Due to unexpected issues, I had beds booked without a technician to cover them. Because we are a small lab that does not have an over abundance of technicians, there is only one solution to this type of problem: I get to rotate onto nights.

Unfortunately, this two night shift rotation was coming after taking a day off.  This meant I needed to catch up on my missed work, plus do this extra work. 

I worked Tuesday and Wednesday for 9 hours.  Then I came in Thursday, worked a 6-hour day and then came back to do a 12-hour night.  Trust me: at 3am, I was fighting sleep. (I remember when I was younger and this 24 hour work day really was not a big deal. As I reach my mid-forties, it is getting a lot tougher.)

When I woke up Friday morning, my biggest fear happened.  I woke my son for school and he had caught the latest bug.  I knew what was going to come, but there is not a lot I could do to prevent it. 

Of course, my challenge sleeping during the day is that I do not do it very often and I live in an apartment with a Westie.  I also have an upstairs neighbor who has three children under 5 years old.  Needless to say, sleeping during the day presents challenges of noise that really do not help. So, I turn on a CD with relaxation and sleep inducing music.  I find it definitely helps but still does not help me get more then 4 hours of sleep. 

Now it is Wednesday and I am sitting here typing between sniffling and coughing.  I know it was my poor sleep that left me susceptible to this bug.  I know what I really needed to do was to get a good sleep.  I know that my patients really wonder who this sniffley person calling them to schedule their test is and whether I will make them sick when they come in for their study.  So now my tech laughs at me and says that I should listen to my own advice and make sure I get a good night sleep.

But what really blew my mind was how hard it is to write an acceptable question and how much harder it is to modify one.

At the BRPT Symposium, they broke us up into two major groups and then into small groups.  I had the privilege of working on question modification first.  They showed us examples of questions that did not work well when trial tested.

It was why they were unacceptable that really was interesting.  Some of them were pretty straight forward but they did not have enough people answer the question correctly.  Other questions had to be reworked because either too many people answered the question correctly or the question was answered correctly by people who did poorly on the test. 

The most confusing though was the one where the question just did not correlate correctly with the percentages.  These questions would then have to be reworked to be clearer in wording.  Maybe two of the answer choices were good choices. Other questions were up for modification because it was too easy to read too much into the questions.

In the hour we were reworking questions, we only got through three questions. 

Next, I move on to question writing.  Question writing was done in groups of 10. We were given a list of subjects we were to write on.  We were then to write three questions and document where we got the information from.  They provided us with A-STEP outlines, text books and montage graphics. 

At our table, we wrote questions about artifact and about math calculations for the CPSGT exam.  It was interesting to see where the new exam will be going.  It also made our table work both as a group and individually to get clear questions that new technicians would need to know.

This two session experience really allowed me to understand how testing is performed.  I really appreciate the amount of work that goes into making these tests fair and still allow accurate testing of technicians to perform basic skills.

The meeting started with a look back at where we came from.  They discussed how many things that are happening now were discussed back when the BRPT started.  Testing has evolved a great deal as has education.  Continuing education has been implemented.  Equipment has changed from paper studies to digital studies that eliminate the work and mess of ink and adjusting dials. 

The future is even more exciting.  There was a lot of discussion about the new credential.  You could hear both positive and negative from the room. I see this as a step in creating a future with accessible training and a way of motivating new techs to move forward. 

Licensure and state societies are moving forward although it is a tough trek. The great part is meeting the people who have been so influential in their state.  They are average technicians with a passion for the profession and are willing to help shape the future. 

The entrepreneurial spirit was really alive and well in the room.  Many of the people had their own business or plans for a future business.  The real excitement though was how everyone really sees their labs as their responsibility and wanted to learn ways to improve them.  You could hear conversations about many topics and ideas being exchanged on policies and procedures, Medicare reimbursement, marketing and growth ideas.  Susan Keller Yenney talked about how she moved up to her dream job in marketing.  It was exciting.

