Transcript Teaching Students How to Stay Up-To

Presented by the Commission on
Accreditation for Respiratory Care
Susan P Pilbeam, MS, RRT, FAARC
St. Augustine, FL

Within the past 12 months I have worked as a
consultant for Maquet, Inc.




Describe faculty and student perspective
on what is important to teach/learn about
mechanical ventilation.
Identify essential concepts that students
need to understand in relation to the
application of mechanical ventilation.
Review relevant behaviors related to
medical care.
Discuss how educators and students
might maintain competency.





www.alumniblog.mayo.edu/people/al
umni-profiles
Dr. Helmholz was born in Indiana in
December, 1911.
Rochester, age 10
His father, Henry F. Helmholz, M.D.,
was asked by Dr. William Mayo to
develop pediatrics at Mayo Clinic.
At Mayo, Dr. Helmholz’s interest in
human physiology began, and he
pursued his medical education.



After medical school, Fred returned to
Rochester
Fellow in Physiology and Pathology for the
Mayo Foundation, in the Physiology Institute.
Dr. Helmholz studied decompression
chambers




Dr. Helmholz put himself into an oxygen
chamber with the equivalent of 40,000 feet in
altitude.
“I promptly passed out and there was much
venting and letting air into the chamber to
resuscitate me.
“I learned that, at 40,000 feet, unless I purposely
hyperventilate or over breathe, I can’t stay
conscious even breathing pure oxygen.
“So I learned something about myself that I could
apply to aviators.”


Then Second World War began
WW II worked at Consolidated Aircraft Corporation
in San Diego. and developed a way for B24 bomber
pilots to safely fly at 35,000 feet



Dr. Helmholz’s most lasting impact -- his
work with respiratory therapists, locally and
nationally.
“I had some friends …who were kind of
interested in getting an organization, the
American Association of Inhalation Therapy,
the AAIT…
“so I worked with them and that’s how my
interest in respiratory care [grew].”
Dr. Helmholz early chairman and
participant in the Joint Review
Commission for Inhalation Therapy
(JRCRTE)
Now the Commission on
Accreditation for Respiratory Care
Appointed to the NBRC and served as
one of its presidents.



He retired in 1978, but continued to remain
active with the CoARC and the NBRC and also
the Sputum Bowl.
He died in 2012.
He was 100 years old.




Responses from schools and hospitals in
Maine, Florida, Louisiana, Texas, Georgia
“As a faculty member who teachings
mechanical ventilation:
“What do you think is most important in
teaching or learning mechanical ventilation?
“And second, what techniques are the best
way to teach mechanical ventilation?









Consensus Items:
Modes of Ventilation (4 of 8)
Graphics (2 of 8)
Lung protective strategies
Troubleshooting
Weaning process and parameters
Learning basic physiology of the lungs such as
compliance and resistance and effects of PPV on
organ systems.
Initial settings for normal and COPD
How to control sensitivity and adjust to patient



Learning how to assess the patients needs in
terms of the goals of mechanical ventilation,
- safety, comfort, and liberation.
Teaching how to identify the technological
capabilities available to meet those needs
Teaching how to match the available
technology to the needs.



Be sure graduate know how to recognize
respiratory distress.
This is key to their function as RTs
Identify the problem before the patient codes.





Patient Safety
Team work
Compassion
Effective
communication
Posting signs


Robert M Kacmarek, Respir. Care, 2013; 58(6)
pg 1087-1092
The RT has to be knowledgeable of the limits
of ventilatory support and competent in
identifying, via waveform analysis, patientventilator asynchrony, since asynchrony has
been associated with patient outcome.


“Flow, volume, and airway pressure
waveforms are valuable real-time tools in
identifying various aspects of patientventilator interaction.”
However, “If you aren’t looking for
something, you surely will not to find it.”
Columbo, et al, CCM 2011, 39:11
Columbo, et al, CCM 2011, 39:11
Columbo, et al, CCM 2011, 39:11
Columbo, et al, CCM 2011, 39:11
Columbo, et al, CCM 2011, 39:11
As a faculty member who teachings mechanical
ventilation, the second question:
What techniques are the best way to teach MV?






