UNDERSTANDING THE BASICS OF ICU/CCU CARE VOLUME 2

A Standardized Shift Handover Protocol: Improving Nurses’ Safe Practice in Intensive Care Units
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Attempts to treat the lung gently during ARDS by undertaking extracorporeal gas exchange proved ill-fated, as the patients rescued with extracorporeal membrane oxygenation were very severely affected and late in their disease course. Materials and techniques of the time inflicted unacceptable injury [ 10 ]. Treatment of ARDS was one central driver of new approaches to respiratory failure, but clearly not the only one.

How to provide partial support, recondition the respiratory muscles, and gauge readiness of the patient to assume the entire ventilatory workload were also pre-occupying concerns of the day [ 11 , 12 ]. As adult clinicians gained more experience in managing such challenging problems, the need to address them efficiently drove the incorporation of better monitoring as well as the radically new modes of assistance such as synchronised intermittent mandatory ventilation and PEEP without assisted breathing [ 13 , 14 ].

Over a relatively brief period of time, microprocessor controls and electronic waveform displays of pressure and flow became embedded into the machines themselves, enabling discoveries related to work of breathing, synchrony, and the effects of adjustments in frequency, PEEP, peak flow, and triggering paradigm on effort and dynamic hyperinflation [ 15 , 16 ]. The importance of improved monitoring and mode flexibility became evident throughout the s and s, as laboratory and clinical investigations revealed the full potential for the ventilator to cause both obvious and hidden forms of lethal injury [ 17 , 18 ].

Awareness of the key roles of maximum transalveolar pressure and high tidal volume led to the approach of accepting higher partial pressure of carbon dioxide permissive hypercapnia as a necessary consequence of using smaller and safer tidal volumes to support, first, intubated asthmatics [ 19 ] and later those with ARDS [ 20 ]. High-frequency jet ventilation and high-frequency oscillation were developed and tested as strategies for limiting the lung-damaging potential of maximum tidal pressure while recruiting the unstable lung units of infants with infant respiratory distress syndrome.

Although jet ventilators were available early on, adult use of high-frequency oscillation awaited the development of capable machines in the late s [ 21 ]. Inhalation of vasodilatory gas mixtures nitric oxide that promoted gas exchange through patent lung units first gained popularity in the s [ 22 ].

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Pressure-regulated modes of ventilation pressure support, pressure control, and their modern variants were developed to address with relative safety the varying flow demands of the patient with cardiopulmonary disease. The ability to respond to the patient's changing flow demands, as well as the need to cycle in timely fashion into the exhalation phase, was introduced to machinery developed in the mids in the form of pressure support pressure support ventilation [ 21 ].

At first, time-cycled pressure control pressure control ventilation was often implemented as inverse-ratio ventilation in the treatment of ARDS [ 23 ], an approach that has since faded from favor. In contrast, pressure support, assist-control, and synchronized intermittent mandatory ventilation with either flow-controlled or pressure-controlled breaths have become entrenched as the flexible standard modes of ventilation for more than 30 years.

Observational studies and clinical trials testing the worth of traditional and innovative approaches to lung protection and gas exchange efficiency characterized scientific efforts in mechanical ventilation through the s and into the first decade of the 21st century [ 24 , 25 ].

Current-generation technology has responded admirably to emerging knowledge concerning iatrogenic upper airway damage, lung parenchymal injury, and the consequences of dys-synchrony [ 26 ]. Present-day approaches - for example, proportional assist ventilation and neurally adjusted ventilatory assist - are immeasurably more effective than before, but still need to eliminate imperfect integration with the patient's neural demands and underlying physiologic needs.

Safety and coordination remain the frontiers for scientific investigation and technological development in this field. Among the first harsh lessons of invasive ventilation was that the protracted presence of an endotracheal tube not only increased the resistance through the upper airway, but also provided a pathway for infection and often damaged irreversibly the delicate tissues of the larynx and trachea.

Even today, the problem of airway debris is difficult to contend with, as the biofilm that lines the unperfused endotracheal tube combined with interruption of the mucociliary escalator and a disrupted coughing mechanism predisposes to retention of contaminated airway secretions [ 27 ]. Accumulation of airway debris causes increased work of breathing, impaires gas exchange, and predisposes to bronchopulmonary infections.

