After 10 years I left

It’s been a very busy winter so far. As can be seen it is a little tough to get back to here as often as I would like, but I want to continue to bring this forward. After the AARC Congress in 2006 I continued along in the position of RC Manager at Regency Hospital of Fort Worth. I really had not realized when I started with Regency what went into starting an LTAC Hospital.

About mid May on 2006 I gave my notice at Kindred. It was a tough ending there. I had had a really good run, I thought. Spring of that year the Kindreds in the DFW area went through some serious belt tightening that was pretty tough for many including me. I had interviewed with the CEO at Regency and had been offered just about exactly what I indicated I needed, foremost of which was ability to hand pick staff and aggressively recruit them, and a true commitment to clinical results. The new Regency Hospital was being built only a few blocks away from the Kindred where I was working. Rumors were flying at Kindred that they would not last, that they were a flash in the pan and that anyone that went to work there would not have a job in a few months. The building was beautiful, the people that were recruiting me were people I knew and trusted, but rumors like that always make one a bit nervous making a decision to change. The pay offered helped though. Working for Kindred I was working full time on salary in IT and working overtime on weekends as RT at any local Kindred that had staffing needs. The offer Regency made me equaled or bettered in one job what I was getting doing one and a half with Kindred. It is just kind of strange how it worked out. If I had any reservation about leaving it was wiped out by the week before I gave notice.

I had made my decision to leave and picked the date that I wanted to give notice. The week before I had chosen to give notice the downsizing started and it was brutal. People that were long time, loyal and highly productive people were let go in what seemed a cold unfeeling way. I am sure that is how it often is, but I hope if I am ever part of administering such an event that I find some way to inject some greater amount of humanity into the situation that the people leaving have to go through than was provided by Kindred at that time. Somehow I was passed over in the lay off choices. I think my level of effectiveness and aggressive regional involvement with the company beyond the walls of my main hospital might have the reason. The week before the day I had chosen was tough personally as I said. I was a direct report to the Director of Education (DOE). This was the third DOE I had worked for during my time there in IT, and she had only been hired a few months prior. In my role I was highly supportive of the hospital’s education, particularly orientation. I had worked with my new manager extensively to help her make the process her own. She had struggled somewhat to grasp all of the threads of the very complex and highly involved position and to really put something special together for the orientees that we saw once or twice a month for a week. We were doing a mid month orientation in May of ’06. On Monday and Tuesday of orientation week we did general orientation. The end of the day on Tuesday I would do an airway safety and accidental decannulation training for any clinical staff. On Wednesday the DOE focused on nursing and did a med test and an EKG strip test etc. with nursing staff. On Thursday I did documentation training with the nurses and clinical staff reported to their unit managers to plan unit orientation and to the nursing office to get their schedule on Friday. The week I gave notice I had taken off on Monday to finalize my paperwork with Regency. On Tuesday I came back to the hard facts that several people had been removed from their position. It was already puzzling. People that were totally tasked to the max to do their job were being replaced by people with the same position at one of the other local facilities having to spread their selves between multiple facilities. Before this event we were a pretty tight team. We had worked together through many challenges and generally had a good working relationship and were a friendly group. On the Monday I took off the Purchasing Director and the Plant Ops Director were informed their positions were eliminated and they were asked to pack and go. On Tuesday, I was called to Administration. I wondered if I would be asked to leave, but it turned out I was informed that I would be required to fill my role within my salaried time at all of the Tarrant County facilities. There are four Kindreds in Tarrant Count. I really think that even though you may see savings on paper of salary expenses, when you consider the effectiveness and what you get for your money that spreading good people too thin gets you less to almost nothing, quality and results are sacrificed for the bottom line. As things went it was very tough for these hospitals to compete with the new kid on the block. I was working hard to get at best fair performance from Nursing in following documentation requirements on which surveys and state inspections often hung. How anyone with any sense thought I or any could get the job done at four facilities that I could barely accomplish at one was tough to swallow. The Administrator informed at our meeting that morning that we were to meet again the next day and I was to have a plan for how I was going to accomplish my role at four hospitals. I went back to orientation in the facilities education classroom. When I got there the DOE received a phone call and was asked to come down to Administration. She had no idea and I could not imagine since that role was tougher than mine, but she was told to pack up and leave. She came back to the classroom in the midst of orientation basically crushed. Some how I got nursing supervisors and mangers  to step in and fill in for her orientation presentations until my Airway Safety class and I limped through the day. The next day a previous DOE who was still on staff prn did the nursing orientation day. I had already made my plans to give notice on that Thursday, but I must say that it was with some pleasure that I went to Administration and provided them with my resignation. I was the second employee to leave for the new Regency. Our Case Management Director had given her notice the week before. I left on good terms with everyone that was left, they even gave me a party, but I know they were not happy and before we were rolling at Regency I am sure they were certainly having some heart burn. I went to the Computer Training Room that Thursday and gave as good a ProTouch Nursing Documentation class as ever.  