Lectures with case studies (3 responses)
Simulations (mannequins) (2 responses)
Regular lab with vents and case studies (3
responses)
Labs with repetition of graphics (1 response)
Inservice from ventilator representative
(1response)
Clinical rotations (1 response)


“I would have to say, however, that I think the
most effective strategy occurs when they
have to breath on the ventilator connected to
a mouth piece with an HME so they
experience the ventilator settings.”
Two faculty mentioned this.



"As you were taking your mechanical
ventilation classes, labs and clinicals,
“…what did you find to be the top 3 most
important things that helped you understand
the application of mechanical ventilation in
the clinical setting?"
(please list in order of importance).

Total of 13 responses
Very limited agreement on what they perceive as
important.

INDIVIDUAL RESPONSES

1. Understanding the concepts of each ventilator settings
2. Comprehension and explanation of wave forms
3. Troubleshooting and ventilator changes
Lecture, Lab, Inservice from vent reps
Boxes, Tables and Cases
(1) Paying attention and TAKING NOTES during
lecture. Including drawing my own scalars
and graphs.
(2) Patients being mechanically ventilated. It is
important to see the application of different
modes and how they correlate with different
pathologies as well as seeing the results in
real time.
(3) Handling several different ventilators in lab
and learning each of their basic modes and
functions.
(1) Visualizing the ventilator graphics in classseeing examples of the scalars on the
different modes was by far and away the best
way for me to truly grasp the principles of the
modes and how they apply to disease
processes.
(2) Use of ventilators on actual patients in the
hospitals.
(3) The textbook and supplemental readingreading, on my own, and having time to
interpret and compare the modes
(1) The way the information linked what was happening
physiologically with the patient and making
appropriate vent changes to compensate.
(2) The hands on exposure (labs) with vents,
mannequins and other equipment was invaluable.
Also being able to physically do certain procedures
on real patients in clinicals was a great confidence
builder.
(3) Trending of pulse oximetry, labs, ABGs, x-rays,
ascultation etc were also helpful in understanding
and following the various stages of a patient's
condition and vent manipulation.








The concepts of transducers and electrical physics
as applied to how a mechanical ventilator works.
Modes that are not presently used in a clinical
setting. (3 responses)
The time spent on learning all the outdated
ventilators which we no longer use, or even see in
the hospital and more time devoted to current
applications. (2 responses)
Working in groups with the ventilators.
The lab activities are confusing and hard to follow.
Every resource provided to me during the course
has been valuable.
Oscillators


Most responded that they felt they were
prepared
I feel comfortable being in the ICU with
another therapist but I am not comfortable
being alone because I tend to panic in certain
situations when the patient appears to be
under distress (like when waking up from
sedation and starting to fight the vent).
by Robert M Kacmarek, Respir. Care, 2013;
58(6) pg 1087-1092



AARC “2015 and Beyond” task force.
Individual RTs must be highly competent in a
number of areas.
They must be experts in mechanical
ventilation





All technical aspects of the mechanical
ventilator
Indications for and pathophysiology requiring
mechanical ventilation
Independent application of mechanical
ventilation
Pharmacology of critical care
Adjuncts to mechanical ventilation
(aerosolized pulmonary vasodilators, prone
positioning, non-conventional forms of
ventilatory support







Modes of mechanical ventilation
Disease specific management approaches
Effects of application on the cardiopulmonary
system
Waveform analysis
Identification and correction of asynchrony
Provision of lung-protective ventilation
The independent management of ventilatory
support by protocols, guidelines, or standard
order sets.





A Technical expert in every aspect of
mechanical ventilation.
Capable of comparing the capabilities of one
ventilator to another.
Discuss mechanism of action of all modes
and adjuncts that exist on the mechanical
ventilator
Monitoring and data trending
“They should be the individual whom all other
professions seek out when questions in this
area arise.” (Kacmarek, 2013 RC)


Limited brain attention span
The human brain can only focus on one thing
at a time
Faculty and Graduates





Educational conferences
Literature
Clinical skills: how up-to-date do you need to
be?
Ventilator manufacturers and their
representatives
How do graduates and practicing therapists
manage?









