Respiratory Therapist - ADVANCE for Nurses

Transcription

RC011909_ID_cover.indd 1
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SHOW US YOU'RE A ST R!
ENTER THE 7 th ANNUAL
NATIONAL SLEEP
ACHIEVEMENT AWARDS
WIN
CASH
PRIZES!
BEST SLEEP FACILITY
BEST SLEEP MANAGER
BEST SLEEP TECH
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$500 CASH
Winners also receive a keepsake plaque to commemorate their achievements!
Plus, ADVANCEforSleep.com, ADVANCE for Managers of Respiratory Care, and ADVANCE for
Respiratory Care Practitioners will feature the winners in special sections online and in print issues.
If your nominee wins, you’ll receive a $25 gift certificate to the ADVANCE Healthcare Shop.
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ENTRY DEADLINE: MARCH 19, 2009
HOW TO ENTER:
Explain how your sleep tech, manager,
or facility excels by answering these
10 questions:
1. Give examples of your nominee’s
efforts to develop innovative programs.
2. Supply examples of how your
nominee supports team members
and uses the team concept to
accomplish goals.
3. Describe the novel approaches your
nominee takes to improve productivity
and patient outcomes.
4. List awards and recognition received
by your nominee, including
commendations from patients.
5. How does your nominee cope with
the challenges of today’s health care
environment?
6. In what ways does your nominee
implement “gold standards” of care
and new technology, listing the
equipment that your staff finds most
valuable?
7. How does your nominee pursue
continuing education and certification,
learn new technology, and share
knowledge? For the Best Facility
category, what percentage of the
number of sleep techs on your staff
are RPSGTs?
8. How does your nominee improve the
recruitment and retention of staff?
9. Explain how your nominee goes
“above and beyond” to reach out
The following sponsors
wish you luck:
to the community and how the staff
promotes the sleep profession.
10. List any other reasons that support
why your nominee deserves to be
recognized.
DETAILS:
Winners will be chosen by a team of
independent judges who are knowledgeable about the unique demands of this
highly specialized field. Nominees will
be judged solely on how well they meet
these criteria—not on the writing ability
of the person who submits the entry. Top
submissions typically include at least a
few paragraphs for each question with
multiple examples to illustrate each point.
Winners will be announced in June 2009.
ENTRY FORM:
All parts must be completed and returned on time with your answers in order to be
eligible for the competition.
NOMINATION CATEGORY: (Check One)
___ Best Sleep Facility
___ Best Sleep Manager
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YOUR NOMINEE:
Name & Credentials: _______________________________________________________
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Facility: ________________________________________________________________
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Work Phone Number: ______________________________________________________
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THREE WAYS TO ENTER:
1. Click on the National Sleep
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submit your nomination online.
2. Mail your completed entry to: Mike
Bederka, Managing Editor, National
Sleep Achievement Awards, 2900 Horizon
Drive, King of Prussia, PA 19406.
3. Fax your nomination to 610-275-8562,
Attention: Mike Bederka.
QUESTIONS?
Contact Mike Bederka at 610-278-1400,
ext. 1128, or mbederka@advanceweb.com.
NOMINATION SUBMITTED BY:
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Number of People at Your Facility: ____________
VOL. 22 | NO. 2 | JANUARY 19, 2009
contents
ADVANCE FOR RESPIRATORY CARE PRACTITIONERS®
COVER STORY
14 Working the Bugs Out
No fewer than 147 clinical trials
are now under way to evaluate
the management of sepsis. However, a Holy Grail cure still eludes
clinicians. (Cover by Jay Wiley/
ADVANCE thanks Amy Callahan,
CRNP, Monvasi Pachinburavan, MD,
Michael Baram, MD, and Thomas
Jefferson University Hospital,
Philadelphia)
advance
for Respiratory Care Practitioners®
is published by Merion Publications, Inc.
Publishers of leading healthcare magazines since 1985
PUBLISHER
Ann Wiest Kielinski
GENERAL MANAGER
W.M. “Woody” Kielinski
EDITORIAL
Editor-Vern Enge
Managing Editor-Mike Bederka
Senior Associate Editor-Michael Gibbons
Associate Editor & Web Editor-Shawn Proctor
Medical Consultant-George G. Burton, MD
Field Correspondents-Margaret Clark, RRT;
Michael Donnellan, MBA, RRT-NPS; Mark Willis, MJ, RRT
Columnists-A.L. DeWitt, JD, BS, RRT; Michael Hahn, RRT;
Larry McGrath, RRT, RPFT; Bonnie Robertson, CRT, RPSGT;
Vernon Pertelle, MBA, RRT
ART & PRODUCTION
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Letters to the Editor
ADVANCE Job Fair Guide
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Speaking My Mind
Legally Speaking
Best in Sleep Entry Form
Education Opportunities
Manufacturer Spotlight
Classified Employment
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Barely Breathing
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ADVANCE for Respiratory Care Practitioners®
(ISSN 1074-2301) is published bi-weekly on alternate Mondays by Merion Publications, Inc., 2900 Horizon Drive, Box 61556, King of Prussia, PA 19406-0956.
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Contents are not to be reproduced or reprinted without permission of publisher.
©2009 Merion Publications, Inc.–a leader in Allied Health Care newsmagazine
publishing since 1985.
Improving CPAP Adherence
Chronic Cough
EVENTS
Public Relations Director-Maria Senior
Job Fair Manager-Laura Smith
ADMINISTRATION
Vice President, Director of Human Resources-Jaci Nicely
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• 2009 Conference Calendar
• Update on SIDS Research
• Sleep Scoring in Infants.
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www.advanceweb.com/rcp ❘ January 19, 2009 ❘ ADVANCE for Respiratory Care Practitioners 3
LETTERS TO THE EDITOR
Aimee Staggenborg, MA, RRT, mentioned a few common items that can serve
as avenues for transport of methicillinresistant Staphylococcus aureus but left out
one important vector: the computer keyboard (“A Nasty Bug,” Dec. 8 issue).
The electronic medical record is ubiquitous, but we fail to consider the keyboard
or PDA as a source of MRSA, despite the
fact that we tap on our keyboards hundreds of times each day.
In the pulmonary function lab at Nemours Children’s Clinic in Orlando, we use
a silicon-based flexible “indestructible
keyboard.”
This flat keyboard is completely washable with no place for MRSA to hide
between the keys.
These keyboards are durable and inexpensive and can be cleaned with disposable wipes over and over again with no
harm to the keys.
CLEARING THE RECORD
The photo that accompanied
“Tempting But Unproven” (Jan. 5
issue) did not accurately depict noninvasive ventilation.
Some experts even have recommended
the keyboards in health care facilities be
disinfected after each use.
I would suggest other labs consider a
flat keyboard as part of their infection
control prevention protocol.
—Bruce Brown, MS, RRT, AE-C
Pulmonary Function Laboratory
Nemours Children’s Clinic
Orlando, Fla.
New Name Suggested
For Therapists
I have coined a term that I am hoping
will catch on. I contend that we, as respiratory therapists who are familiar with
mechanical ventilation, are “artificial life
support specialists.”
The title conveys our specialized expertise and knowledge and the critical lifemaintaining role that we play.
This strong job title would increase
our respectability among society and
other medical personnel who notoriously
undervalue us.
People often say “wow” and get wideeyed when I say artificial life support
specialist versus RT. The latter job title
doesn’t usually conjure up much or convey truthfully what we really do.
—J. Ethan McDermith, BSRC
San Antonio
EXCLUSIVE WEB FEATURES
Room to Grow
Transitioning CF patients from
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Test your smarts with our crossword
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respiratory therapists.
4 ADVANCE for Respiratory Care Practitioners ❘ January 19, 2009 ❘ www.advanceweb.com/rcp
JAMES D. NORTHEY PHOTOGRAPHY
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Letters are subject to editing for
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Send comments to Mike Bederka,
managing editor, at mbederka@advance
web.com. We look forward to hearing
from you!
Cryptogram
By Dave Kissin, BS, RRT
Clue: S = I
NFP LXNSBSRSLO LSXCLI
CSNF NFP MOZCSAM
PAW SE LA P.N. NGYP.