June of ’06 we started hiring at Regency. I contacted people I knew were good and had many apply that turned out great. We put together a phenomenal starting staff that stuck together through the four years I was there. It really was one of those rare times that almost never happens in the hospital clinical environment where the administration, and the bedside staff come together in a commitment to do in all things what was best for the patient.

 Kindred Hospital Fort Worth Southwest

 Kindred Hospital Fort Worth Southwest

 Kindred Healthcare's Corporate HQ the last time I was 

there for the 7200 Vent Replacement Demos/Project

Regency Hospital of Fort Worth

My passion has always been with doing the best for the patients. Starting up was tough at Regency Fort Worth and we went through a low census period that was an early test for our new hospital, but once we came through that we came up strong in a very tough market. This passion for the patient result is what ultimately attracted me to the RTX. A device that can offers a means of non-invasive support, often prevent intubation, shorten time on vent if intubation is required, can facilitate ventilator weaning, support patients post extubation to provide greater assurance of successful ventilator discontinuance, allow tracheal decannulation, provide long term non-invasive support without risk to facial tissues, and provide the most potent secretion clearance tool ever for patients from 2-350 lbs is the most significant advancement in improving clinical results in bedside respiratory care in my greater than 30 year career. Today’s post is about me, but soon I will get to the BCV part of this blog and offer support of these assertions. 

Meet the Game Changer

Another key event happened for me at the 2006 AARC National Congress. I felt pretty cool with my Conference ID badge with the yellow  "Speaker" ribbon attached. I gave three presentations that year. As I was wondering the vendor booths looking for and learning about the new and interesting technology especially relative to mechanical ventilation I encountered the booth of MediVent International from England. They are the UK distributor for United Hayek medical products and they had the Hayek RTX on display. If you haven't been introduced visit http://www.unitedhayek.com/.

There really is no way to describe the level of excitement I had for the product. I was introduced to the President of Respironics later that day. I don’t remember his  name, but I recall he asked me if I had seen anything that stood out as really exciting or special and I told him about the RTX. I told him Respironics should make a deal with them to bring it to the US.  I didn’t know, but at the time Respironics had the NEV 100 cuirass ventilator and had distributed the Hayek Oscillator when it came to the US. Both good products, but neither with the capabilities of the RTX.

