Maria Madden, MS, RRT, RRT-ACCS
VERO-Biotech & ICON
Karsten Roberts, MS, RRT, RRT-ACCS, RRT-NPS
Hospital of the University of Pennsylvania
Maria Madden, MS, RRT, RRT-ACCS
In our Summer edition of the Adult Acute Care Section Bulletin, two talented respiratory care professionals, Rena Laliberte, BS, RRT, and Danielle Marie Hardy, BSRT, RRT, RRT-ACCS, lead us in education and opportunity in adult acute care.
Rena touches upon considerations we all should be aware of regarding those new to our profession. Her article, “Pandemic Class of 2022, Uncharted Education Territory for Respiratory Care Students,” is enlightening and thought-provoking. Danielle’s article is something that I am passionate about, the “Role and Impact of Respiratory Care in the Golden Hour of Trauma.”
Moving forward, our Adult Acute Care Section meeting will be scheduled on a quarterly basis. Our next meeting is July 12, 2 p.m. EST. To fulfill a popular request, our next few meetings will focus on education and topics related to extracorporeal membrane oxygenation (ECMO) from talented professionals.
Our first presentation on July 12 will be from John R. Priest, BSRT, RRT, RRT-NPS, who is serving as both a respiratory care practitioner and an ECMO specialist. Rena and Danielle will also present their articles. Join us in what will surely be an informative and thought-provoking discussion.
In closing, I wish to stress the importance for all of us as respiratory care professionals to continue the search for new opportunities in education and additional training sessions. Take pride in your work on a daily basis and find comfort and satisfaction in knowing you have the ability to make a profound impact during one of the most trying moments in a patient’s life! Keep striving to serve your communities, provide top-level support with excellent attitudes, and elevate our noble respiratory care profession.
Rena Laliberte, BS, RRT, Clinical Education Specialist, Emergency Room Coordinator, Respiratory Therapy, Henry Ford Hospital, Detroit, MI; Acute Care Section Chair, Michigan Society for Respiratory Care
The COVID-19 pandemic has been a health care crisis that none of us had experienced before. As respiratory therapists we’ve had more critically ill patients than ever, have used therapies and ventilation strategies far from standard protocols, and have been forced to use our critical thinking abilities at levels beyond what we may have thought was possible. We continue to build on our knowledge, clinical skills, past experiences, and what feels like never-ending updates from the WHO, CDC, and peer-reviewed research to guide the care we provide.
The role of the respiratory therapist has been highlighted more than ever. Our specialized training has been brought to the forefront for the world to see. But amidst our newfound recognition may be another crisis that we were unprepared for — how best to prepare the graduating respiratory therapy classes of 2022 for practice beyond theory.
The class of 2022 both began and ended during the pandemic. Some institutions were closing their doors to students in all health care professions. Colleges and universities struggled to seek placement for clinical rotations during the height of patient admissions. Students were pulled from clinical rotations due to increased health risks for them, or lack of available placement for all students.
In contrast, our institution made no changes, despite the initial COVID surge, and continued to allow clinical experiences to any health care profession, including RT students.1,2
In fact, we felt it was important to open our doors wider. We accepted additional students from our primary institutional partners, along with two additional colleges. At one point at the peak of the pandemic, we had 16 students rotating through our hospital.
While some clinical sites did not provide PPE, our facility assured students were fitted with appropriate PPE and worked side by side with their clinical preceptors for both COVID and non-COVID patients. Students spent much of their time performing more conventional therapies on non-COVID units without exposure to ICU experience.
As the initial surge began to subside we began to hear more stories about the challenges RT programs were having due to the pandemic. Students shared with us stories about what members of their cohort were experiencing at other clinical sites. Some reported sitting in break rooms or other open areas of the hospital and “hands on” simulation in equipment rooms with staff therapists.
Damage was done
Some of the students never attended one class in person; lectures were prerecorded and could be viewed at any time. Communication was limited to emails with their instructors or prearranged Zoom meetings where questions could be asked. While some RT programs had live classes online and questions could be asked in real time, those same lectures were also recorded and could be reviewed later, if desired.
Lab time was also challenging to navigate, sometimes being full, sometimes limited, or perhaps nonexistent. A lack of hands-on lab time makes it impossible to have any significant experience, instructor discussion, or simulations.
For those that had access to lab time, access to mechanical ventilators was limited because the ventilators were borrowed by area hospitals for patient use. Despite the return of some normalcy in the second year of their education, the damage to the typical, pre-pandemic, RT student experience had been done.
Students understood the strain
Therapists who worked with these students were stressed beyond their limits, tasked with high workloads, critically ill patients, and the added responsibility of a student. They felt overwhelmed, frustrated, and upset that they could not give students the attention they deserved.
Despite this fact, the students we talked to did not feel unattended to, and responses were quite the contrary. Students stated they understood the strain, because they had seen it firsthand, and they were very grateful for the opportunity to be present during codes, intubations, daily rounds, and terminal weans.