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By Bonnie Robertson, AAHM, CRT, RPSGT
SLEEP
Sleep Can Help Us Achieve Our Resolutions
minor accidents and depression,“ researchers concluded.2
3. Exercise improves sleep in patients with insomnia. Also, good
sleep habits contribute to better athletic performance, and routine
exercise leads to better results when accompanied by adequate
quantity and quality of sleep, according to a recent study.3
4. Alcohol may help initiate sleep, but it certainly causes disruptive sleep during the sleep cycle.4 As the alcohol metabolizes, sleep
lightens and multiple awakenings occur. People with sleep problems should reduce the number of alcoholic beverages they drink.
5. The successful adherence to the above resolutions will result
in better sleep. But the most important element gained from good
sleep habits is good health itself. Our immune system is strongest
during sleep.5 Loss of sleep and poor quality sleep result in a reduction of our body’s ability to fight infection. ■
AS 2009 STEAMS ahead, many of us have made
resolutions to improve our physical and emotional
health in the new year. Did any of you make it a
goal to sleep more or to sleep better? Probably not.
People still take sleep for granted.
Sleep should be at the top of your new year’s
list. But as always, the popular resolutions remain
the same: eat better, lose weight, quit smoking, exercise more and
drink less.
These resolutions are commendable, and improving your sleep
behaviors can help you accomplish them as well.
Five Links to Sleep
1. Research shows a correlation between sleep and our metabolic
function. An adequate sleep pattern is fundamental for the nutritional balance of the body, and individuals who sleep less have a
higher probability of becoming obese.1
2. Nicotine addiction negatively impacts sleep. “Cigarette smokers were significantly more likely than nonsmokers to report problems going to sleep, problems staying asleep, daytime sleepiness,
Bonnie Robertson is the president of Robertson Sleep Medicine Consulting
LLC in Indianapolis.
For references, visit www.advanceweb.com/rcp and click on the “magazine”
tab.
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SPEAKING MY MIND
By Vern Enge
It’s Time to Apply Logic
To Our Belief Systems
WE ALL chuckle at wall
plaques bearing legends
like, “More than 90 percent of drivers believe
they are above average in
ability.” However, logic
should dictate only 50
percent can achieve the higher category.
And judging from the drivers I encounter,
I would say more than 90 percent possess a
driving ability far, far below any standard
of mediocrity.
In a similar vein, it has been years since
I met anyone who didn’t profess to be
above average in intelligence. If you were
to judge your department, you would
probably find only one person who might
even remotely fit into the intelligencechallenged category. We all know that
individual.
Let’s face some facts. We all have biases
and we’re always right; the opposition, 100
percent wrong. We know, for example, those
with Viking blood in their veins are far
superior to Johnny-come-lately Spaniards
who claim to have discovered America.
Sorry. They were about 500 years too late.
In broad terms, nearly everyone can spot
logic fallacies. Unfortunately, most people
forget to apply logic when their own beliefs
are concerned, especially when engaged in
disagreements about politics and religion.
We were bombarded intellectually during the presidential election. Conservatives blamed the nation’s woes on left-wing
media liberals, and far-left groups blasted
right-wing types as stodgy, uninformed,
unenlightened and prejudiced.
We can argue religion and politics until
we’re blue in the face, but we must remember
we’re dealing with issues of faith, not fact.
We can summon all types of scientific studies, philosophical tracts and anecdotal evidence to support our views, but the bottom
line still remains we’re building our governing principles on plain and simple biases.
It would be helpful if we could readily
discern between beliefs and facts. Sadly, I
don’t believe this is possible. Instead, we
plow ahead in our belief we’re above average thinkers and superior drivers.
In health care, we conclude our leaders
are involved in objective science. In reality,
their findings are as likely to be based on
faulty logic and skewed data as not.
Too many accept scientific findings as
truths rather than opinions and don’t bother
to question the logic behind them because
the answers already fall into their realm of
beliefs. On the surface, we may accept findings that black males, for example, are more
likely to succumb to asthma, heart disease,
liver failure and stroke than their white
counterparts because they lack insurance or
live in less affluent neighborhoods. Aren’t
such questions based on a biased premise
there are racial disparities at work?
If you ask health questions based on
biased assumptions, you will assemble data
that will prove there are indeed racial and
economic imbalances at work. We can fall
into the same fallacies if we compare males
to females in areas like earnings and job
opportunities. Not everything is equal.
It’s time we evaluate our beliefs and apply
logic to situations confronting us. We all
need to question everything before accepting conclusions. We’re so used to relying on
generalizations that we fail to realize we
have even formed them. As a result, we cling
to notions like all minorities and women are
part of disadvantaged social groups.
In that context, consider white males are
really an unrecognized minority group in
the U.S. They’re vastly outnumbered by a
combination of women and minorities and
account for probably less than 25 percent of
the entire population. As such, they can’t be
blamed for everything.
It’s time to watch out for flawed arguments, folks. ■
Vern Enge, editor, can be reached at venge@
advanceweb.com.
EDITORIAL BOARD
David Kissin, BS, RRT, CPFT
Staff Therapist
Maine Medical Center
Portland, Maine
George W. Lantz, BS, RRT,
CPFT, FAARC
Clinical Manager of
Cardiopulmonary
Services and Hyperbaric Medicine
Doctors Hospital
Augusta, Ga.
Thomas A. Madrin, BS, RRT
Director of Respiratory Care Services
Medical Center of Central Georgia
Macon, Ga.
William J. Niedert, BS, RRT, RCP
Senior RCP
SNF-Ventilator Care Service
Harmony House Care Center
Waterloo, Iowa
Alphonso Quinones, MA,
RRT, RPFT, CCT
Director of Respiratory Therapy
Asst. Director of Central
Therapeutics
North Shore University Hospital
Brooklyn, N.Y.
Tim Sharkey, BS, RRT, RPFT, RPSGT
Clinical Consultant
Mallinckrodt Corp.
Norfolk, Va.
Helen Sorenson, MA, RRT, FAARC
Assistant Professor
Department of Respiratory Care
University of Texas
Health Sciences Center at
San Antonio
John M. Weis, NHA, RRT
Health System Consultant
Siemens Medical Systems
Malvern, Pa.
Kathy Yandle, BA, RRT, CPFT
Hospital Services Coordinator
Gift of Life Donor Program
Philadelphia
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MEMBER OF THE GETINGE GROUP
LEGALLY SPEAKING
By A.L. DeWitt, JD, RRT, FAARC
Approach Any Subpoena with Extra Care
TO JOHN ROE: “You are commanded to give deposi- his correspondence with lawyers. The simple act of writing the lettion testimony in the matter of Doe v. Doe and to bring ter has the effect of stopping the subpoena.
with you the following documents: The medical record
In health care, it is common for attorneys to serve subpoenas for
of John Doe and any letters received from your attor- health care records. Often, subpoenas of this nature will be accomneys in this case.”
panied by a signed release that complies with HIPAA. If not, howSubpoenas are scary things. They direct you to ever, both HIPAA and common law place a duty on the provider to
appear or to produce documents. They usually resist enforcement.
come via either a process server or a law enforcement officer. If you
Normally, the issue arises like the following:
receive such a document, it is fair to assume you have information
Mr. Smith and Mr. Jones collide at an intersection and Jones is
someone else wants and that individual has asked a court to direct injured. He sues Smith claiming long-term medical injury. Smith’s
you to provide it.
lawyer wants to see the medical records; Jones’ lawyer refuses to
In most state courts, the subpoena must be served by a sheriff. In provide them.
federal court, the document can be served by anyone over age 18
Smith’s lawyer then sends a subpoena to the hospital, and that
who is not a party to the action.
facility’s lawyer files a “motion to
At first glance, nothing in the
quash.” That motion is heard in
subpoena suggests a person may
front of the judge assigned to the
While every health care provider
do anything other than comcase.
has the right to resist a subpoena,
ply. The document commands; it
In most cases, because Jones has
does not suggest your appearance.
placed
his medical condition at
no one has the right to ignore one.
But HIPAA, among other statissue, the court will issue a court
utes, recognizes a subpoena is a
order compelling the production of
request, not a demand, and that providers have not only the right the records.
to resist a subpoena but sometimes the duty when one party or
Sometimes, however, lawyers attempt to get around patient conanother objects to the production.
fidentiality by serving subpoenas directly on the care provider.
A subpoena is usually not issued by a judge. In most courts, the
Instead of requesting records, they serve a notice to take the
clerk of the court is authorized to issue it and doesn’t apply a lot of deposition of the witness and plan on asking questions that might
thought to it. In fact, it works pretty much like this:
require the provider to reveal patient information.