During a brief period around 2002 I was the lead supervisor in a RT department at a teaching hospital. For the size of our facility I thought we had a large number of ARDS cases. I started looking into ways to improve on this and found the ARDS Net studies and recommendations. It became my mission to change the practice of our docs there at the time of using 10-12 ml/kg to something around half of that. We used a lot of volume targeted pressure control type of ventilation or PRVC, but generally at volume settings that were causing more problems. We had about half of our vents patients at some points on dialysis or continuous renal replacement therapy.  It was a major deal that took a lot of effort, but I finally started making some headway. It was still rare for us to get orders for PEEP > 10cm, but we did start seeing the VTs coming down some. We had one doc that liked to use HFOV as a rescue. Machine rental was pricey, so he saved it to last resort.  Usually the patients that we used it on wound up with renal failure and ultimately not making it. The few we had success on were electively paralyzed for such a long period that they wound up almost impossible to wean after they were returned to conventional vent settings. Whether it was PRVC or HFOV, patients  were usually laid out on Propofol or opioids or some version of narc coctails that would keep them somewhat settled in the bed with the low VTs and the severe dyspnic anxiety that accompanies ARDS. I have always kicked around ideas in my head about better ways to do things. I recall back then as I pondered the damage we were doing to our patient lungs first then other organ systems later with our ventilators thinking that some means of pulling the air into the patient’s lungs with a negative pressure ventilator, while still pushed with less pressure and potential of damage with a positive pressure vent while being able to monitor the volume exchange and exhaled gas data through a controlled airway and keep it all syched somehow would be a much better way. I remember giving my concept a term called the "Push Me, Pull You" mode.

When I encountered the Hayek RTX and they began explaining to me how it could be used as an adjunct to a positive pressure vent allowing essentially what I had envisioned years before and thus improving outcomes for ARDS patients I was awestruck. As the people in the booth went on to explain the other non-invasive uses and the multitude of  indications that BCV was beneficial for, how  it could facilitate weaning from PPV, it so clear and made so much sense.

Almost two years passed between that time and the approval of the RTX for use in the US. Four and half years passed between that time and my decision to leave bedside clinical practice in a hospital and join Hayek Medical as a clinical specialist. More than five years passed between that initial encounter and my first opportunity to see BCV applied clinically. I always knew it would be a useful clinical tool. I was surprised; however when I got to see what it was capable of. What I have seen it do for some very sick patients is why I say I have never seen any single device or therapeutic intervention that offers the same potential of altering the clinical course of patients with cardio-pulmonary compromise than BCV.

SPOY Maybe This is Why

So it was Fall of 05. As IT Manager I had a bit of a budget for education so I got approved to go to San Antonio to the AARC Convention along about then. I had to pay for my room and travel, but Kindred covered my tuition. I had not even worked in RT for some time, but I still wanted to keep up. I had added a membership to the Long Term Care Specialty Section when I renewed my AARC membership that year, and I had had some contact with the Chairperson and Chair elect prior to the conference so I was really looking forward to going since I would know some of the section members there.

In October of that year at my home facility we put together the policy and started educating on the new ICU rounds process. It was mainly to be an interdisciplinary discussion on each patient in the ICU and moved from bedside to bedside with the group. My role was to be facilitator of the process and monitor the RT staff for compliance with the weaning protocol. When we started we had 9 vents running. That was a bunch for this hospital. We had usually been a very aggressive weaning facility and got the vent admissions weaned in 1-2 weeks, but for some reason the vents were not getting off as in the past. The rounds became a daily process and became a part of the unit routines. Each day we would round at about 0900 and any patient that should be going on a spontaneous breathing trial that was not got to it. We worked through clinical issues as a team and the patients came off of their vents. By the first week in December when the conference rolled around even with a few vent admits being added, the facility was down to no vents in use and every vent admit and all of the 9 vent patient we started with were weaned. This might have happened anyway, but it sure felt good to be back in the ICU and doing what I loved.

As I mentioned before, the 2005 convention seems like a watershed event for me. I didn’t realize it at the time, I just had a great time and met some great folks. All I could talk about with everyone was our successful Grand Rounds, vent care and weaning. I have always been excited about RT, but with being deprived of that feeling of accomplishment that I have when I participate in the care of a vent patient who has failed to be separated from their vent successfully at the hands of a world class acute care hospital’s ICU team and their medical specialists and I am part of the successful effort had left me totally jazzed by my dip back into clinical care. I guess my excitement and passion came through at the conference. I have always appreciated the recognition, but I hardly worked clinically in 2006, but the Long Term Care Specialty Section selected me as the Specialty Practitioner of the Year for that year. 

