there are people who like to be busy all the time--I'm one of them. But I defy anyone to deny that it's nice to be paid to take it easy for a little while.

Truth is, after a few weeks, you start to miss it. Marathons of "Unsolved Mysteries," morning pancakes, "Halo" and movies cannot compare to the rush of being in the ICU, even on a slow day.

I miss it all, from talking to the staff over morning coffee (and my AMP energy drink), seeing familiar faces and doling out countless aerosol treatments. I even miss bugging doctors all day to change their orders.

So please do me a favor. While you're at work this week, take a moment and soak it all in. Stop, take a deep breath. Live it! Every tiny bit, the dynamic and mundane things, and appreciate it. Then project that positive feeling to your patients.

These are heavy times, but don't let it weigh you down!

B.J. Smith

Talking to an old classmate the other day brought up the memory of a very distinct clinical experience, which most students go through and never forget: my first terminal wean.

"It's depressing, you know. Some of these people you actually want to see taken off the vent, because they are already dead. It's just hard for the family to accept that," said Peggy, who works at a long-term ventilator facility.

"I know, I get disgusted by the sheer number of drug overdoses I seen on a daily basis," I replied.

The particular patient Peggy was referencing was a heroin addict, who essentially overdosed herself into a vegetative state. She was brain dead, but her family was hoping the situation could turn around. The patient was only 30 years old and had two small children.

"It's hard, but you learn to not get involved. Not look at the pictures on the wall of the patient's room," Peggy said.

"I know what you mean. It's kind of cruel, but absolutely necessary, like self preservation. If you don't protect yourself and your emotions, the negative aspects of our job and the things we see on a daily basis will eat you alive," I said.

That short conversation got me thinking about the irony of our job as respiratory therapists. We work so hard to save lives, but in cases like this, when you know it's time to let go, we actually sort of root for the death side of things. Even when the inevitable wean is to happen though, it's still painful.

I remember the face of the old woman I had to terminally wean for the first time. I was in my last semester of RT school, at a large surgical ICU. The therapist I had been following all week--a tough, drill sergeant type--walked me over to the room.

"You know what to do," he said to me, in a low tone.

"So, I just do this like any other extubation?" I asked.

"Exactly the same," he replied as he pointed me into the room.

I approached the ventilator, took her off, and started the procedure. Everything seemed to move in slow motion. "Hallelujah" sung by Jeff Buckley ran though my head. The woman eyes met mine as I withdrew the tube and that stare that is forever etched in my mind. Then as quickly as it started, the procedure ended. The woman held on for an hour or so before finally succumbing to her disease.

I walked out of the room with my head down, trying to comprehend the gravity of the situation.

"That's the hardest part of our job. No one will ever ask you to do anything more difficult," the therapist explained. "It's our job to save lives. That's why terminal weans are so difficult. But you have to take solace in knowing that you did the right thing, and don't dwell on it. The family in that room isn't going back to work today. You are. You have so many more patients that need you at your best. That's why you cannot dwell on it, that's why you have to guard yourself," the therapist explained.

And I believed him.

-- B.J. Smith

"You don't have to go home, but you can't stay here." I got a call from my mother while in the middle of vacation informing me that I was coming home unemployed. Now, for many, this would be a shock. Not so much for me. For those who follow this blog, I've stated on a few different occasions some specifics about my chosen hospital. Please allow me to be slightly redundant and catch everyone up:

• Brownsville General Hospital was bought out my some greedy doctors and run into the ground. The small hospital officially closed its doors in early 2006.
  
• Almost immediately, the former administration worked frantically to reopen the hospital (a feat which was never achieved before in Pennsylvania health care history.)
  
• Plagued by financial woes from the start, the hospital struggled all the way to the reopening. Falling under new health codes and having to repurchase all auctioned off medical equipment delayed the reopening significantly.
  
• On May 22, 2008, the hospital reopened with a bare crew of people and just an Emergency Room, and Telemetry and Psych units.
  
• June 9th, the newly renamed Brownsville Tri-County Hospital hired an attractive, intelligent, young Respiratory Therapist: Me.

Flash forward to present day, skipping over late paychecks, bounced paychecks and a lot of what I deemed "guerrilla therapy" (Read: practicing respiratory therapy in a condition of little to no money being spent, while still providing quality care. The most common form involves a lot of "borrowing" and "testing" equipment, because your department has none of its own.). Not that guerrilla therapy is a bad thing, I think all hospitals could stand to spend less; imagine how health care costs would change if every facility cut back a little bit ... but I digress.

What would have been our final paycheck never actually arrived; hospital-wide, no one got paid. Now, in what is probably the most remarkable event of the story, only a few people quit.