Lawyer: “I need a subpoena in Doe v. Doe.”
In most states, however, the provider can object or ask the court
Clerk: “OK.”
for a protective order that places certain subjects off limits to
Then the clerk hands the lawyer a subpoena form, the lawyer questions.
fills it out and the clerk signs and seals it. The clerk does not look
If an answer to a question would reveal patient-confidential
at the subpoena to see whether the lawyer is asking for info he can information, the caregiver has both a legal and ethical duty not to
lawfully get. The clerk just issues the subpoena.
disclose it.
In many cases, a subpoena may be issued without notifying all
This is why a health care provider (even one who is not named
the parties on the other side. As a practical matter, smart lawyers as a defendant) must have legal counsel if subpoenaed. If the subprovide notice to all parties; but it is never safe to assume anyone poena relates to work performed at another facility, the care proelse has been notified.
vider should alert that facility and allow its legal counsel to become
What is not readily apparent is a person who gets served with a involved.
subpoena doesn’t necessarily have to appear or do what the subIn most states, willfully disobeying a subpoena can result in a
poena commands. In Missouri, the rules regarding subpoenas contempt of court jail term. Remember, lodging an objection to
state:
producing records is lawful. Not showing up isn’t. So while every
“A non-party … may serve … a written objection to inspection health care provider has the right to resist a subpoena, no one has
and copying of any or all of the designated materials. The objection the right to ignore one.
shall state specific reasons why the subpoena should be quashed
If you are served with a subpoena, your first call should be to
or modified.
an attorney to find out whether you need to comply or resist the
“If a timely and specific objection is made, the party seeking subpoena. ■
discovery shall not be entitled to inspect and copy the materials
except by a court order.”
A.L. DeWitt is a partner in the law firm of Bartimus, Frickleton, RobertIn the example above, Mr. Roe could simply send a letter to the son and Gorny, Jefferson City, Mo. This column is not a substitute for the
lawyer who served the subpoena saying he objected to producing advice of qualified legal counsel.
10
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help patients gain insight of their own needs, some of which they
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In the Details
Consider Comfort and Compliance
When Setting Up CPAP
By Aimee Staggenborg, MA, RRT
T
reating sleep-disordered breathing is among the core
duties of respiratory therapists and a primary task of sleep
techs. Most often, the disorder is treated by continuous
positive airway pressure (CPAP).
This therapy, however, cannot follow a one-size-fits-all approach.
Every patient should undergo an initial basic needs assessment to
gain the best possible outcome and compliance with CPAP.
Clinicians must consider numerous variables when beginning
treatment, including physical comfort, logistical considerations and
emotional roadblocks.
Always remember each person has unique needs. Consequently,
a thorough pre-interview is a crucial first step for developing a
good working relationship between the patient and health care
provider.
During this pre-interview, the caregiver should ask questions
about anything and everything that will help in the needs assessment. These interviews don’t strictly benefit clinicians. Rather, they
Limiting Factors
Muscle and skeletal contortion also may limit the use of some
masks, and these physiological attributes may additionally cause
positional leaking in the mask.
If the patient is a mouth breather, that is if a dry mouth is present,
then sleep experts should recommend a full face mask or use a chin
strap to help alleviate leak complaints.
In addition, facial hair at contact points can cause leaks at the
mask interface.
Pressure levels greater than 15 cm H2O also contribute to problems with seal leaks. To counteract that issue, caregivers should
carefully select a mask with a rigid seal. An interface with a flexible
membrane, aka a dual wall seal, will help control leaks.
Clinicians should examine other comfort considerations beyond
the patient’s preferred sleeping position. Individuals with poor arm
mobility or limited dexterity in their fingers should be given an
interface that’s simple to put on and take off. Also, the caregiver
should include family members in equipment orientation sessions
because they may be the caretaker in charge at home.
Keep in mind the physical structure of a patient’s face may limit
the use of some interfaces (for example, very small, wide, narrow
or large noses). Similarly, patients with high foreheads or very long
faces can be difficult to properly fit.
Because most interfaces aren’t custom-made, the caregiver
should select the best option for the patient, considering these
limitations.
SHAWN PROCTOR
Initial Assessments
Logistical considerations include mask selection. Poorly fitted
masks can lead to problems and non-compliance. Also in this
category are breathing problems. Patients with recurrent sinus
infections, for example, should discuss that tendency with their
physicians prior to starting therapy. This is important because
CPAP can lead to increased sinus pressure.
Any sinus infections should be treated effectively and quickly to
keep patients motivated and comfortable during treatment.
Nasal/septal deviations may prevent a patient from using a nasal
or direct nasal mask. This subset of individuals may need to be fitted with a full face mask.
Examine sleep positions in the assessment phase as well; some
positions may prevent the use of certain masks. Therapists and
sleep techs need this information so they can best determine the
type of mask that will work the best from purely a logistical standpoint.
Patients who sleep on their back with a slightly elevated head
position are the ideal candidates for benefitting from CPAP. However, this sleep position isn’t comfortable for all people, and trying
to change their normal positions will doom therapy compliance
almost from the start.
OSA TREATMENT
Tailor-made Plans
From the offset of treatment, caregivers should determine the
most sensible plan of action for the patient and then work to keep
it simple. A person’s preference always should play a role when
addressing the initial comfort fitting.
By selecting the right mask the first time, the caregiver can do a
lot to promote long-term compliance and confidence and ultimately
help keep costs down.
A thorough pre-interview is a crucial
first step for developing a good working
relationship between the patient and
health care provider.
Sensations of overwhelming pressure or oxygen flow may interfere
with compliance. Caregivers need to detect and tackle this problem
carefully because pressures cannot be changed without a physician’s
order. On the other hand, caregivers can make some comfort adjustments on the machine to make the patient feel better.
People who cannot tolerate high pressures delivered by CPAP
might benefit by being switched to an auto-adjusting or bi-level
device. Again, remember any change in the therapy-delivering
mechanism requires a physician’s order.
From the onset, caregivers must stress that patients need to commit to optimal usage if they’re to gain the maximum benefits.
They also need to emphasize it’s important for the patient to communicate with all pertinent care providers if problems arise after
initial set-up.
It’s helpful for caregivers to think outside the box too. Those
working with apprehensive patients or those having difficulty
adjusting to the mask might consider using a gradual time-increase
strategy. For example, have the patient practice wearing the mask
for 15 minutes three times a day.
This should continue for about a week; and at the end of the trial
run, the patient should try wearing the mask to sleep for one or
two hours. After two weeks, the goal would be for the patient to
increase the use to a full night.
Be flexible on this trial. The time elements initially may need to
be adapted to fit each patient’s needs and limitations.
Mental and emotional roadblocks, of course, present special considerations and concerns as well. Caregivers should encourage their
patients to conduct their own research into specific interfaces and
take responsibility for their own care. Encouragement, reassurance
and pep talks may help to promote usage.
Sleep may be inhibited if the patient has any anxiety, depression
or other mental disorders; but don’t try to make any assessments
about root causes of the anxiety or mental disorders. Your job is to
treat the patients to the best of your ability and refer them again to
their sleep doctors if all interventions and efforts fail. ■
Aimee Staggenborg is a Missouri practitioner and freelance writer.
January 19, 2009 ❘ ADVANCE for Respiratory Care Practitioners 13
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COVER STORY
Working the Bugs
Can Clinicians
Conquer Sepsis?
By Michael Gibbons
14
JAY WILEY
Amy Callahan, CRNP, left, Monvasi
Pachinburavan, MD, and Michael
Baram, MD, discuss sepsis control
protocols at Thomas Jefferson
University Hospital in Philadelphia.
COVER STORY
N
Antibiotic Selection
To manage sepsis, Baram and his colleagues use various algorithms to select the correct antibiotic. “Patients in the bone marrow
unit get a certain antibiotic regimen; folks with community-acquired
pneumonia get another one,” he said. “We’ve standardized it.”
These algorithms and a tracking system to reduce errors are the
result of a multidisciplinary collaboration among pharmacy, the ID,
the ED, and pulmonary and critical care.
When antibiotics are ordered, patients are “pan cultured” to help
identify the source of infection. Also, mini-bronchoalveolar lavages
identify infection type and help to “customize antibiotic use to prevent antibiotic resistance,” Baram said.