Even Superman has his Frustrations

The weaning protocol that I put together wound up serving that Vencor which turned Kindred Hospital well. During severalof the years I worked there as one of the main day people in ICU and as staff educator we hit greater than 90% wean rates. Looking back it was Sept. ’98 through Sept ’02. It probably took about 6 months from the time we first took the protocol and associated documentation to the committees for approval until we started using it. I always have enjoyed my work, but this was an exceptionally good period. The protocol gave us new autonomy. It was written so that every vent patient went on and allowed us to move the patients as quickly as they would go and provided good monitoring parameters that kept things safe. I love just about everything about accomplishing a successful wean quickly, getting someone’s trach out for them, and getting them back to their  life.

Several changes occurred with the facility while I was there. When I hired on it was a THC Hospital. THC wound up getting merged with Vencor and Vencor became Kindred. When the merger with Vencor came about, I had been working previously for Vencare, the therapy division of Vencor that went into nursing homes. During slow times I worked in some of the other local Vencor Hospitals. Most of my RT career I worked multiple places usually for at least 60 hrs per week. When Vencor and THC merged, the THC hospitals became Vencor hospitals. Anyone that has worked in a Vencor or what is now Kindred hospital knows that one of the common denominators of that chain of hospitals is a documentation tool known as ProTouch, or VenTouch when I was introduced to it. I had been instrumental in the roll out of a documentation system at a county hospital where I had previously been a director, and with my experience already working in other Vencor hospitals when VenTouch was introduced into our facility I was selected as the RT “SuperUser” when VenTouch was introduced at our facility.  I was on nights at the time and got to go to days for 2 months while I was trained and while we trained everyone else.  After that was done, I went back to nights and continued as before except I had some VenTouch training and QA duties added.

In the summer of ’02 the RN SuperUser/IT Manager left to take an educator position at a local short term acute hospital. I held her in high regard and always thought she was excellent at the position. That position went unfilled for a while, and my Director came to me and let me know that the position did not require a RN but came with a RN salary/pay rate, was a 9-5 M-F gig, that he thought I should apply and would support me with administration. I applied and really to my surprise got the position. I started in Sept. ’02. It was certainly different. There were definitely percs. I worked at the SW Fort Worth facility primarily, but the other 3 Tarrant County Kindreds were often without someone in my position so if I went to one of them to help with training or IT support I got OT. The hard part for me was that since I was no longer part of the RT department I was no longer clinical in my home facility. I no longer trained the RTs or worked in what had been “my house” the ICU there. There was essentially never any opportunity for OT in RT at that facility as it was one of the most efficient Kindred RT departments. The other Tarrant County Kindreds were not so efficient and they were often requesting me to come in and help on weekends for OT. This helped some, but it was not the same. It was really a source of frustration after what I had in “my house”. None of these other departments had ventilator care by protocol. I remember once being admonished at one of the facilities to not be too aggressive with weaning their patients or I would always get floor assignments. One day I recall a lead RT telling me that under no circumstances was I to call physicians, rather I had to go through her. When I got to my patients I had one that was ordered on resting vent settings of SIMV 6, VT 500 PS 10 PEEP 0. My orders for the day aside from the routine nebs etc. was to perform a CPAP trial on CPAP 5, PS 20 for one hour and then rest for two hours as tolerated all day. First I chafe at on and off weans. I believe firmly that once a day weaning trial is usually enough. I also believe that if a patient can breathe off the vent then they should and as long as they tolerate it. Well I found this patient initially breathing at a total f of about 40+. Mandatory breaths on the 7200 were not even pressurizing so low pressure was alarming frequently and PS of 10 with the PEEP of 0 was not conducive to synchrony or rest, so the resting settings were really working the patient. When I got him to the “weaning trial” the 5 of CPAP and the PS of 20 were adequate to provide him with about 1500+ cc per breath and a f of about 4. I went to the supervisor and explained and asked for a call to the doc to request better settings and she said that he wrote the orders and he knew what was happening and that was how he wanted it. I have found that some facilities the staff do not want to wean too fast as if the vent count goes down so does OT this turned out to be one of those places. What do you do? I shied away from that particular facility.

