Tabatha Dragonberry, MEd, RRT-NPS, RRT-ACCS, AE-C, CPFT, C-NPT
2016 started out in full swing at the AARC. The Program Committee met in January and went through the various submissions for the 2016 International Respiratory Convention & Exhibition being held Oct. 15-18 in San Antonio, TX. As usual, the committee had to make some tough decisions, as so many interesting topics were submitted by our members. I look forward to seeing the final lineup of lectures.
Nominations are now underway for our 2016 Specialty Practitioner of the Year. If you work with or know a Transport Section member who goes above and beyond for his or her team and patients please consider nominating that person for this prestigious award. This is an opportunity for us to recognize section members for the great work they do.
I would like to thank everyone who is participating on our discussion list on AARConnect. I love seeing our members exchange ideas and experiences to enhance the patient care we provide.
And I especially want to thank Jon Inkrott and Ryan Sura for submitting articles for this month’s Bulletin. If you are interested in submitting an article for our next issue please email me and I’ll help you get started.
Ryan Sura, RRT-NPS, C-NPT, Children’s Hospitals and Clinics of Minnesota, Minneapolis, MN
Respiratory distress syndrome (RDS) is characterized as respiratory insufficiency related to surfactant deficiency and/or inactivation, along with structural immaturity of the lungs. It is commonly seen in 23-34 week gestational age infants, but can occur in all infants.
A commonly overlooked patient population that is affected by RDS is the late-preterm infant. Late-preterm is defined as infants born 34 0/7 weeks to 36 6/7 weeks gestation. This patient population has a morbidity and mortality rate that is three times higher than that seen for term infants.
The incidence of RDS decreases exponentially with increasing gestational age (34 weeks=19.6%, 35 weeks=12.33%, 36 weeks, 6.96%). Other factors that will affect RDS incidence for this patient population include: C-Section delivery, diabetic mother, multiple gestation pregnancy, maternal substance abuse, race, and gender. Late-preterm infants delivered via C-Section have a 44% chance of developing RDS. White, male late-preterm infants have a twofold higher chance of developing RDS.
The best method for treating RDS is to prevent it from occurring. Delaying birth as long as possible without compromising fetal or maternal health improves outcomes. Each additional day that extraction is delayed reduces the likelihood of respiratory morbidity.
Antenatal steroids are given to mothers when preterm birth is expected. These steroids stimulate the sodium channel subunits that are responsible for intra-alveolar liquid resorption and maturation of alveolar surfactant. Literature strongly supports the use of antenatal steroids prior to delivery for infants less than 34 weeks gestation. Only three studies have evaluated the use of antenatal steroids in patients greater than 34 weeks gestational age. In those studies, steroids appeared to reduce the frequency of RDS at an appreciable rate; however, the data were not statistically significant. Therefore, efficacy for utilizing antenatal steroids in that patient population has not been recognized.
Many late-preterm infants are delivered at centers that do not offer neonatal intensive care. As a result, this patient population frequently needs transport to a higher level of care. RDS should be on the minds of all neonatal transport teams when receiving a call to transport a late-preterm infant. Due to their gestational age, these patients are also at higher risk for developing pulmonary hypertension (PH). When transporting an infant with late-preterm RDS, extra care should be taken to avoid acidosis, hypoxia, and hypotension.
Jon Inkrott, RRT-ACCS
Fight Respiratory Therapist, Florida Hospital Orlando, Orlando, FL
When a patient is having a heart attack, time is muscle. And getting the patient to a cath lab that can perform percutaneous coronary intervention (PCI) is paramount to patient survival. When we have one of these patients present to one of our satellite hospitals that does not perform PCI, the flight team is activated and we automatically launch to retrieve the patient and get him to the cath lab at the main hospital campus as fast, and as safely, as we can. This is just one of our stories.
“I don’t feel very good . . .”
In the latter months of 2015, my nurse partner, Joe, and I received a page of a 57-year-old patient at a nearby campus who was having a STEMI. We launched and were at the hospital in six minutes. Upon arrival at the bedside, we learned from the ER nurse that the patient had just been shocked due having gone into v-fib arrest. He recovered to baseline with one shock at 150J. His mentation was alert and oriented to person, place, and time.
As I introduced myself and was explaining to him what we were going to do, he stated, “I don’t feel very good . . . it’s happening . . .” His eyes stared off in one direction and he became unresponsive. The monitor showed v-fib again and no pulse could be palpated!
The pads were already on the patient and I charged the defibrillator to 150J, cleared the patient, and shocked him. This time he did not achieve return of spontaneous circulation (ROSC) and Joe immediately started CPR as I increased the energy level on the defibrillator to 200J.
After approximately two minutes of CPR, the patient was defibrillated at 200J and successfully achieved ROSC. Pulses were present and the patient was alert, pale, and diaphoretic, but answering questions appropriately. Needless to say, an antiarrhythmic drip was initiated.
Looking for the “happy place”
As a team about to put this man in a helicopter, even for a short six-minute flight, we didn’t want to have to worry about an airway while at 800 feet. We concluded we would sedate this gentleman and secure his airway prior to our departure.
After explaining our plan to the patient, who agreed with what we wanted to do, we prepped him for intubation and successfully completed the rapid sequence intubation (RSI). However, before we could get him on to our flight stretcher, he started to arouse and reach for the ETT we just placed. Getting a patient sedated and not tanking their blood pressure, especially one with cardiac compromise, can get a little tricky at times. Too much and you’re chasing the blood pressure. Too little and you’re losing a tube or fighting with a surprisingly strong patient — man or woman, it never matters.
We were able to achieve a “happy place” for this patient and we quickly gathered our equipment, loaded him into the helicopter and transported him without incident to the main campus. We arrived and off loaded our patient as soon as we touched down and expeditiously transported him to our cath lab where a team was awaiting his arrival, including the RRT who was there with a ventilator. We offered a detailed report of the previous events to the RN, RRT, and awaiting cardiologist. Then we left the patient in the capable hands of the cath lab folks and off we went, waiting for the next call.
Why we do what we do
Later that evening, as we do with all our patients, we rounded in the ICU to see how he was and to follow up with his family members. In light of the last time Joe and I had seen him, we expected to find him intubated and on multiple drips. As we walked into the room, there he was sitting upright in bed, his son at his bedside, and he was extubated and smiling.
He recognized us as soon as we walked in and was so very thankful and appreciative of the efforts of all involved. He was the same guy we picked up — alert and oriented to his surroundings, talking about the events of the day! He held his son’s hand while he shook ours, and was just happy to be there, knowing it could have been much different. We extended our gratitude for his and his son’s kind words and we left, smiling at what we just saw because he is why we do what we do — the living proof!
The cath report found a previously placed stent 100% occluded, which was remedied in the cath lab without incident. This all took place not long before Thanksgiving, giving it all the more meaning!
Specialty Practitioner of the Year: Nominations for this annual award are underway now through August 6. Visit the section website to access our online nominations form.
Recruit a new member: Know an AARC member who could benefit from section membership? Direct them to section sign-up. It’s the easiest way to add section membership to their overall membership package.
Next Bulletin Deadline: Fall Issue: September 1.