Of course if you really want excitement you needed to come to the party.  It was great to see people let loose, dress up, and have fun. 

More insights to come...

In this case, it's fear of the walk-through part of the accreditation process.  The part I have been dreading since the day I was hired: having some stranger physician walk through this lab that I love so much, examine every little detail and then decide if we will pass their standards.

I have been through similar processes before when I worked in the hospital.  The month of panic leading up to the week of sheer terror when the JACHO inspector came to inspect the hospital. Always wondering if you or your department will fall under the eyes of the inspector. Memorizing the topic of the year so you can answer any question the inspector might ask you.  By the time the week happens, you just wish you had enough vacation time that you could avoid the hospital for the week. 

My dread was this only ten times worse because I am the one who wrote the policies and procedure, I am the one who filled out the application, and I am the one who will have to answer to the owner and to the AASM if I do not pass our accreditation. 

I have had every possible scenario run through my head: everything that could possibly go wrong, every question that possibly could be asked. Every negative thought I have looked at, examined, and planted in my head.

So what did happen? 

The whole experience was really nothing like what I thought it would be. 

The person who came to inspect the lab was great.  I learned so much from him. The changes he asked me to make in the policies and procedures really made sense.  He did not ask for any big changes, just wording changes and procedure changes that would help streamline the lab.  He gave us ideas in areas to grow the lab as well. 

Several of the labs in our area were being inspected at the same time so all the managers were gave each other a hand meeting some of the requirements.  It allowed us to change from competition to community.  This is something I see as a strong positive experience.

In the end, the fear that I created in my own head over the last months and year was for nothing.  It might have made me a little more meticulous in my writing but it did not change the outcome of the inspection. All it did was cause me many sleepless nights. 

Oh and by the way, I still have no idea if I have passed the inspection.  I am told they will let me know after they have reviewed the inspector's report.  As of this writing I am still holding my breath, but I am not worrying because it will not change a thing. Eventually my lab will become accredited.

There are others who say that having a separate person score allows for better quality control, not reading things into the study and better overall care because the techs running the study do not have to split their attention.

But today really taught me why I hold the opinions I now do.

I have had a long couple of hectic weeks because of a series of incidents I had no control over.  I had one technician end the night by leaving  in an ambulance; and that very same week, another technician ended up with swine flu.  That is how I ended up switching between days and nights.  It is also how I ended up scoring on the fly.  Not that I minded doing it because it does keep me busy and makes the night go faster.  It also gives me a chance to look at something I might have missed running live.

What I found was that when I reviewed one of the studies a couple of days later, there were several things I missed.  Now it could have happened because I came to work after I had worked a day shift.  And the errors did occur in the second part of the study.  I know for a fact that 3 a.m. is not my finest hour.  But when I reviewed the study, I found I had missed several arousals and an artifact that had the computer scoring snores that did not exist.

In the grand scheme of things, I do not believe these mistakes really changed the final evaluation of the patient very much. The fact that my scoring was not up to par reminded me why I prefer scoring separately rather than on the fly. 

I hate to admit that I am not perfect.  I despise the fact that I make mistakes because I am just too tired sometimes.  The fact is  I can multitask only so much, and then something has to give.  My priority is to care for the patient optimally, and each lab owner and manager needs to decide what is best for that lab.

At any rate, the debate will go on until some association states unequivocally that it has the right answer.

In my lab, I find that the new techs have difficulty remembering how to do the paperwork and the routine chores at our facility.  They work at another facility and get used to doing it their way and then come here and want to continue their familiar routine.  I ask instead that they move out of their comfort zone and do things as we do it in our facility. 

The result is usually the same every time. RESISTANCE. People do not like to move away from their comfort zones so they try to change me and my routine to match their familiar routine. 

Sometimes they are passively resistant.  I have one tech who is absolutely fantastic, however; I have yet to have him fill out the computer page correctly. I have shown him, I have talked to him, and I have put it on his reviews and he still fills in the computer screen the way he feels comfortable. 