I had another patient during that time that I’ll never forget who demonstrates some of the frustrations I had working outside my home unit. He was on a vent on a step down unit. I was there on a Saturday. I received report from the night shift that he was 80, s/p stroke, a DNR, should have never gone on the vent, and was a likely terminal wean for that day. All week, every time CPAP was tried he went apneic.  What I expected and what I got were completely different. I expected a comatose patient who was completely unresponsive. What I found was a man who was relatively alert with a devoted wife that was spending every night at the facility to keep watch over him and the care he received. In this case I knew the doc and had for many years. He had been my Medical Director when I was Clinical Coordinator at the nursing facility. I knew he would not mind me doing a little safe experimentation so I went forward with a CPAP trial. During the week the patient had gotten the good old CPAP 5 PS 20 trial. What I found was similar to the patient I described previously from the other facility, he had a huge VT on those settings and sure enough within only a few minutes he was setting off the apnea alarm on the 7200. I adjusted the alarm from 10 seconds to 30 and was able to continue the trial with no more apnea alarms. Within 30 minutes I had titrated him down to PS of 8 for a f of 16 with good VTs and VE. I called his doc and got an order for a t-collar trial and an ABG. An hour later I got a perfect gas on FiO2 of .28 via t-collar and he never needed the vent again. At some point during his stay he had received an SLP eval and was provided a PMV and had an old order to use it as tolerated. It had apparently been forgotten about, but I found the valve and got him talking with no problem. After the doc rounded and spoke with the patient and his wife and told them that he was fine and probably would not need the vent any more and should do fine, I got the biggest hug from the wife when I next went in. “You are an angel sent by God coming here today. This morning I thought we were going say goodbye to him. You show up and this afternoon I am speaking with him like always”.  It was somewhat of a sweet moment, except it happened because someone called a patient setting off an apnea alarm due to very high VT and low f apnea and just went about their business. This is what got back to nursing and the doc and the patient was written off. When that ship sails some times the patient will surprise you and a terminal wean results in a surviving patient, but in my experience with the high dose, high frequency narcotic orders, and the angels of mercy that give it so freely, true apnea will be the result and a totally weanable patient will be lost due to the ineptness of a team of licensed, credentialed professionals so ready to dole out mercy and call it a day.

These and many similar frustrating experiences were the clinical exposure I got while I worked my main day gig as IT manager/SuperUser. I dove into that role. While I was in that role we moved corporately from a Windows 95 environment to W2K. I wound up being on corporate steering committees for updates to ProTouch. I began working around the Southern Region training nurses. The way I trained nurses to document looked good to surveyors on review so they wanted me at facilities that were expecting surveys to get their nurses brushed up. They called me Superman. I knew the documentation pathways for all disciplines by heart. I knew the network and the information system inside and out. I was able to recognize issues before they became problems; however for me it was not fun work. I grew more and more frustrated with both my regular M-F work and my clinical RT for OT work. That was about the time the discussion of grande rounds came up for the ICU at my home facility, and I jumped on it.

Birth of a Protocol

I mentioned 2005 AARC Conference  in San Antonio. I think that was some kind of turning point or watershed for me. I was working for Kindred Healthcare as an IT Manager/Superuser/Documentation trainer between 4 hospitals and training regionally while working most weekends in RT for OT at one of the 4 hospitals. I had been doing that for about 2 years having moved from my position as Staff Edcuators in the RT department at the Tarrant County SW Kindred Hospital. The IT position came with a pay increase, but it never fit right. When I went to AARC that year I really missed doing RT FT and had really built up a passion for LTAC critical care and vent weaning.