When there was time to discuss cases and ask questions, the potential effect of these limitations became clear. Anecdotally, basic ventilator modes were not well understood, with specific features and functions of each ventilator unknown. Some students had difficulty answering
questions about basic respiratory therapies, along with medications and their indications and mechanisms of action.
Clinical preceptors did their best to try to supplement educational needs, but that is difficult during a busy unit schedule. Unfortunately, students have begun to see their own deficiencies. Preceptors have continued to try their best to remain empathetic to the difficulty of attending classes during a global pandemic.
Time will tell
Ostensibly, students who had a more “normal” program experience with class and lab, became more confident in their ability and knowledge levels compared to others. Occasionally, when students become too confident, they tend to lose sight of their true limitations. Which brings to mind the adage, “You don’t know what you don’t know.” Which can also become a problem to some. They seemed to notice the differences between their program and others. These stories and experiences will undoubtedly affect new graduates when they enter practice over the summer.
Successful credentialing and pass rates for the class of 2022 should be of interest to all RTs. In addition to monitoring their initial entry into practice, managers and educators should remain aware of their professional performance, engagement, and retention.
Respiratory therapists and RT students alike experienced unprecedented situations over the past two years. It will be important for experienced RTs and hospital-based educators to follow-up with this class over the next few years. Time will tell how successful they become, and hopefully this unprecedented time is not repeated.
Danielle Hardy BS, RRT, RRT-ACCS, ECU Health Medical Center, Greenville, NC
The early management of trauma is categorized by most surgeons as the most crucial period for patients to receive intervention following rapid assessment. Trauma centers must have resources available, so if a patient requires hemorrhagic control or other means of intervention within a goal of 60 minutes from the scene of an event they can get it.
A 2008 analysis from Gerado and colleagues noted an overall reduction in mortality of 8.3% amongst dedicated trauma programs.1 Trauma systems are designed to reduce preventable death and ailments by providing swift, effective care. The team that assists in these efforts is made up of a group of health care professionals whose purpose is to facilitate an organized approach to trauma care.
Role delineation of the trauma team is imperative for each trauma center, whether it be in policy or protocol. This serves to define each health care provider’s role in a trauma resuscitation effort.
In a trauma resuscitation effort, there are specific expectations that guide the role of the respiratory therapist. To achieve classification as a trauma center, an RT must be present on site and available to assist the patient.
Once alerted to an incoming trauma patient RTs are to respond to the trauma resuscitation area. This response includes the need to assure a manual resuscitator, emergency airway equipment, and ventilation equipment are readily available in the area.
Upon patient arrival, the trauma team must obtain report from the emergency medical transport team. The patient’s respiratory status should be assessed quickly and thoroughly, with an update given to the trauma team leader.
If there are any signs of airway compromise, oral, nasal, or tracheal intubation must be established with the assistance of the RT. The role of managing and evaluating a difficult airway should be held by the attending provider and an experienced clinician. Anesthesia should be on standby and alerted by the team leader if assistance is required.
Once airway management is established, the RTs assume the responsibility for the patient’s ventilation and oxygenation needs by providing mechanical ventilatory support, in addition to continuous end-tidal and pulse oximetry monitoring. Primary assessment, secondary assessment, and diagnostic tools should typically be completed within 20 minutes of arrival, which is the standard set by the American College of Surgeons’ Committee on Trauma.2
Finally, the trauma resuscitation team will prepare the patient for transport to scan, surgical intervention, if needed, or admission to the ICU.
Preparedness is key
In these intense settings, RTs must be well equipped to handle various traumatic injuries, including chest trauma, spinal injuries, traumatic brain injuries, and near drownings. Initiation of mechanical ventilation protocols beginning in the emergency department has been shown to reduce mortality from 34.1% to 19.6% in respiratory complications, including acute respiratory distress syndrome (ARDS) and ventilator associated events.3
Five to ten percent of adult trauma patients are at risk for developing ARDS initially. Furthermore, during the course of an ICU stay, roughly 19% of adult trauma patients are impacted by ARDS.4 Due to the risk of lung injury, lung protective strategies must be implemented early.
Implementation or early application strategies such as airway pressure release ventilation (APRV) have been shown to stabilize the alveoli and reduce mortality in high-risk trauma patients, according to a systematic review by Sadowitz and colleagues in 2013.5-6 As clinicians at the bedside, RTs may quickly implement respiratory care driven protocols during the resuscitation effort and thus set the tone for admission of the patient to the trauma center.5
Preparedness is key in the so-called “golden hour” of a trauma. That calls for a resuscitation protocol, the availability of equipment, the delineation of team member roles, and the presence of skilled clinicians.
Interdisciplinary collaboration in trauma simulation or skills days will create a positive impact in staff engagement. Respiratory care departments can improve performance and enhance skills by creating continuing education courses within the department in addition to annual competencies, such as managing airway emergencies or reviewing ventilator graphics and lung protective strategies.
By investing in education of evidence-based practice, RTs can assist in improving mortality among trauma patients.
Section discussion list: Go to the Adult Acute Care Section on AARConnect to network with your fellow section members.
Next Bulletin: Please email Karsten Roberts if you would like to contribute an article. He will be happy to help guide you through the process if you’re a new contributor!