For infection accompanied by low blood pressure, Baram and
his colleagues practice aggressive fluid resuscitation, source control (removing an infected catheter, draining abscesses, surgically
removing infected tissue, etc.), GI prophylaxis, DVT prophylaxis
(boots and/or a heparin-type agent), and the standard vent bundle
that includes elevating the patient’s head 30 degrees.
As a further therapy, “we assess their need for recombinant
human activated protein C, a component of our coagulation
cascade,” Baram said. “Those with severe ARDS and unbridled
inflammation can develop micro-vascular blood clots. Activated
protein C can prevent clotting so patients don’t suffer clot-induced
organ damage.”
Enriched Enteral Feeds
Meanwhile, the National Institutes of Health-backed research
initiative known as the ARDS Clinical Network (ARDSnet) has
launched two major sepsis studies, Neil MacIntyre, MD, told
CHEST 2008 delegates.
In a cost-saving coup, both studies will occur simultaneously
and test the same cohort of 1,200 mechanically ventilated patients.
So long as the two investigations don’t impinge on each other, the
same patients can be recruited for both, explained MacIntyre, medical director of respiratory care services, the pulmonary function
lab and the pulmonary rehabilitation program at Duke University
Medical Center, Durham, N.C.
In one study, ARDSnet researchers will assess the value of bolstering the enteral feeds of those patients with omega-3 fatty acids
versus omega-6 fatty acids. ARDSnet investigators hope to build on
the results of a 2006 Brazilian study that found a mortality benefit
to immuno-nutrition in patients with sepsis.1
The second study will compare the benefits of early versus late
enteral feeding in mechanical ventilation. “Some clinicians believe
early feeding is advantageous by reducing the risk of aspiration, but
this is controversial,” MacIntyre said.
Updated Guidelines
Last year saw the release of the Surviving Sepsis Campaign,
updated international guidelines for managing severe sepsis and
septic shock.2
A panel of experts reviewed the body of evidence-based
▼
o fewer than 147 clinical trials registered on Clinicaltrials.
gov are now under way to evaluate the management of
sepsis, the pathogenic poisoning of blood and tissues
that threatens the lives of critically ill patients.
While this impressive body of literature is arming humans with
many weapons to fight the bugs that infiltrate the intensive care
unit, a Holy Grail cure for sepsis continues to elude clinicians.
“There are still more questions than definitive answers,” Robert Balk, MD, told clinicians at
CHEST 2008 in Philadelphia in Thomas Jefferson clinicians
October. Follow existing guide- customize antibiotic use to
lines and recommendations but individual patients.
be alert for modifications based
on age, gender, co-morbidities and other variables, advised Balk,
director of pulmonology and critical care medicine at Rush University Medical Center, Chicago.
Preventing sepsis whenever possible and minimizing its effects
when it strikes are also in the financial interests of hospitals: Insurers are growing increasingly reluctant to reimburse for extended
ICU stays resulting from hospital-acquired infections.
At Thomas Jefferson University Hospital, Philadelphia, patients
on mechanical ventilation automatically generate a sepsis-prevention order set. That includes oral hygiene with chlorhexidine to
minimize oral bacteria, explained Michael Baram, MD, attending
intensivist.
Other automatic orders include daily sedation “holidays” to
reduce the risk of over-sedation and expedite weaning. “We also
have a once-a-day automatic spontaneous breathing trial for vent
patients unless they are very hypoxic or paralyzed,” he said.
COVER STORY
literature and strongly agreed on several courses of action: early
goal-directed resuscitation during the first six hours after recognition, blood cultures before antibiotic therapy, prompt imaging studies to confirm potential sources of infection, and broad-spectrum
antibiotic therapy within one hour of diagnosis.
However, questions linger. For example, is low-dose vasopressin
preferable in septic shock? In one study, researchers found lowdose vasopressin did not reduce mortality rates compared with
norepinephrine among patients with septic shock treated with catecholamine vasopressors.3
And a 2007 study found no difference in efficacy and safety
between epinephrine alone versus norepinephrine plus dobutamine to manage septic shock. This study did, however, find higher
early lactate levels in the epinephrine patients “suggesting either
increased formation of lactate or decreased clearance of lactate, or
some combination of the two, in patients treated with epinephrine
compared to those treated with norepinephrine,” Balk added in a
follow-up interview.
Another question concerns glucose. Both the American Diabetes
Association and the Surviving Sepsis Campaign recommend tight
glucose control in the critically ill. But a 2008 analysis concluded
tight glucose control not only doesn’t reduce mortality but can
increase the risk of hypoglycemia.4 “With hypoglycemia, you run
the risk of brain damage,” Balk said.
The war against sepsis continues, and sepsis guidelines, while
impressive, “are not written in stone,” Balk concluded. ■
References
1. Pontes-Arruda A, Aragao A, Albuquerque J. Effects of enteral
feeding with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants in mechanically ventilated patients with severe sepsis and
septic shock. Crit Care Med. (2006; 34, 9: 2325-33).
2. Dellinger P, Levy M, Carlet J, et al. Surviving Sepsis Campaign:
international guidelines for management of severe sepsis and septic
shock: 2008. Crit Care Med. (2008; 36, 1: 296-327).
3. Russell J, Walley K, Singer J, et al. Vasopressin versus norepinephrine infusion in patients with septic shock. N Engl J Med. (2008;
358, 9: 877-87).
4. Wiener R, Wiener D, Larson R. Benefits and risks of tight glucose control in critically ill adults: a meta-analysis. JAMA. (2008;
300, 8: 933-44).
Michael Gibbons, senior associate editor, can be reached at mgibbons@
advancweb.com.
Too Much of a Good Thing
ICU patients face another danger besides sepsis: inadvertent injury from the very machines that help them
breathe.
Fragile lungs are vulnerable to ventilator-induced lung
injury (VILI) from too much tidal volume during mechanical ventilation (MV), particularly the upper regions of the
lungs considered by pulmonologists the “zone of overdistension,” said Neil MacIntyre, MD.
Several trials are now assessing the value of several lung
protective strategies in MV, he said—with mixed results.
One recent study found no mortality benefit for higher
positive end-expiratory pressure (PEEP) settings, MacIntyre noted. While higher PEEP recruits more closed alveolar units, it also, unfortunately, increases plateau pressures
and “the two cancel each other out for no net benefit,”
he said.
High-frequency ventilation (HFV), a lung-protective
mode MacIntyre characterized as “CPAP with a wiggle,”
while interesting in theory, is “in desperate need of more
clinical trials,” he said.
Some experts think jet pulses can help clear secretions in
the lungs, MacIntyre said, but to date, only one study has
compared HFV to conventional MV and the results were
not significant.1
However, two new studies are under way to compare
jet ventilation and lung-protective conventional MV.
Meanwhile, airway pressure release ventilation (APRV),
a pressure-targeted mode in which the patient activates
the breaths, is showing promise as a lung protective
mode.
16
APRV has a longer inspiratory time and a shorter expiratory time to improve recruitment without adding more
PEEP or tidal volume, MacIntyre said.
APRV “is our salvage mode” when patients fail on assist
control mode, said Michael Baram, MD. “(With APRV), we
are able to dramatically reduce dead space and reduce
minute ventilation to improve oxygenation.”
Up to now, APRV has not shown it can improve patient
outcomes, though the mode “is something in need of looking at more closely,” MacIntyre judged. Researchers from
Johns Hopkins in Baltimore are planning to do just that.
In a trial scheduled for completion by July 2010, they
will determine whether APRV can reduce agitation and
delirium, reduce the requirements for sedative medications and lower the risk of VILI.
They plan to randomize 40 patients with acute lung
injury to APRV or conventional MV for 24 hours. Then
they’ll switch the patients to the opposite ventilator mode
for another 24 hours. At the end of each 24-hour period,
they will measure the amounts of sedatives each group
of patients needed, plus measure the concentrations of
cytokines and other markers of inflammation in the blood
and lung. Those markers are indicators of VILI. ■
Reference
1. Stephen D, Sangeeta M, Thomas S, et al. High-frequency oscillatory ventilation for acute respiratory distress
syndrome in adults: a randomized, controlled trial. Am J
Respir Crit Care Med. (2002; 166, 6: 801-8).
—Michael Gibbons
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received by the deadline.
To register, please visit
www.hsc.stonybrook.edu/shtm/rcsleep/
index.cfm or call (631) 444-6654.