Better materials, lower cuff pressures, and improved nursing practices have addressed some of these problems, but clearly not all of them. In-hospital use of noninvasive ventilation was born from the need to address such issues, and with continually improving interfaces now allows for intubation avoidance, improved sleep quality, and safer treatment of patients with diverse cardio pulmonary problems of moderate severity [ 28 ].

Also learned relatively early in the experience with positive-pressure ventilation was the fact that controlling flow rather than pressure could result in high effort and could predispose to breath timing dys-synchrony [ 29 ]. Furthermore, insistence on targeting near-normal pH and partial pressure of carbon dioxide in patients with airflow obstruction often produces dynamic hyperinflation and auto-PEEP [ 15 ].

This pervasive gas-trapping phenomenon, which is nonhomogeneously distributed, impairs breath triggering, increases work of breathing, and may impedevenous return.

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In patients with expiratory flow limitation, counter balancing auto-PEEP with added PEEP can improve the sensitivity of breath triggering, improve the homogeneity of ventilation, and reduce dyspnea without further lung distention, hemodynamic compromise, or disadvantage to the muscles of the respiratory system [ 30 , 31 ]. High airway pressures and tidal volumes have been shown to damage both healthy and diseased lungs of laboratory animals since the s. Investigations into the causative relationships among mechanical forces, machine settings and cofactors continues to the present day.

It is generally understood, however, that the repetitive application of transalveolar pressures and tidal swings of pressure driving pressure that substantially exceed those normally encountered during normal tidal breathing will give rise to hemorrhagic edema and inflammation that mimic ARDS [ 17 ]. Sustained re-opening of collapsible lung units that are points of stress focusing is, in general, desirable.

But debate continues as to the feasibility and relative importance of fully recruiting all collapsed units, as the latter requires that alveolar pressures do not fall below a high threshold that initiates closure of refractory-dependent units [ 32 ]. Because recruiting unstable alveoli can dramatically reduce the incidence of ventilator-induced lung injury, a persuasive rationale exists for recruiting maneuvers, prone positioning, and the early use of high-level PEEP - the latter obligating use of relatively small driving pressures and accepting resultant hypercapnia when necessary.

We have learned only slowly to account for the important influence of the chest wall on measured values of pressure at the airway opening. The lung may thus be exposed to lower or higher transalveolar pressures than suggested by the unmodified plateau pressure or PEEP.

Even when considering alveoli in different sectors, stresses and strains upon tissues almost undoubtedly vary greatly, in part because of variations in the environment surrounding those lung regions. Few rules governing mechanical ventilation apply across all phases and severities of acute illness; choices must be conditioned by stage and by patient response.

Yet even those interventions that seem amenable to such dichotomous testing are nuanced by considerations of their dose, duration, timing of use, and patient selection. Knowing these key principles of effective clinical practice, it is wise to remember that few clinical trials have been undertaken with detailed or proven knowledge of the underlying mechanism driving the outcome variable or have accounted for the complexity and timing of pathophysiology and management.

As a simple example, none of the multicenter cooperative trials of mechanical ventilation yet conducted has assured passivity of the study cohort, despite the implications of muscular effort for the transalveolar pressures that lie at the root of ventilator-induced lung injury. Dichotomous nature of clinical trials. Without question, we have learned substantially from the conduct of clinical trials.

But, as with physiologic principles gathered from laboratory models of disease, results from population-based clinical trials are only a starting point to guide thinking in many matters related to mechanical ventilation of the critically ill. Examples abound; high levels of PEEP are relatively helpful in the early stage of ARDS management when the lung is relatively wet and recruitable and benefit outweighs hazard [ 34 , 35 ].

During this initial period of support, recruiting maneuvers in themselves may be only transiently effective are often required to set optimal PEEP, which is best selected using deflation characteristics and functional gas exchange responses. Later in the patient's course or when the lung is poorly recruitable for other reasons , PEEP simply adds to the peak and average airway pressures, both accentuating stresses and strains associated with a given tidal volume and creating deadspace.

Advisability of prone positioning may also be time and severity dependent. Meta-analysis of clinical trials data indicates that prone positioning seems to reduce mortality only in those patients who are both severely affected and in the early stage of illness [ 36 ]. Persuasive evidence suggests that we are learning similar lessons regarding timing and empiricism when using glucocorticoids [ 37 , 38 ] and recruiting maneuvers [ 39 ] in the management of such patients. Another important lesson learned is that there is a need to strike a balance between the benefits of spontaneous breathing and the dangers of oversedation and neuromuscular paralysis.