My experience with discomfort comes from marketing.  I do not have experience marketing but it was added to my job description.  I was not given any education in the field of marketing and the last two attempts I had had in the field I was not as successful as others. 

So how do I handle this situation? To be truthful: I avoid it when I can.  I am as human as everyone else.  Then I move past that and I create a plan.  I ask others who I admire in the field of marketing.  I read books.  Then I went out there and started visiting doctor's offices.  I have handed out information about sleep.  I have handed scripts and insurance lists.  I have gone door to door.  I have no budget so I can not buy the items that my competitors hand out.  So I just come in, smile, make small talk while telling them I am available for all questions and then I leave.

Has this gotten easier?  I believe it has but I can not tell how I am doing.  I have gotten some new orders but I am not sure if I am doing the best job I can.  Will I continue to do this?  Yes, absolutely, because you can not grow if you do not leave your comfort zone.

I may never be the world's greatest marketer but the more I do it the better I will become.  The more feedback I get the more I can change my technique to one that will be successful.  The more I read the more educated I will become.  In the end, the goal is to make the sleep lab a strong facility and to keep growing.  The nice part is as it grows, so do I.

One of my jobs as a lab manager to is to send the orders for the CPAPs, BiPAPs and oxygen to the homecare companies.  For the most part, this is an easy job.  I call the patients to tell them what company is going to call them to set up their equipment and what the setting will be.  If they have any questions about the test, I will answer them.  I also tell them to make an appointment with the ordering physician for 45 to 60 days after set up.

So where is the issue with this?  It actually falls with some of the homecare companies.  The problem comes when I get a phone call like the ones I received today.  The first one was from a patient who received a CPAP via mail and called me to ask, "What am I supposed to do now?" The patient does not even know who sent it because the box was not very well marked. It actually took her a couple of weeks to open it because she did not know it was important. 

I knew who sent it but I also know that it would be easier to have the patient come in to the lab. I will teach her how to use the machine and help her to fit the mask.  When she called, she said there were three masks in the box.  This is a motivated patient who wants to feel better but I could hear the frustration in her voice. 

The second patient was someone I called to do a follow up.  He said he is using his machine however, his nose had a sore on it, his mouth was dried out and he was still tired all the time.  This does not sound like a successful patient to me. 

I called the company and when I spoke with the customer service rep, she informed me she did a follow up the previous week and the patient is wearing the machine 7 hours a night, so what was the problem.  I explained that although the patient was wearing the machine--due to high motivation levels--if he continued to have these issues then he would stop using it and that was not the goal.  After some more back and forth, she said she would arrange to have a tech go out and change masks but the other issues were not the company's problem. 

This company wonders why it does not get more of my business.  I say it is because I want my patients to continue to get the service we try to provide. 

Customer service is an important part of our job. I have not met any sleep technician or respiratory therapist over the years who does not understand this fact.  So I ask those who spend their day working with people, whether it is patients or professionals, how is your customer service looking today?

When I started as a manager there was a great deal of disorganization.  Every time there was a problem, my solution was to create a new form. And so began the paperwork monster. 

We all know him intimately.  The paperwork monster is there whenever you decide to spend more time filling in forms, writing a patients name thirty seven times in one night. He's there when you have developed a writer's bump on your finger from charting over the last year. 

So why do we create a paperwork monster?  I think there are a couple of reasons.  Paperwork shows you have done something.  If you bring a new form or written policy then you are showing what a hardworking and great employee you are.  I also believe it is to create a paper trail to deal with many issues.  Every action we take today in health care is done to protect us so if we add more paperwork we will be better protected. 

So what was the solution to get rid of this monster in my sleep lab?  I considered a bonfire but really computers do not smell so great when they are on fire so that was definitely out.  Instead, we turned to a more paperless approach to charting.  This has helped slightly.