EMERGING RESEARCH
No Longer ‘All in Their Heads’
By Shawn Proctor
C
ough expert Alyn Morice, MD,
remembers a time when doctors
simply dismissed patients’ complaints about chronic cough. It
was psychosomatic, they argued.
Some physicians still cling to this obsolete notion.
“At the British Thoracic Society meeting
last year, someone commented that it was
all in their heads,” said Morice, head of cardiovascular and respiratory studies at Castle Hill Hospital in Cottingham, England.
“That kind of ignorance makes me angry.”
No one could blame doctors for hating
chronic cough even more than their patients
do: The condition remains difficult to treat
and greatly misunderstood.
European Respiratory Society (ERS)
guidelines officially define chronic cough
as a persistent cough lasting eight weeks or
more. In the real world, it causes patients
to skip personal activities like the movies
and church. At work, they may feel embarrassed when coughing fits disrupt meetings
or bother peers.
For the 7 percent of the population affected
by the condition, heightened cough reflex
sensitivity can exacerbate their response
to even minor stimuli. In short, persistent
coughing leads to more coughing.
After penning the ERS cough guidelines,
Morice wanted to make the info accessible
and easy for patients to use. His solution,
the Online Cough Clinic (www.coughclinic.org.
uk), gives U.K. residents a 16-question tool
designed to assess the most likely cause of
their cough.
Since January 2006, a total of 9,340 patients
have taken the questionnaire, he reported at
the ERS Congress in October. One in three
reported suffering from chronic cough for
over a year and 13 percent for over five
years.
More than 75 percent of those who replied
20
to the follow-up survey said the recommended treatment helped their condition.
Morice’s team plans to adapt the Online
Cough Clinic for other countries.
“This is like bypassing the ordinary physician and going to see an expert. And it’s
better than traditional diagnoses because
you get my opinion,” he added, laughing.
Find the Cause
Approaches to treating chronic cough
have improved in recent years, thanks to
a growing awareness of the condition in
the medical community. However, diagnosis requires diligence, said Toni Kiljander,
MD, PhD, head of respiratory medicine at
Suomen Terveystalo in Turku, Finland.
“We know now that cough is a symptom
of underlying disease,” he said. “We treat
the cough by focusing on treating the cause.
Examination takes persistence because there
is sometimes more than one cause.”
Every patient who complains of chronic
cough should receive, at minimum, a physical exam, spirometry and chest X-ray, Kiljander said. Depending on the results,
additional investigation could include bronchoscopy, exhaled nitric oxide measurement,
bronchoprovocation challenge and sputum
culture.
The most common causes of chronic
cough are upper airway cough syndrome
(which includes conditions that trigger the
reflex), asthma and gastroesophageal reflux
disease, according to the American College
of Chest Physicians’ guidelines.
Due to differences in the health care systems, true cough specialty clinics are scarce
in the U.S. That means primary care doctors, who often by necessity use an empiric
or educated “guess approach,” act as the
frontline caregivers, said Brendan Canning,
PhD, associate professor of medicine at the
Johns Hopkins Asthma and Allergy Center
in Baltimore.
“They give patients corticosteroids based
on a suspicion of asthma, and if the cough
responds, then great. The diagnosis is
asthma (but without any further diagnostic evidence for asthma). Labeling a patient
asthmatic based on a cough that responded
to corticosteroids is often incorrect,” he
explained. “That being said, I don’t think
treatment in the U.S. is worse. But it does
frequently lack the careful workup characteristic of the clinics run by Morice and
Kiljander in Europe.”
Today, nearly every major pharmaceutical company has antitussive agents under
development, and they may give patients
with chronic cough more treatment options.
Though far from Food and Drug Administration approval, new drugs targeting the
bradykinin B2 and vanilloid 1 receptors offer
the lowest hanging fruit, Canning said.
For a country that spends $2 billion a year
on useless cough syrups, any effective therapy would be welcome, he added. “Studies
have shown that as formulated, the effects
of these syrups are difficult to differentiate
from placebo effects.” ■
Shawn Proctor, associate editor, can be reached at
sproctor@advanceweb.com.
For resources, visit www.advanceweb.com/rcp and
click on the “magazine” tab.
JAY WILEY
New Approaches Needed
For Chronic Cough
SPECIAL ADVERTISING SUPPLEMENT
MANUFACTURER SPOTLIGHT
Ventilators Becoming More Dynamic
By ADVANCE Staff
JAY WILEY
E
very year, caregivers hook up patients ranging from newborns to the elderly to lifesaving ventilators to provide
temporary or permanent breathing support. Unfortunately, vents, even the most sophisticated models, are not
problem-free and can cause lung injuries that are fatal or costly to
correct.
Human errors account for some injuries caused by ventilators,
such as incorrect settings or disconnected alarms. But perhaps the
most common problem is ventilator-associated pneumonia (VAP),
one form of hospital-acquired infection (HAI). Each year, almost 2
million patients contract an HAI in U.S. hospitals, resulting in a loss
of nearly 100,000 lives and $20 billion in health care costs.
Only urinary tract infections are
more common than VAP in hospital settings. And while pneumonia
comprises 15 percent of all HAIs, that
figure jumps to 24 percent in cardiac
care units and to 27 percent in intensive care units. The major risk factor
for hospital-acquired pneumonia is
mechanical ventilation.
Needless to say, quick weaning is
important in the struggle to circumvent VAP.
At the same time, it is vital for
clinicians to decrease the cost of
care while still maintaining quality
health care.
Ventilator manufacturers have
taken the lead in improving the
safety and capabilities of the modern lifesaving machines, and some
vendors have carved out specialty
niches. Bunnell, for example, has crafted a jet vent for infants. “The
vent has only three control settings and this makes it simple to use,”
explained Dave Platt, director of sales and marketing for Bunnell.
Versatility is also important in today’s hospital setting, so vent
builders like Maquet, Draeger Medical and Newport Medical have
crafted models suitable for both invasive and non-invasive care.
Some are designed for potential use beyond hospital walls.
Models like the Savina can be thrust into disaster situations, noted
Marion Varec, senior marketing communications associate for
Draeger.
Ease of use becomes a major concern in every health care setting
where in-services are time-consuming and staff and equipment are
continually changed or upgraded.
It should be no surprise new terminology is a given in the ventilator marketplace. Here are a few examples of terms bandied about
by Michael Haspel, marketing manager for Hamilton Medical Inc.,
for inclusion in the 2009 respiratory therapist lexicon: ventilation
autopilot, lung protective ventilation, human factors training, ventilation cockpit and intelligent ventilation. To this list, Maquet’s Marketing Manager Rich Peres adds his company’s entry: backward
compatibility.
Long gone are the days when therapists reverently uttered only
Bird or Emerson terms in a subdued patient room. By contrast,
modern ventilators need to move freely from the operating room
and ICUs to a helicopter or ambulance for transport duties and then
to a home care setting.
Likewise, they must accommodate the tiniest premature babies
with fragile lungs to morbidly
obese adults where the very
weight of the patient’s chest
makes it difficult for clinicians to
provide sufficient volume.
Today’s ideal ventilator has
to incorporate the needs of the
patient, staff and institution and
be equipped with a variety of
modes to accommodate a long
list of clinical conditions.
At the same time, it should be
quiet, interface seamlessly with
the ventilated person and capable of responding on a breathby-breath basis to ever-changing
oxygen demands.
Optimally, any ventilator
being added to a hospital fleet
of equipment should be not only
small and light but also sturdy
and dependable.
It should be self-contained and designed to inspire confidence in
patients, their family members, nurses, therapists and physicians. It
must be able to withstand spilled liquid, a sudden electrical surge
or an accidental drop.
Don’t forget, the equipment should be budget-friendly in the
initial purchase and maintain that status during routine maintenance and upgrades. The latter is essential to keep equipment from
becoming outdated in the fast-changing world of technology we
inhabit. ■
Resource
1. Closing the Quality Gap: A Critical Analysis of Quality
Improvement Strategies. Agency for Healthcare Research & Quality. Available from: URL: www.ahrq.gov.
Classified Employment Opportunities
Faculty, Connecticut, Massachusetts
ADVANCE
for Respiratory Care
Practitioners
reaches over 45,000 active, qualified
respiratory care practitioners
nationwide every issue.