Ventilator-induced diaphragmatic dysfunction should clearly be of concern when fully controlled ventilation is imposed for extended periods [ 40 , 41 ]. Furthermore, unlabored spontaneous patterns of breathing not accompanied by dyspnea or expiratory muscular effort , appear to be more mechanically efficient than are those administered to a passive patient [ 42 , 43 ]. Yet taking control of ventilation during the earliest phase of life-threatening sepsis and ARDS may enable reductions in potentially damaging mechanical forces arising from high cardiac output and minute ventilation [ 44 , 45 ].

Brief use of paralytics during the most vulnerable early period of illness is not necessarily associated with delayed neuromuscular recovery or ventilator-associated diaphragmatic dysfunction. That being said, it is now strongly suspected that sustained suppression of awareness by large uninterrupted doses of sedatives without periodically returning the patient to consciousness extends the likelihood of prolonged mechanical ventilation, delirium, inability to wean, and consequent adverse clinical outcomes [ 46 ]. Self-evident rules regarding mechanical ventilation have emerged from decades of our collective experience at the bedside.

But as yet these rules remain unproven by rigorous clinical trials - and some may never be proven. Ventilatory management of the acute phase of ARDS provides several good examples of our unproven folk wisdom. A major step forward in the prevention of lung damage was to relate tidal volume to predicted lean as opposed to measured body weight [ 47 ]. Using predicted weight helps scale tidal volume to the underlying anatomical dimension of the lung. Because tidal volume enters only the aerated compartment, it may depending on compartmental capacity generate an inadvisably high specific tidal volume and consequently excessive transalveolar pressures and strain during passive inflation.

Any inspiratory muscle activity adds further to actual mechanical stress on delicate tissue. Influence of minute ventilation on breathing frequency for two patients of differing body size. Minute ventilation influences on breathing frequency for two patients of differing body size 50 kg and 85 kg. We should also modify therapy according to the patient's physiological need.

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For example, employing a guideline-approved small tidal volume without reducing a high minute ventilation demand may incur dyspnea as well as inappropriate high breathing frequencies. Whenever possible, we should attempt to reduce the ventilation intensity as well as the patient's demand for support. Reducing agitation, pain, body temperature, and metabolic acidosis are often addressable. Sedation may also be required to tolerate permissive hypercapnia. Refocusing on the pressure difference across the lung is important, as the peak and driving transpulmonary transalveolar pressures are those that count with respect to the causation of iatrogenic lung damage [ 48 ].

In theory, knowing the functional residual capacity and the transalveolar as opposed to plateau static pressure would be necessary to interpret the safety of our tidal volume selection. Thoughtful clinicians seek ways other than modifying the tidal volume and PEEP to ventilate protectively. From the viewpoint of clinical trial evidence, most methods remain unproven. One aspect of management that may have received insufficient attention in ARDS management is the need to reduce the effects of high flow on tidal shearing forces. Because the baby lung has a reduced number of open airways, flows that would be tolerable in a larger, high-capacity, fully open lung can theoretically result in unacceptable rates of tissue opening.

Whereas the open conducting channels may not be directly injured, units that open quickly during inflation may be more vulnerable to epithelial shearing. Moreover, the popularity of pressure control ventilation promotes very high peak inspiratory flows that occur just at the time during which unstable units have yet to be opened. Some experimental evidence in small and large animals strongly implicates high peak flow and delivery profiles as key to generating or avoiding ventilator-induced lung injury [ 49 - 51 ].

Although stretching, shearing, and small airway trauma have been demonstrated to occur when transpulmonary pressures are excessive, tissue tension cannot be directly measured. Experienced clinicians are aware that airway pressures alone may be misleading when the chest wall is stiffened by obesity, surgery, trauma, or disease as well as when the patient makes forceful inspiratory and expiratory efforts. Even measuring transpulmonary pressure with the aid of an esophageal balloon catheter may not be enough [ 52 - 54 ].

A challenging aspect of managing the stresses and strains developed within a mechanically heterogeneous lung is the amplification or stress focusing that occurs at the interfaces between fully open and closed lung units [ 55 ].