What really helped was streamlining paperwork. Although we need structure and we need to perform a great study and to take care of our patients, we do not need endless checklists.  In my lab, we do not have multiple check lists anymore on chart creation, night time work flow, day work flow, and the multiple other checklists we had.  Instead, I have an orientation checklist that serves as it all.  When the techs show they know what they are doing we eliminate it unless there is an issue. Then the same checklist will reappear.  It is not part of the chart.  It is part of the educational process. 

We also started charting in the computer so there is less paperwork. This eliminated writing patient's demographics on each and every sheet of paper. At one of the other places I worked we had stickers created so that there was even less writing involved and everything was uniform.

This has not scared off the paperwork monster but it has tamed him a bit.  I am going to have to keep a strong vigil to keep him at bay. 

When I started in respiratory care back in the early 1980s, I had a closet full of conservative business clothing and several starched lab coats with my name and credentials embroidered. I would walk into a room and the patient would ask if I was the doctor. I would explain my job and role and spend some time teaching them proper breathing techniques.  The feeling of pride in my career and what I was doing for my patients was undeniable. 

Then entered scrubs, a color-coded uniform that would tell the world what profession you were in. They were loose, drawstring pants and v-neck tops with one pocket that reminded you of the guys with pocket protectors in high school. You would hope every day when you arrived at work that they had your size or you would have to trudge down to the laundry to ask for your size--which would then be shouted to the entire hospital--and then run back up to the department to change so you would not be late for report. 

This gave way to the money-saving requirement of buying our own.  That at least saved the run to the basement and the changing at the department, but it brought up the issues about germs.  Immediately, the hospital I work at showed us several studies that proved we could not give our families any illness simply from our clothing.  Now, we could purchase scrubs ourselves but would have to stay within the color assigned to our department.  Who knew there were that many different shades of dark blue or burgundy?  We looked like Easter eggs gone amuck.

Eventually, you knew that scrubs would go high fashion. Today, when you walk into our facility you see every print imaginable. You see designer scrubs and you see scrubs from fitted to loose. There are no rules and you cannot tell who does what job by their dress. 

All you know is what each person's favorite color is, who has the loudest taste (my favorites are Hawaiian prints, yellows, and pinks) and who took their scrubs directly from the dryer.

So, did we lose some of our professionalism with this dress code?  Did we lose some of our identity?

Since (generally speaking) the patient calls me nurse even though I introduce myself as her sleep technician for this evening when I walk into a room wearing a scrub top with flowers and geometric shapes all over it, I believe I have lost some of that pride I had when I first came to work and took care of my patients all those years ago.

As a sleep tech and a manager, I have learned that education is everything.  The more information we give our patients, the more successful the study and (ultimately) their therapy will be. It is this part of the study that should really start at the doctor's office and continue all the way through the process.

In our lab, it starts with the call for the appointment.  I call each patient and explain what to expect and the fact that there may be two studies depending on how the night goes. I explain that our rooms have queen-size beds and that we will attach some wires with paste and tape. I answer their questions from "How much will this cost?" to "What should I wear?" I also send out the packet with the questionnaire and all the directions I go over with them on the phone.

But once they walk into the lab you would think I had never spoken to them. 

Many times, they have forgotten their pajamas. Or the best are the ones who explain they have to sleep in their underwear. We have hospital gowns for these patients. I explain that they really do not want to be videoed without clothes. That usually fixes the problem. 

We show them the AASM video about sleep. After the video the only thing they seem to focus on is how big the mask is. How could they ever wear something that big? We go over mask choices then to calm them down.  After seeing that, it is amazing how well-recieved one of the pillow systems is. Maybe that is why they show a full face mask in the video.

During the setup, it is more explaining and information-gathering. Sometimes I think I am a motor-mouth because I talk so much-- but this is essential to the study. Besides, I have the next 7 hours for silence. 

If I do a good job, I can tell because the patient relaxes enough to do the study. On the nights I am quiet or when there is a language barrier (I took four years of Spanish and still can not speak a word of it), the tests start off with the patient much more restless. 