Classified Employment ads are arranged
geographically by state within each zone
FACULTY
NEW ENGLAND
EDUCATIONAL OPPORTUNITIES
Respiratory
Therapists
• CALIFORNIA •
Make a contribution to the future of your
profession. Enjoy your week-ends off
and feel satisfied your work truly
makes a difference!
San Joaquin Valley College offers an advanced-level Respiratory Therapist program
that leads to an associate of science degree
(A.S. Degree in Respiratory Care Practice).
We are currently seeking an exemplary candidate for the following position:
RT Instructional Faculty
Provide classroom instruction, laboratory
integration, and participate in visitation of
designated clinical sites and bedside clinical
instruction. Job code: BAK/RT
1
2
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Faculty . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Middle Atlantic . . . . . . . . . . . . . . . . . . . . .
Upper South Atlantic . . . . . . . . . . . . . . . .
Lower South Atlantic . . . . . . . . . . . . . . . .
East South Central . . . . . . . . . . . . . . . . . .
East North Central . . . . . . . . . . . . . . . . . .
West North Central . . . . . . . . . . . . . . . . . .
West South Central. . . . . . . . . . . . . . . . . .
Southwest . . . . . . . . . . . . . . . . . . . . . . . .
Mountain . . . . . . . . . . . . . . . . . . . . . . . . .
Pacific. . . . . . . . . . . . . . . . . . . . . . . . . . . .
US Territories . . . . . . . . . . . . . . . . . . . . . .
National . . . . . . . . . . . . . . . . . . . . . . . . . .
International . . . . . . . . . . . . . . . . . . . . . . .
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Erythromycin May
Reduce Exacerbations
Long-term use of erythromycin may
reduce the frequency of exacerbations
in patients with moderate to severe
chronic obstructive pulmonary disease
by as much as 35 percent, according
to a study in December’s American
Journal of Respiratory and Critical Care
Medicine.
DON’T LET YOUR
SUBSCRIPTION EXPIRE.
CALL 800.355.1088
22
Minimum Requirements for Faculty:
RRT credential; 3-5 yrs work exp, AA degree, CPR provider, and CA licensed and/or
eligible for CA RCP license. Bedside clinical instruction affiliated with an accredited
RT program may be substituted for clinical
teaching exp. Strong organizational skills,
verbal-written communications, resultsfocused, exemplary professional and work
ethic, with demonstrated technical competence required.
Apply online: http://jobs.sjvc.edu
Submit resume w/ Job Code:
Jennifer.Cox@sjvc.edu; Fax: (661) 8347407; SJVC, 201 New Stine Rd.,
Bakersfield, CA 93309. Application
questions/help, call Jennifer Cox at
(661) 834-0126 EOE
(Part-time - Weekends Nights)
Looking for a part-time opportunity?
If you’re a Respiratory Therapist, The
Hospital of Central Connecticut’s Bradley
Memorial campus in Southington has just
what you’re looking for.
We are seeking a CT licensed Respiratory
Therapist (CRTT or RRT required). We
offer the Respiratory Care practitioner an
exciting opportunity to expand their skills
in Med/Surg, ICU, and the Emergency
Department. Experience in an acute care
setting required. Work 8-16 hours on
weekend night shift (11 p – 7 a) and
some holidays as needed.
Please apply on-line at www.thocc.org or
send your resume to: The Hospital of
Central Connecticut, Bradley Memorial
Campus, Human Resources Dept., 81
Meriden Ave., Southington, CT 06489 or
fax to (860) 276-5058. Equal Opportunity
Employer. M/F/D/V.
at
FEEL EMPOWERED TO
MAKE A DIFFERENCE
If you love Respiratory Therapy, you’ll
love practicing at Spaulding Rehab
REGISTERED RESPIRATORY THERAPISTS
• Night shift (7pm-7:30am) full time 36 hour
Part time 24 hour
• W/E, Night shift (either every or alternate W/E’s)
Premium Night & W/E Differential
RESPONSIBILITIES INCLUDE:
• Drawing & running Arterial Blood Gases
• Ventilator Weaning
• Trach Decanulation Protocol
• Sleep Evaluation
• Member of the Rapid Response Team
Uncompensated Care
Rises in 2007
Interested applicants please apply online at:
U.S. hospitals provided $34 billion in
uncompensated care in 2007, up from
$31.2 billion in 2006, and nearly onethird of U.S. hospitals lost money on
operations in 2007.
Spaulding Rehabilitation
Hospital Network is a member
of Partners HealthCare System
& affiliated with Massachusetts
General Hospital & Harvard
Medical SchoolSpaulding has
been ranked in the U.S. News &
World Report’s “Best Hospitals”
survey since 1995.
www.spauldingrehab.org/careers
Spaulding Rehab is an equal opportunity employer
embracing the strength diveristy brings to the workplace.
S PA U L D I N G
R E H A B I L I TAT I O N
H O S P I T A L
N
E
T
W
O
R
K
FAST • LOW-COST • FLEXIBLE • ADVANCE REPRINTS!
CALL 800-355-5627
ADVANCE for Respiratory Care Practitioners ❘ January 19, 2009
www.advanceweb.com/RCP
Connecticut, Massachusetts, Maine, New York, Pennsylvania
Reaching Out
We’ve all had points in our careers
when we were lost. Needed help.
Wanted guidance.
I was the beneficiary of quite a bit
of this wisdom early in my career. I
was poked and prodded into becoming
the therapist that I am today. Now the
time has come for me to pass along
the guidance and wisdom that I have
acquired.
We have a new grad that just joined
our department. She is an exact version of me. It’s like looking into a mirror reflecting me five years ago when
I was a terrified new grad. Now that
she is in the workforce and without
the benefit of someone to watch over
her, she seriously doubts her choice of
peds, even her choice in career.
Will someone please stand up to
help this poor lost RT?
I will. I was there. That was me all
over, no doubt about it. Everyone else
seemed wiser, so much more knowledgeable. I had to have totally picked
the worst career for me! I felt like I
would never get the experience that I
needed without looking like a complete
moron. …
—Excerpted from the “Peds’ Place”
blog by Stephanie Scarbrough, RRT.
To read more, visit www.advanceweb.
com/rcp and click on the “community"
tab.
$6,000 - $8,500 IN SIGN-ON BONUSES
4PVUIXFTUFSO$5t)VETPO7BMMFZ3FHJPO/:t-POH*TMBOE/:
Imagine a workplace
where your needs
are taken care of and
support is at your
fingertips. It is a reality
with SleepTech.
Contact us for more
information about
openings for experienced
or RPSGT sleep
professionals.
DBSFFST!TMFFQUFDIDPNtXXXTMFFQUFDIDPN
INQUIRE ABOUT ENTRY LEVEL OPPORTUNITIES
For a lifetime of caring
MID COAST HOSPITAL
WE ALL STRIVE FOR
Mid Coast Hospital, located in beautiful mid coast
Maine, has the following positions available:
our personal
best.
★ POLYSOMNOGRAPHY
TECHNOLOGIST
24 hr/wk, nights
★ RESPIRATORY THERAPIST
36 hr/wk, 7p-7a
Respiratory Therapist
Part-time position with benefits, 24 hours
(two 12 hr shifts), 7am-7pm, w/every 3rd
weekend rotation.
This position assesses, plans, organizes and
administers respiratory therapy diagnostic
and therapeutic procedures in accordance
with physicians’ treatment plans and ensures
operation and maintenance of all respiratory
therapy equipment. MA licensure is required.
1 year of previous related experience is preferred.
Please forward your resume to:
Winchester Hospital
Human Resources
41 Highland Avenue
Winchester, MA 01890
fax: (781) 756-2908
online: www.winchesterhospital.org
or call our 24-Hour Jobline: (781) 306-1009
Award winning careers.
Closer than you think.
ORDER ARTICLE
REPRINTS
CALL 800-355-5627
MIDDLE ATLANTIC
RRT/CRT Needed
Per diem day and night shift positions available
• New Grads Welcome • 12-hour Shifts
• Excellent Salary • On-site Parking
Contact: Ana Perez/Director of Respiratory Care
at Fax: 718-681-4820
E-mail: perez@concourserehab.com
1072 Grand Concourse
Bronx, NY 10456
RPSGT, Registry Eligible or exp. PSG Tech
www.winchesterhospital.org
EOE
RENEW YOUR FREE SUBSCRIPTION TO
To apply and for more information:
www.midcoasthealth.com/jobs
Forward your resume to:
Mid Coast Health Services
Human Resources
123 Medical Center Drive • Brunswick, ME 04011
or by fax to: (207) 373-6744
An affiliate of Mid Coast Health Services
An Equal Opportunity Employer
REVIVE YOUR CAREER
FT and PT night positions to staff our clinical
sites in PA, MD and NY. Comp salary and benefits.