We were flat-out told by administration that pay was not guaranteed, but almost everyone stuck around. It wasn't because we were rich, or because we loved the administration of the hospital. We cared about our patients. If we weren't there to watch over them, who would? I suppose I can't speak for everyone, but that was my logic. So we continued working without pay.

Unfortunately, six unpaid days later, the hospital went bankrupt. Now, I'm sure every hospital would love to have such a dedicated staff (and one who works for so cheap!), but there is the question I pose to you, which is not so different from the last blog with faith playing a part in terminal weaning: When does faith end and naivety begin?

Was everyone -- myself included -- naive to think the hospital could survive? It's noble to sacrifice for the good of your patients and facility, but at what point does it become a detriment to yourself and your family?

Let me know what you think!

-- B.J.

P.S. Got some really terrific replies on the last blog! Thanks for reading and giving your input!

When I was a student in my last clinical rotation, we had a trach patient in the ICU in terrible condition. COPD, pulmonary edema and on a vent to boot. The vent was the only thing keeping this poor man alive, and his wife was approached in regards to ending the life support.

The lady was a good, godly woman who wouldn't do anything to prolong her husband's suffering. My clinical partner even shared with me that this woman used to be his Bible School teacher.

The woman chose to continue mechanical ventilation with the faith that a miracle would happen. She truly believed that her husband would take a turn for the better.

That is all that I am going to tell at this point. What I would like is for you, the reader (particularly the students-brush off those ethics books), to share your opinion below.

Do you feel the woman is justified? Is she shielding herself from the inevitable truth? At what point should we accept reality and let go of our faith?

We've all seen or read about medical miracles. They happen; unexplainable by science or medicine. We've seen prayer affect things or unexplainable healing. Is it wrong to hold out for a miracle?

Let me know what you think.

B.J.

Nothing quite like a 16-hour shift when the hospital is dead. Thank God for my laptop, which allows me to get some other work done.

The cool thing about our profession is that things can turn around instantly. There's really no way of predicting how the day will go. In the midst of the almost-midnight calmness of our department, I get a call for a continuous neb. Continuous neb turns into BiPap. BiPap turns into ventilator. Ventilator turns into me spending two and a half hours in a hot room, working my butt off on this "slow night." Coming out of the room, covered in sweat and mucus (pulmonary edema shooting out of the tube, always a fun thing to happen in the middle of a double), the ER doc approaches me.

"Hey, thanks for your help. I think she's going to do well," he said.

"Yeah, the gas looked great. I think the tube will be out tomorrow morning," I replied.

I may be new to this, but in my experience, it's not too ofen you get a "thank you" from a doctor. Especially not for just doing what your job. But there's nothing more gratifying for me than a doctor looking at me and asking me "What do you want to do?", and then thanking me afterward.

So sometimes it's nice to hurry up and enjoy the "slow nights."

-- B.J.

As I sit here typing, my hands are shaking. Furthermore, every chart I've signed or every thing I've written looks like an eager three-year-old just got their hands on their very first ink pen.

I just got back from an unsuccessful code.

Doesn't matter how many you do, they all have that mix of adrenaline and nervousness, mixed up in your gut and taking a toll out on your hands. It doesn't help when you've been doing compressions through the whole code either. My hands are mush right now.

The person we just coded happens to be the mother of a young fellow employee at my hospital. This person also happens to be a patient I've seen more than once. It's always rough when something like this happens, and unfortunately, it's like the third or fourth time a relative of a fellow employee has coded (maybe I'm unlucky, maybe it's a more common occurance than I realize). We always feel an obligation to do everything possible to bring people back, but when there's a connection like this, those obligations seem heightened. Maybe compress a little harder, faster...push a few more meds. Often it seems like it's all been for nothing.

When this particular patient was pronounced, amidst the tears and expressions of sorrow to this young girl, we all had to suck it up and move on rather quickly. We see multiple patients, so most times there's not too much down time to mourn/unwind after an event like this. So I headed out to the telemetry floor to start my morning rounds.

Luckily, despite the heaviness one might be carrying after such an event, there's often little moments that happen that help us get through the day.

I walked into the next patient's room.

"Hi, are you ready for your breathing medicine?" I asked.

"Sure."

I started to squirt the Unit Dose DuoNeb into his neb.

"Hey, let me ask you something," he spoke up. "Where do they get those cooks in the cafeteria at? I'm not complaining, and I don't want you to say anything to anyone, but that spaghetti was awful! I couldn't even finish it."

I stood there in mid laugh appologizing for the horrendous food, as the patient was also laughing.

"Let me tell you something, bud," he said. "If the food here was as good as your care, I'd rent a room."

Finally my hands stopped shaking.

-- B.J.