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Effect of chest wall stiffness and active inspiration on plateau pressure. Although transalveolar pressure and lung dimension are unchanging, airway plateau pressure is strongly influenced by chest wall compliance left panel and by inspiratory effort right panel. Numbers refer to pressures cmH 2 O in the respective alveolar and pleural compartments. It is humbling to consider that practices which have gone many years unquestioned might contribute to the generation or extension of the primary disease we are trying to resolve.

Acute illness progresses through phases. In general, we have not taken into account that the underlying pathophysiology varies with disease stage, and that such physiological differences should factor strongly into our management. Here is one possible example: We often encourage such patients to breathe spontaneously, with each forceful call for and assisted breath resulting in the delivery of relatively high transpulmonary pressure and tidal volume.

PEEP is not considered helpful in lobar disease unless maintenance of adequate oxygenation requires it. With the patient's ability to expel secretions impaired by intubation, we suction the airway frequently and promote coughing in the process. Yet we may need to rethink our approach in this earliest stage of pneumonia [ 56 ]. Thin proteinaceous and mediator-laden fluids with great potential for spreading through the airway network characterize this earliest phase [ 57 , 58 ]. Later, the well-intentioned suctioning, movement, and lower PEEP with higher tidal volume are perfectly rational in helping to expel the thickened and less dangerous biofluids known as sputum.

One must emphasize that this 'propagation prevention with injury avoidance' hypothesis is mechanistically plausible but unproven. A clinical trial to determine its validity would be informative. Transition to adult respiratory distress syndrome from left lower lobe pneumonia following airway intubation. Transition to adult respiratory distress syndrome ARDS; right panel from left lower lobe pneumonia left panel over the 18 hours following airway intubation and conventional management in a year-old woman without heart disease.

Progression of left lower lobe pneumonia treated consistent with containment of mobile airway biofluids. Sequence of progression in a year-old woman with left lower lobe pneumonia treated by principles consistent with containment of mobile airway biofluids. Although infiltrates spread through the dependent left side over a hour period, adult respiratory distress syndrome did not develop.

Although we have learned important lessons much too slowly regarding the dangers of protracted endotracheal intubation, ventilator-induced lung injury, sedation issues, and breathing dys-synchrony, our cumulative experience has given rise to advances with potential for better care of the ventilated patient. Greatly improved noninvasive ventilation may obviate the need for more invasive approaches in many patients. For the foreseeable future, however, intubation will continue to be required to protect the airway, to extract retained secretions, to allow deep sedation, and to control ventilation for purposes of manipulating the airway or performing cardiothoracic surgery.

Secretion retention will therefore probably remain a vexing source of complications so long as invasive intubation is required. The unperfused biofilm that lines the tube is inaccessible to host defenses, providing a safe haven for large infective inoculums to form and later seed the lung. Nonetheless, approaches that minimize or remove the infective endotracheal biofilm, visualize the proximal airways, reduce secretion impaction, and assist with sputum elimination by attention to inspiratory flow modification, percussive vibration of the air column, and mechanically aided coughing promise to minimize secretion-related complications [ 60 - 64 ].

Genuine progress has also been made in the attempt to link appropriate patient demands for ventilatory assistance with synchronous triggering and power. Initial benefits from pressure support and pressure control have paved the way for recently released innovations such as proportional assist ventilation and neurally adjusted ventilatory assist [ 65 , 66 ]. With better monitoring of mechanics and gas exchange, automated goal-directed algorithms integrated into the machine circuitry may enable automated upregulation and downregulation of power assistance, fraction of inspired oxygen, and PEEP, according to demands and patient response.

These algorithms have only recently gained traction in the clinical setting but clearly are steps in the right direction. Direct measurement of functional residual capacity allows estimation of the size of the baby lung, which does not always coincide with estimates based on transpulmonary pressure [ 67 ].

Position of esophagus between open and closed lung units in adult respiratory distress syndrome. Position of esophagus in relation to the interface between open and closed lung units in a patient with early-stage adult respiratory distress syndrome. Regional pressure recorded within the esophagus P es and along the sagittal and coronal planes that intersect it may be representative of pressures relevant to the stress-focused and relatively unstable units at the aerated and airless interface.

VILI, ventilator-induced lung injury. Regarding the force amplification at points of stress focusing, there is still a considerable gap that needs closure. Here too, however, tools needed for regional and dynamic monitoring of the heterogeneous lung are becoming available in the form of bedside regional imaging methodologies such as electrical impedance tomography and ultrasonic probing of the diseased lung [ 68 , 69 ].