Positions currently available in the central PA
area. Dave Brooks, Respitech Medical,Inc.
ph: 866.251.7451 fax: 866.741.8455
davebrk@respitech.com
January 19, 2009 ❘ ADVANCE for Respiratory Care Practitioners
23
Virginia, Maryland, Florida, Illinois, Texas
UPPER SOUTH ATLANTIC
LOWER SOUTH ATLANTIC
Kids believe in miracles.
And so do we.
Experience
Better Ways
with Carilion
Put your RT career on the fast track to
success with an award-winning
healthcare leader headquartered in
Roanoke, Va. Visit www.carilionclinic.com
to learn more about how we reward
our employees from hire to retire by
providing them with a Total Rewards
package including competitive pay,
comprehensive benefits and employee
recognition. EEO/AA
Join All Children’s Hospital in St. Petersburg, Florida,
where making miracles happen is all in a day’s work. We’re
an award-winning tertiary center for pediatric treatment,
teaching, research and advocacy. We’re currently
seeking the following professionals to join our team:
Pediatric Respiratory Therapists
12 hr shifts & Per Diem
Candidates must have Florida licensure and CRTT
with 2 years Critical Care experience or RRT with
1 year Critical Care experience. Pediatric/Neonatal
ICU experience preferred.
Apply Online Today: www.allkids.org
St. Petersburg, Florida
Creating healthy tomorrows... for one child, for All Children.
EOE
EAST NORTH CENTRAL
To end each day with your heart soaring and your face beaming takes
more than skill. It takes passionate caring. Experience it for yourself at
Centegra Health System, where we truly live our values of genuine respect,
passionate caring and a joyful spirit.
w w w. f r a n k l i n s q u a r e . o r g
Respiratory Care Practitioners
Registered or Certified • Night & Registry positions available
One of the largest...
and the best.
Franklin Square Hospital Center is a 357-bed
teaching facility located in Eastern Baltimore
County. We are the third-largest hospital in
Maryland, providing a comprehensive array of
services with top-of-the-line technology.
Currently, we have excellent opportunities to
work with a great staff.
Respiratory Therapists
do you value?
Candidates must be a CRT or currently enrolled, or have completed an
approved school of respiratory therapy; up to 1 year experience preferred.
We provide great career opportunities with exceptional compensation and
benefits, and one of the best workplaces in all of health care.
To learn more and apply, visit: www.centegra.org or call Julie Glombicki
at 815-759-4365.
“Every day, when
I get home, my kids ask,
‘Did you help a lot of people today?’”
EOE M/F/D/V
(Full Time, Day Shift)
Must have completed a Respiratory Therapy
Program. MD license required, as well as CRT
or RRT certification. 1-2 years of experience
preferred, but new grads will be considered.
We offer highly competitive salaries and
benefits, including health, dental and vision
insurance, life insurance, disability coverage,
tuition reimbursement and more.
For more information and to apply, call
Judy Sakalas at 443-777-7232, or visit our
website at:
www.franklinsquare.org
EOE
{ ADVANCE }
NOBODY DOES IT BETTER THAN THE BEST
WWW.ADVANCEWEB.COM
24
What
Due to rapidly increasing volume, we currently have full-time, night &
registry positions available. Primary responsibilities include providing
intensive and general floor therapeutic and diagnostic services; assessing
patients; implementing and evaluating respiratory care plans; and making
recommendations towards optimum treatment selection.
WEST SOUTH CENTRAL
BEAUTIFUL TEXAS HILL COUNTRY
PETERSON REGIONAL MEDICAL CENTER in Kerrville, Texas
is looking for a full-time LEAD RESPIRATORY THERAPIST. Under
the direction of the Supervisor/Director of the Cardiopulmonary
Dept., the Lead Therapist will be responsible for providing optimal
diagnostic and therapeutic cardiopulmonary care on their assigned
shift. Provides leadership, clinical expertise and serves as a role
model for staff. RRT or CRT with at least 4 years of clinical/
diagnostic experience. Lead/Supervisory exp. preferred.
• Competitive Salary
• Tuition and Continuing Education Assistance
• Weekend rotation at premium pay
• Comprehensive Benefit Package
Beautiful community built along the
Guadalupe River just 60 miles north of San Antonio.
Contact: 830 258 7440
www.petersonrmc.com
ADVANCE for Respiratory Care Practitioners is on Facebook!
Visit www.advanceweb.com/rcp and click on the “Find Us on Facebook” link.
What Makes a Good
Clinical Educator?
Let’s see, I remember my clinical
rotations in 1983: “Here’s your buddy
you will be going with, and here is
your assignment list.”
If I had any questions, all I had to
do was ask my buddy. After all, that
is how the hospital staffed half of its
respiratory work force. Now I don’t
think there is anyone out there that
would agree this is how to teach a
therapist, but I do believe to some
degree it still happens. Students
become the floor care jockeys.
Hospitals under the staffing crunch
may be tempted to this type of practice, but students and academic facilities stand firm. Hospital directors, we
are only hurting ourselves. This is our
future respiratory therapist. Don’t use
the students for equipment techs or
send them off as floor staff therapists.
Or even worse, sitting in a blood gas
room or PFT lab reading a magazine
for the day. …
—Excerpted from “The RC Director’s
Chair” blog by Scott E. Leonard,
MBA, RRT. To read more, visit
www.advanceweb.com/rcp and
click on the “community” tab.
NUS
O
B
N
O
N
IG
$5,000 S
Texas
Covenant Health System, the largest health system between Dallas and
Los Angeles, is located in Lubbock, Texas (population 210,000). Covenant
has over 1,300 beds, 5,500 employees and 600 admitting physicians.
Home to Texas Tech University, Lubbock boasts a thriving economy, low cost
of living, and a superior public school system.
Relocation Assistance, Impressive Benefits, 401K
• Certified or Registered Respiratory Therapists
• Areas include SICU, MICU, Level II Trauma Center and Cardiac Care
• Covenant Children’s Hospital respiratory care includes 34 subacute beds, 12 PICU
beds, ECMO, and Pediatric heart program
• First Pediatric Level II Trauma Center in Texas
• Level II NICU
• Countless Continuing Education opportunities, including quarterly skills fairs
and ventilator conference
Please apply online and send resume:
www.covenanthealth.org
Covenant Health System
Attn: HR Recruiting
3615 19th St, Lubbock, TX 79410
Phone: 806-725-4220
Fax: 806-723-7189
At Southwest General, we recognize our employees are
our most valuable asset. Here you’ll find an environment
where your opinions matter and your ideas will make
a difference.
Known as the most enchanting city in the southwest,
San Antonio offers breathtaking landscapes and an
abundance of shopping, dining and recreational activities
including Sea World, Fiesta Texas, and the world famous River Walk.
Respiratory Therapists & Certified Respiratory Therapists - Full-time and Flex positions available for
evening shifts. Registered or eligible for the registry through the National Board of Respiratory Care,
Licensed by the Texas Department of Health as a Respiratory Care Practitioner. Current CPR certification
required with ACLS and NRP required. Previous experience in NICU Transport Team desired.
We offer an exceptional benefits package that includes generous tuition reimbursement program,
continuing education opportunities and relocation assistance.
JOB NOW?
EOE
Visit Our Exciting
Respiratory Forums
NE
CALL THE ADVANCE JOB HOTLINE
AT 800.355.6504 FOR OPENINGS IN
YOUR AREA AND ACROSS THE NATION.
If you’d like to explore this opportunity,
please visit www.swgeneralhospital.com
or call Human Resources at 210-921-3437
ED
NEED A NEW
SUBSCRIBE TODAY!
CALL 800-355-5627
Chat with your peers on myriad topics. Stop by our bustling online network
at www.advanceweb.com/rcp and click
on the “community” tab.