Recognition that a Respiratory Therapist is a
professional.
Knowing when to get help
Learning to work as a team
Keeping everybody safe
Critically evaluating medical literature
Sharing what they learn
Being compassionate
Communicating effectively
Staying motivated
By Dr. Stephen Sinatra, M.D. Cardiologist
Dr. Jonny Bowden, Ph.D. Nutritionist



True or false – lowering cholesterol reduces
the incidence of heart attack.
True or false – people with cholesterol values
more than 260 mg/dL are more likely to die.
True or false – statins reduce cholesterol
levels.
Triglyceride to HDL ratio
 Example: 150 mg/dL: 50mg/dL = 3
 Harvard publication Circulation
 Those with the highest risk of myocardial
infarction had the highest triglyceride-toHDL ratio.
Gaziano JM, et al Circulation 96, 1997, 2520






Parent molecule for sex hormones
A cholesterol level of 160 mg/dL or less has
been linked to depression, aggression,
cerebral hemorrhage and loss of sex drive
We make vitamin D from cholesterol
Only a problem when it is oxidized
The true cause of heart disease is
inflammation.




There is a better relationship between
sugar consumption and heart disease
than fat consumption and heart disease.
2003 World Health Organization – no
more than 10% of diet from all added
sugars.
Sugar Association annually given $406
million to the WHO.
Threatened to lobby Congress to cut off
the $406 million.



Hypothesis: Cholesterol is a good predictor of
mortality.
From 1995 to 2007
Final 5 studies of 150,000 people total
followed for about 5 years.
(Japan Atherosclerosis and Thrombosis 14, 2007, 5.)

Less than 160 mg/dL
◦ 160 to 199 mg/dL
◦ 200 to 239 mg/dL
◦ Over 240 mg/dL

Current AHA guidelines:
◦ 200 mg/dL or lower desirable
◦ 201 to 239 borderline
◦ Higher than 240 is bad



Those with the lowest cholesterol (<160) had
the highest mortality rate (death from any
cause)
Rate of death decreased in highest two
cholesterol groups. (200-239 & >240 mg/dL)
So, are cholesterol levels just so much hocuspocus?

Learn to be very critical of
medical literature and the
media-hype about
medications.
“It must be true.
I saw it on the internet.”


Lack of teamwork leads to medical errors and
poor patient outcomes. (Dr. Martin Makary,
M.D.)
The key to collaborative function of any
clinician in critical care is effective
communication and teamwork. (Kacmarek
RM, Respir Care 2013; 58:1087.)



2010 Harvard study (NEJM)
As many as 25% of all patients are harmed by
medical mistakes.
Over the past 10 years error rates have not
come down, despite efforts
By Dr. Martin Makary, M.D.
www.ahrq.gov/qual/patientsafetyculture
1. Is the teamwork good?
2. Would you feel comfortable having your own
care performed in the unit in which you work?
3. Do people work well as a coordinated team?
4. Do doctors and nurses do what’s in the best
interest for the patient?
5. Is communication strong?
6. Do you feel comfortable speaking up when
you have a safety concern?






Reduces incidence of errors.
Teamwork survey scores correlated with
infection rates and patient outcomes.
Most hospitals do not want to provide this
information.
Government does not make public access to
survey results possible.
www.hospitalcompare.hhs.gov



“Properly weighed data transparency would
empower patients to make informed
decisions about where they spend their health
care dollar.” (Dr. Makary)
Hospital CEOs and Medical Directors should
reward employees who act on behalf of their
patient-safety concerns.
“At your hospital, is priority given to what’s
best for the patient..” and not for what is
financially best for the hospital?




Humans make mistakes
Less of a punishment culture?
What are possible ways to reduce errors?
What part of this should we teach?




“Motivation just like lack of motivation
spreads like wildfire.”
Can you teach someone to be motivated….
That would be
“No”

If we don’t change the direction we are
headed, we will end up where we are going.