These methods currently offer impressive qualitative insights, even if they lack quantitative precision at this time. Reducing the need to ventilate and to generate high pressures for ventilation, lung recruitment, and oxygenation with the patient remaining fully conscious and with spontaneously breathing has been a clear but elusive goal that is now much closer to widespread implementation. Prudently administered pharmaceuticals and judicious use of renal replacement therapies applied in a timely fashion can dramatically lower ventilatory demand and improve the efficiency of oxygenation.

Moreover, a variety of bedside adjuncts, both extracorporeal and intravascular, assist in eliminating carbon dioxide and replenishing the oxygen content of venous blood returning to the heart [ 70 , 71 ]. Such methodologies were urgently and successfully applied in the treatment of severely affected patients with H1N1 lung injury [ 72 ]. We will probably have fewer personnel deployed per patient for both observation and intervention. Caregivers will be aided by electronic information handling, but it is unclear at this time how well prepared the individual caregiver will be to think analytically when managing the required information stream and knowledge base.

Hospital administrations are likely to demand faster hospital throughput while emphasizing the priorities of safety, timely intervention, and avoidance of complications. Aggressive attempts will be made to protocolize many aspects of care. Smarter machines will reduce the need for user input and monitoring.

Flexible equipment will be needed to address patients of all sizes and conditions and to apply multi-element protocols automatically while carefully monitoring the patient for unanticipated deviations and complications. To make such automation safely possible, advanced ventilators will not only monitor pressures and flows, but also exhaled gas analysis and inputs from the hemodynamic side.

I anticipate that machines of the future will be goal-directed and self-adapting, fully capable of integrating mechanics, gas exchange, and cardiovascular information to achieve the clinical targets. Remote reporting and machine adjustment are a clear and natural evolution. Emerging economic realities related to critical care that must be confronted in the future. Unchanging needs for providing effective life-support with minimized risk and optimized comfort have been, are now, and will remain the principal objectives of mechanical ventilation.

Important lessons acquired during almost half a century of ICU care have brought us closer to meeting these elusive goals. Perhaps the over-arching theme of our education, however, is that a solid understanding of organ system physiology is the fundamental and irreplaceable tool for guiding our progress. This article has been published as part of Critical Care Volume 17 Suppl 1, Future of Critical Care Medicine. Today's practice and a look to the future' symposium. Articles were commissioned by the journal, were independently prepared by the authors and have been peer reviewed by the journal.

The supplement was edited by John Marini, who declares that he has no competing interests. If it is the 1st one you will have to have everything done before hand or at least be in the situation where you are just waiting for the physical paper license and you have everything sent in and done. The 2nd option just fill in what licenses you do have.

It depends on each hospital and some hospitals are willing to wait and other want someone asap. Also the managers will also usually call you after you submit an application and they will ask you about your state license status and you can let them know your in process or of your situation. I love my job. I had full-time with benefits before I graduated with my bachelors. In my state, we can take our license exam early if we are enrolled in a bachelors program. Our hospital is constantly hiring due to population growth.

At this hospital, we order respiratory medications and therapies without physician orders and we change the physicians orders as we see fit except in ER, peds and NICU. We order ABGs without physician orders and we manage ventilators and consult the intensivists if needed. We have a lot of responsibilities and autonomy but we get paid for it. Joben in Peoria, Illinois.

Man I feel bad for all of you who can't find a job lol I graduated in May and had a job lined up after graduation. Not only that I had another hospital in the same town wanting me to come to them, also had a hospital in Minnesota wanting me to go out there and a hospital in Tennessee who wanted me to come out there. Fresh grad and the nurses love me, Doctors listen to me and take my opinions seriously and I can suggest damn near anything and they will put the order in. Bradley in Indianapolis, Indiana. The problem is not necessarily the job market, it is the lack of RT's making the steps needed to be competitive in the field.

You could go over to a nursing forum and find the same complaints you see on this thread. If you want to be competitive, make sure you get your RRT and then specialize in a certain specialty, I would highly suggest adult critical care. Another mistake that students make, is not taking advantage of working in a hospital while in school or applying for the Respiratory Therapy Student permits that allows them to work in the field while attending school. It is important to network while attending your clinicals and making sure that you are making a positive impact to the hospital.