25
Wyoming, California, Nevada
MOUNTAIN
HUMBOLDT GENERAL HOSPITAL
FULL-TIME REGISTERED POLYSOMNOGRAPHER
AND RESPIRATORY THERAPIST POSITIONS AVAILABLE
2100 W. Sunset, Riverton, WY 82501
(307) 857-3465 or Fax (307) 857-3586
Web site: www.riverton-hospital.com
Human Resources E-mail:
norma.atwood@lpnt.net
RESPIRATORY
THERAPIST
Competitive salary DOE; excellent benefits
including Public Employees Retirement System,
group health insurance, accrued PTO and sick
leave, and no state income tax. Discover a
great place to live and work, 74 miles from
Oregon border and three hours from Lake
Tahoe. Modern, rural 52-bed facility in Northern
Nevada. Mail, fax or email resume to:
Lofty mountains, clear lakes, natural beauty = a perfect vacation. In Central WY it’s a way of life! Our
70-bed, acute care facility is located near the Wind River Mountains. Join our healthcare team of over
200 employees who have chosen RMH. We offer Medical, Dental, Vision, Life, AD&D, STD, LTD, EAP,
401(k), PTO, EIB, a competitive salary, a $6,000 professional recruitment bonus, and a great working
environment. EEO Employer
Human Resources
Humboldt General Hospital
118 E. Haskell St., Winnemucca, Nevada 89445
(775) 623-5222 or fax (775) 623-5904
rose@hghospital.ws
EOE
PACIFIC
WWW.ADVANCEWEB.COM
UPLIFT Trial Results
San Joaquin Valley College
http://jobs.sjvc.edu
(See our ad on page 22.)
FIND THOUSANDS OF JOBS ON
www.advanceweb.com
26
Become a fan of ADVANCE for
Respiratory Care Practitioners!
Check us out on Facebook.
Visit www.advanceweb.com/rcp
and click on the “Find Us on Facebook” link.
One of the largest COPD trials ever
undertaken reaffirmed the clinical safety of tiotropium, a commonly prescribed
corticosteroid, according to a study
presented at the European Respiratory
Society Annual Congress in Berlin.
Researchers in the Understanding
Potential Long-term Impacts on
Function with Tiotropium (UPLIFT) trial
enrolled nearly 6,000 patients in 37
countries, who were randomized to
receive the drug or a placebo. In both
arms, patients were allowed to continue with their normally prescribed
respiratory medications, including dose
adjustments throughout the trial, except
inhaled anticholinergics.
Results indicated that the tiotropium
group experienced significantly reduced
risk of exacerbations leading to hospitalizations. Yet, the UPLIFT trial showed
no treatment differences in the rate of
decline of trough or postbronchodilator
FEV1, the primary objective of the study.
“The patients at the end of the trial
are better than they were at the beginning, in terms of quality of life,” said
Marc Decramer, MD, PhD, the study’s
lead author. “You win about four years
by giving the treatment.”
Alaska, National
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Time to Tidy Up
It’s time to look at inventory. Time
to see what works and what doesn’t;
what’s outdated and what’s still OK. It’s
time to wonder why we ordered some
things during the year, laugh at how
our expectations were way too high on
others, and make our wish lists for the
next year. It’s time to rearrange departments to the way they were a year ago
when we straightened them up for the
Joint Commission, or to rearrange them
to a new, more efficient office that will
make use of space.
Clutter in the office is the most
common cause of housekeeping
headaches. Seems obvious, but looking
in some respiratory offices, you would
think no one knew that but me. Each
office has the packrat. Each office has
the chronic food nibbler and drinker.
Fortunately, each office usually has a
person to pick up after the others. …
—Excerpted from the “In My Opinion”
blog by Jim Thacker, CRT, AE-C. To read
more, visit www.advanceweb.com/rcp
and click on the “community” tab.
The Sign of a
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27
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My Night in a Grey's
Anatomy Episode
On a recent episode of Grey’s
Anatomy, one of the residents, Dr. Yang,
found an area of the hospital that was
like heaven to her. When she stumbled
into dermatology to get a cream, Dr.
Yang saw residents getting massages.
She found them pouring water infused
with raspberries. They had time to relax
and get facials. She was so fascinated
she paged her friends to come watch,
in her words, the “freak-fest.”
I laughed the whole thing off, thinking
it wasn’t possible. Not in a hectic
hospital. No way—so I thought. ...
—Excerpted from “Peds' Place” blog
by Stephanie Scarbrough, RRT. To read
more, visit www.advanceweb.com/rcp
and click on the “community” tab.
28
National
BRPT Offers Webcast
On Application Process
The Board of Registered
Polysomnographic Technologists now
offers “For Aspiring RPSGTs: The
Application Process.” The free, ondemand, 30-minute Webcast gives
applicants who want to enhance their
career by becoming a credentialed
sleep technologist the inside track on
eligibility, the application process and
common pitfalls with advice from Becky
Appenzeller, RPSGT, REEGT, CNIM,
BPRT president.
“We want to encourage sleep technologists to apply and to pass the
RPSGT test,” Appenzeller said. “We
hope the Webcast helps take the mystery out of the process and makes it
easier to take the first step.” For more
info, visit www.brpt.org.
29
BARELY BREATHING
By Brent Swager, RRT
Top 10 Reasons to Like Being a Therapist
up much’ reason.”
I was a little relieved when my beeper jolted to life and announced
an impending emergency on the sixth floor. I’ve always been better
doing rather than thinking.
“I like it that you don’t ever get to sit down and eat an entire
meal,” I told Carl as we raced down the hall and through a door to
the stairwell. “You don’t have to worry about getting fat as an RT.”
“Hey, that’s a good point,” Carl panted as he pounded up the
steps behind me, jotting a note as we ran. He studied the page as
we rounded the fourth floor and started in on the stairs to the fifth.
“Only nine more reasons to go.”
Five intense minutes later, I fanned my sweaty scrub top away
from my chest and grinned. “I like saving lives,” I said.
“I think that’s it,” Carl agreed. “The rest is just icing on the
cake.” ■
Brent Swager is a Florida practitioner.
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RC 1/19/09
“HEY, WHAT’S THAT you’re writing?” I asked,
and made a slow grab for Carl’s pad.
“Stop it,” Carl snapped and slapped my hand
away.
“I was reading this book about how to live up to
your potential,” he explained after calming down.
“It said the way to determine if you’re in the right
profession is to sit down and write 10 things you like about your
job. If you can’t, you’re probably in the wrong profession.”
“Well, heck,” I laughed, “I could think of 10 things I don’t like
about this job. That’s easy.”
“Really?” Carl said with genuine surprise.
“Nah, just joking,” I admitted. “I love this job. I bet I can name 10
reasons to love it without even thinking.”
“Do it then,” Carl smiled, flipping a page to record my thoughts.
“I will,” I said, but as soon as the promise left my mouth, all
thought dried up. I did the only thing I could. I stalled.
“I will,” I repeated. “Just let me eat this delicious Chicken Tampico first. Don’t want it to get cold now, do we?”
I chewed the greasy, fried chicken smothered in melted cheese
and topped with ketchup while I thought.
“Here’s one,” I said. “I like the immediacy of this profession. I
like knowing that almost every night I walk through these doors,
I have the opportunity to make a difference in someone’s life. Are
you going to write that one down?”
“Nope,” he said.
“Why not?” I cried. “That was a really good one.”
“I can’t spell ‘immediacy,’” he said.
“OK,” I said, “we’ll find a reason with smaller words.”
“Good,” Carl said and we resumed eating and thinking.
“Oh, I know,” he said. “We make good money.”
“Well, yes,” I tentatively agreed. “It’s good, but not as good as
nurses and doctors.”
“Good but not great,” Carl echoed as he carefully wrote. He peered
at the words. “That’s a good but not a great reason though.”
“Right,” I said as he erased.
“Here’s one,” I said. “We don’t get vomited on much.” I wiped the
front of my scrubs where I clearly recalled a patient had thrown up
on me a few days earlier. “OK, forget that one too.”
“Are you two taking the rest of the day off?” the department
director asked pointedly as he passed by our table.
“You always have someone to keep your ego from getting too
big,” Carl noted.
“While that’s true, I’m not sure it’s something I like about being
an RT,” I countered.
“And by the way,” the director backtracked and stood next to
us, “there’s a new invention you two should discover: It’s called an
iron.” He arched an eyebrow and moved to a faraway table.
“I like the wrinkled look,” I said as Carl furiously erased.
“Darn,” he mumbled. “There goes my ‘You don’t have to dress
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Respiratory Therapist - ADVANCE for Nurses

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