Now, sending them home with educational material is harder than getting my son to do his homework.  No matter what I say to them, they always leave behind the handouts on sleep hygiene, CPAP troubleshooting, and what happens after the study.  I think it reminds them too much of school and studying. Maybe that is the problem with all the questions we ask before the study -- they feel like they are back in school and the joy of skipping homework is just too fun to not take advantage of.

I love my patients, but I have to admit there are some patients that make this job more challenging. They are not the patients with severe apnea or the patients who do not believe they have apnea; They are the patients who do not have anything. 

You know the ones I am referring to: you put them to bed, you read their questionnaire, and you expect to see an AHI of at least 15 events per hour.  Then it is 1 a.m. and you hear nothing.  Not a snore, not a gasp, nothing.  You look at the study and they have had plenty of stage 3 and REM already.  You look to see if maybe they had not done any sleeping on their back.  Nope, they have been asleep on their back the whole time. 

When you talk to them the next morning you get one of two responses.  My favorite is "This is the best night sleep I have had in years." The other type of patient is convinced he did not sleep. 

We had the former patient in our lab last week.  He teaches college.  He scores papers on his laptop in his bed until 1 in the morning, most nights.  His wife complains that he snores but he says she snores as well.  The best part was when I handed him the sleep hygiene tips sheet.  He said I left one item off the sheet.  He informed me that he slept with his two children in bed with him.  Now I was standing there trying to figure out how he did not tell his doc this before the doc sent him to the sleep lab. 

I do not know about you, but if I stayed up until 1 a.m. every morning, had two squirming children in bed with me every night, and taught college all day, I would be exhausted.

So what do we learn from this patient?  That every once in a while it is nice to have an easy patient. 

Oh yeah, and if he even remotely looks young enough to have kids, ask if they have their own room.

From my days doing homecare, I know that the support a husband and wife give each other to get tested and to use their equipment can be the difference between success and failure on their road to health.

I started the month with a husband and wife who needed sleep testing.  The husband said the wife was a restless sleeper and the wife said the husband snored like a freight train.  With this information, we made certain assumptions about how these studies would go. Little did we know that they had no idea what really happened while they slept. 

The husband had so many leg movements that you thought he had jogged a 5k in his sleep.  He snored a little big and has sleep apnea but his restlessness was not what we expected.

The wife? Now, she could have given a freight train a run for its money, which makes me wonder if her snoring was actually causing her arousals. She snored and gasped and has worse sleep apnea then her husband. 

They came back for their titration and did great.  I know--having done their titration and the support-that they are the perfect support for each other as they start using their CPAPs at home. With the change in both their sleep, you should see a happier household and marriage as well. 

My other couple was a husband who had a sleep study three months ago.  He came for fatigue and because his wife said he was snoring.  He had significant sleep apnea and was put on a CPAP.  His wife is still restless at night and it turns out she snored as well.  She came in for her titration study and needs a CPAP as well.  She already knows what to expect because she had the opportunity of watching her husband adapt.  He had a tough go of it but he is using his every night and is feeling better. 

I have learned more then I could ever imagine working with these couples helping them to get the good night sleep they deserve.

One particular couple snored in unison.  They were in different rooms and they were wired for their study.  Their sleep onset was within minutes of each other.  They snored at about the same pitch so as not to disturb each others' sleep.  They also woke up within minutes of each other to go to the bathroom.  They had created these habits over years of living together you would think, but I have seen other things in the lab that make me wonder.

I have had complete strangers go into REM at almost exactly the same time.  I know that circadian rhythms can be similar but it always made me question.  How can two people sync that closely?  It does not happen all the time but it has happened quite a few.

The case of the married couple just shows you that there is so much more then enjoying your time together.  They have been married for 40 years and they have become so ingrained in each others' lives that their breathings syncs and their snoring syncs and even the time they get up has become routine.  I wonder what will happen when they start on their CPAPs together. 