If you perform poorly in clinicals, those hospitals keep track of that and skip right over your application when you apply. You may have to move, take a prn position for awhile or work night shift but make sure you are presenting yourself in a positive light. The field is really a good field to get into, it is just about setting yourself up for success! RT is SO hard. I have to deal with 5 vents, do my assessments so I can order whatever medications I think the patient needs. And nurses do not boss me around. Worse part is that I get paid 30 an hour with amazing benefits and doctors love it and trust us so much.

The worse part about it all is that I had job offers the second I graduated from school. They kept bugging me to take my boards so I would be hired right away. So I never had time for a vacation. Feel for you guys without job opportunities but they're a plenty in Pittsburgh. Then I get all of the overtime I want on top of that. Looking to jump higher than this year. RT21 in Dublin, California. I never leave comments on forums like this, but I guess just this once I will.

If you're thinking about getting into the RT field here's the best advice I can give you. If you act like you don't give a damn and are just doing it for a paycheck then you'll end up sounding like some people on here. If you're looking for the higher pay rates you have to look in metropolitan areas and specifically hospitals that have an active ER and hopefully a healthy surgical unit.

Those are the places that not only have the demand for more and better RTs but also have the volume of pts to pay the higher rates. A facility's ability and willingness to pay is directly related to patient flow and volume, which of course correlates with the amount and types of procedures they expect their RTs to take part in. A good gauge for pay expectations is using glassdoor, and in doing so look at what the RT salaries quoted by reviewers for the individual facilities and not so much the average given area, that can be misleading in both directions.

As for as education and licenses, here's what I did.

Stay far, far away from Respiratory!!!!

Went to school, got pretty decent grades, I was not a show off nor was I even remotely always in the top of class for every module. But I made sure I learned everything I felt was important and what my instructors said was important, I good foundation and grounding within the science and procedures of care are a lot better than trying to know it all. You'll get a lot of real training on the job if you have the fundamentals down pat.

Trying to learn fundys OTJ is no bueno. When you do your clinicals, network with the staff, make an impression. Join the ATS and other groups and throw them on your resume too. But the main reason is how I marketed myself. Set yourself apart from the rest get your credentials, target the big hospitals, network with other professionals and when you get to the interview KNOW what you're talking about. And probably practice your interview skills and dynamic questioning.

After that tell everyone to kiss it Joben in Peoria, Illinois said: I wish you all the success and hope you enjoy working in the Healthcare Field as much as I do. I have been a Respiratory Therapist since graduating in and I absolutely love what I do. I appreciate the autonomy, challenge and versatility my job provides and have immense respect for everyone I have worked with.

Enjoy the journey, my fellow RT. I don't understand what all this whining is about. I hear you on the fact that nursing makes more maybe in some places and that maybe they are a little more respected. I don't agree with the fact that you are whining and calling the RT profession as a whole terrible. I find that really hard to believe. I am a new RT myself. I have had my RRT since April. As far as you saying there are no jobs anywhere, that is BS.

Around me there are jobs all over the place. There is a big hospital with in your mile search radius of me that has 14 RT jobs posted. Other hospitals close to me with in the same mile radius where there are several jobs posted. Like I said I live in a hole in the wall backwoods place and there are plenty of job opportunities. I love what I do and I love helping people. Its not all about the money, or the respect, or any of that other nonsense. I do it to make a difference in someone's life. RT is a great profession but it is like everything else it is what you make of it. Stop whining and fix your situation.

It is not a problem with the RT profession as a whole it is a problem with you and your situation. If you want a change then change it. How is it surprising that I'd be so upset about being unemployed for so long, and with such bleak opportunities, despite all my accomplishments in my field? What world are you living in? I don't know about you but, i didn't bust my butt like crazy to succeed in my clinicals program, for the "intellectual fulfillment" alone. I did it so I'd have a good career waiting for me when i got out. So i could finally make my own way for the first time in this life.

To stand on my own two feet as a independent, strong, confident adult. Not only do i work full-time but, its night shift at that. And my hospital is no joke. They expect me to give that job But thats Respiratory for ya. The sad thing is, if i didn't get this job, i don't know what i'd do. I'd probably still be at wal-greens with the rest of the losers. My Respiratory program wasn't easy either. At one point i was stressing out so bad that i thought i was developing heart problems. Sadly, i pushed myself to such insane degrees to succeed for such relatively little return.

Even after all this time, i job search for whats out there, and find almost nothing. If i ever lost this job, i'd be so screwed. Its a bleak field. In which facility do you work? Honestly, if you were willing to take that salary, that is not a problem with the field that is a problem with your healthcare facility. RRT in Houston, Texas. My program was only 1 year long too. I can't believe some RT school program's last 2 years straight!! That blows my mind. Those out there who are seriously considering this field?

From someone who is living it first-hand. Again, i emphasize the fact that I'm a sad, extremely lonely bachelor with no life outside of my job. And i can't even take care of myself on full-time RRT pay. A 1 year RT program?

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When exactly did you graduate? No way you will receive an Associate Degree with 1 year of RT work. Yes, RNs have way more opportunities, but they also have to deal with so much more. I do understand what you're saying to a certain extent, but that salary is just not true. Also, if you're bringing in 23 or 24 an hour as an RRT, you're being ripped off. It also depends on your mouth piece. RRT in Bellaire, Texas. I have no idea where you all are working. There are jobs out there for RT's it just depends on where you live in the country. I don't like respiratory all that much, but I'm doing something about it by getting more education so I can get into a different career.

RRT for 10 years and have only worked 2 days a week have been roughly 40K yearly. Not sure what jobs you all are accepting but that's a fantastic financial field. Pediatric Intensive Care Unit with a level 3 hospital. Maybe the field in where you are using your respiratory degree makes a difference. Julie in Tucson, Arizona.

I am a Registered Respiratory Therapist, and I have been for 3 years. I got a job within 2 weeks of getting my license and have worked ever since. My point with all of this is some markets are more saturated than others. Also, you get what you put into it.

Principles of sedation

UNDERSTANDING THE BASICS OF ICU/CCU CARE VOLUME 2 is just an awesome colorful book, it is intended for any nurse, not just the ICU nurse, as it is . 3 days ago Volume 6 (), Volume 5 (), Volume 4 (), Volume 2 (), Volume 1 () Dimethylarginine dimethylaminohydrolase 2 (DDAH2) regulates the of intensive care may provide opportunities to understand patient and family The original article was published in Critical Care

I love being an RT. This is a second career for me. I say, if you don't like your career, do something else. If you're considering respiratory, see if you can shadow one. The thing to remember is different hospitals allow RTs to practice various things in their scope. The hospital I work for allows RTs to do quite a bit, so it keeps us learning.

Don't worry about the negativity of some RTs. You will have your own experience. JF in Hopedale, Illinois. I currently have two openings at my small critical access hospital that pay better than what the OP has stated that they earn. Lowpay in San Antonio, Texas. It's interesting why only unemployed RRTs get so insanely negative about their profession. I know people with BS in computer science, nursing, accounting and they can't find job sometimes for years, but they don't get so hateful about their field. Many of the posts here look at least suspicious to me.

I believe that is not smart to trust everything we can read on forums, as we don't know why people write what they write. This post written in such a way, that it makes me think it is written by a nurse, not respiratory. I'm nurse' aid, and know that there are a lot of nurses who just MUST feel superior to other health care professionals and they get crazy offended when other people don't like nursing. I simply do not believe about RRT working full time and making 26K a year. It is also interesting why so many so called RRTs who yell nursing is superior.

RTs do not make a lot of money and unless this is going to be your stepping stone into something else such as PA school make sure you make a 3. The lack of respect from all facets of various healthcare providers is sad. Do not go into RT do not bury yourself in debt. I've told many people to stay far away from the profession.

Hospitals do expect you to jump when they say jump. Majority of tenured staff is jaded. I've worked other places and have never met people quite as hostile and negative as I have in this field. Pawprince in Findlay, Ohio. I'm an RN, have a close family member who's an RRT and one thing we have in common is that we hate the 'politics' and abuse from healthcare. I don't have unlimited time and funds, so I won't find out And remember why I chose the schooling I did at the time; without diminishing any one else's role in healthcare. RT guy from Cali in Laredo, Texas. Do you have any job connections for me?

I graduated back in California, could not land a jobs for many years, currently working with different registries to pay bills.

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I'm currently in Laredo all the way in South Texas. Please let me know. Hi, do you mind telling us what hospital? I'm desperate for a job. I can't find it in OC California. Tired of applying for jobs without any calls back. It is fricking hard. Their program is hard, half of the class are failing mental health right now.