I have been doing a great deal of orientations lately due to unforeseen staffing issue. Anyway, it is always interesting when you orienting a new person to see what they really know and what they tell you they know. Somehow they never quite meet. But it gives me a chance to expand my horizons, teach new things, and learn that greatest of skills: patience. (This lesson usually coming after I have had another run-in with my 16-year-old.)

It was on one of those orientation nights when I realized doing a set up for a sleep study and doing it correctly are two different things. I also realized that my need for doing things according to AASM protocol confuses a great many new people. In particular, the need for all my technicians to measure the patients head. It amazes me how so few technicians know how to do this.

And then, even if they do, they do not understand how to put on a lead without pushing on the lead so hard that you think it is going to become a permanent part of the patient's body. To me, this is a basic skill that was learned within the first two weeks of becoming a technician.

Then, there is the middle of the night lead fix. Now, I was taught you want to disturb the patient as little as possible, so if you can wait for an arousal or awakening, great. Do you really want to go knocking on the door, reintroduce yourself, and explain what you are doing to a person at 2:30 in the morning?

I personally think the more unobtrusive you are, the quicker the patient will go back to sleep. I do not even turn the light on. I can usually correct the problem just from the light the hallway gives off. There is always the concern about the patient who will wake up swinging, but those patients usually tell you before lights out not to touch them when you wake them in the morning. Of course, I have had a patient or two over the years take a swing at me, but I have learned how to duck very quickly when necessary.

Lastly, it amazes me how little people document. Of course I am of the belief if you did not write it, it did not happen. (A lesson taught to me at one of the hospitals by their lawyer during orientation.) I think that lesson has stuck with me low this 20 plus years.

I think new techs are afraid to write too much. Me, personally: I am afraid of writing too little. I tell all new techs that they should pretend they are the reading doctor and they have received the study the next day but they have no video. Write to me so that I know why what I am seeing looks the way it does.

If that does not work, I use the lawsuit scenario. Its five years from now, you just received a request to show up at court about a sleep study you did eight years ago. How are you going to know what you did? What was going on? Write it out and it will never be a problem. That usually scares people to my way of thinking.

I know that orientation is important and needs a great deal of attention, but I really hope that they will get easier over time. I really believe that as our field gets more regulated and licensed, we will all be working on the same page to create the best sleep studies possible.

I am what you would call a sleep nerd. You know the type. I love those nights when the patient has something unusual or the perfect tracing. I just love to watch them, then talk about them with my fellow technicians.

Take the other night. I am working nights and have two patients. One is a very high stress patient who needs a great deal of attention. He kept insisting he had to have the television on or he would leave. The other patient was a very quiet man who was in the lab because he was tired all the time and asked for an early lights out. When I finally got the chance to sit down and look at his study, I found he had perfect Cheyne Stokes respirations. To me this is so cool. Not so much for the patient but as a technician we very rarely get the opportunity to see this and his was almost exactly the same: every episode nine breathes in an increasing then decreasing volume followed by twenty to twenty-five seconds central apnea and then it would start again. His EEG was not easy to read due to alpha intrusion but I am sure that was due to the medications and health issues this particular patient had.

So what do I do while working the next night with one of the new technicians? I show him the study. Of course, he finds it as fascinating as I do. Then he tells me the story about the patient he had that he picked up on central apnea and how he was able to get a good titration using BiPAP. This, of course, leads to the discussion of AutoSV and how we like that for treating central apnea. He also requests that he be there when my patient comes back for his titration study.

What this really comes down to is that I love working in the field of sleep, whether it is day shift or night shift, because I get to learn something new from each of my patients and more than every once in a while I get to make a difference in their life. Of course, this also means my kids and husband know more about sleep than they really want to and that at an average dinner party, I am probably one of the most boring conversationalists there. Oh well, at least they know that they really should get a good night's sleep and if they have a problem they should go talk to their doctor.