The conference was in early December of that year. Some time in late summer I was approached by the ICU nurse manager about my thoughts about performing grand rounds in the ICU. I had encountered an article that demonstrated that daily rounds to enforce and instruct on the weaning protocol and to monitor care had a profound effect on clinical results. I developed a tool and with the nurse manager’s help and the blessing of the RT Manager we started in October.

I had been at that facility for quite some time. I believe it was about 7 years at that time. When I was there a couple of years I left and took a position as Clinical Coordinator at a Vent Program at a local nursing home. I had developed some very successful techniques for weaning while working at the LTAC. It was a THC hospital then a Vencor at the time I left back then. My greatest frustration back then was I worked 12s and I would nearly get someone weaned and go off for 3 or 4 days then come back and find them back at square 1. We did not have a protocol at that time and we had nothing to use to keep everyone on the same page. I would try writing detailed weaning orders and getting them signed off by the docs, but others could just as easily get orders to put them on hold. So when I went to the vent program at the nursing home I started by writing in detail what at the time I thought was the considerations and techniques that were making my efforts with the vent patients effective as a sort of protocol and used it at the nursing home. I have to say caring for respiratory patient in a nursing home may be some of the hardest work I have ever done. Many of our patients were neuromuscular patients and we tried to have each of them up and out of bed and outside or in a common area daily. We also made sure every patient with any potential was assessed for weaning potential daily. In a program that accepted unweanable patient from area LTACs we had real success at weaning and decannulation of the patients that came to us without criteria that would exclude them from weaning efforts. That protocol served us well for the year or so that I was there until Medicare quit paying for RT in the nursing facilities and the home essentially eliminated the program.

When I went back to the LTAC to negotiate for my old position I insisted that if I were to come back that we would make the protocol I had written into policy and put it to use in that facility.

Bursting to spread the word

What I hope to create here is mainly a means to educate those that might follow it on what I see in Biphasic Cuirass Ventilation (BCV). I have so much in my head and so much to say about it I have a difficult time figuring where to start. I have a long experience as a Respiratory Therapist, and I am happy to say I have had a very stimulating and satisfying career so far with very few periods of burnout and many high points. I can readily characterize my feeling about my career and vocation as passionate. I love Respiratory Therapy. I love taking care of patients, interacting with their families, working as a team with my peers, and as a matter of fact I have a strong sense of camaraderie with other RTs, particularly those that share my passion for our special profession. I will get much of my past experience in my profile, or cover it here possibly, but what this is about is discussing and describing BCV. The title of this blog is Biphasic Cuirass Ventilation and Me. It is my intention at this point to make it more about BCV than me. I do need to start somewhere and that seems best to be to start with me. Once I get some things out of the way, I will get down to BCV. I will start my introduction by returning to the 2005 AARC Convention in San Antonio, but I will save that for next time.

To wrap this first post entitled Bursting to Spread the Word up I would like to relate that almost exactly one year ago I was looking at a major change in the direction of my career. I was working as a RT Director in a small LTAC Hospital in Fort Worth Texas. I had started in the position with the opening on the facility four years prior and had enjoyed an amazing run. It was a highly satisfying and enjoyable position at a facility where I was really appreciated. I felt I had managed myself into the enviable position of big fish in the little pond. I was also very certain we were making a great difference. I knew my competition and how we compared and I was very certain our care and results were without a doubt excellent. At the TSRC Conference in August of 2010 I was offered the position I now hold, that of Clinical Coordinator for Hayek Medical. Hayek Medical is the sole distributor for United Hayek medical products in the US and Canada. The only product United Hayek currently has available in the US is the Hayek RTX Ventilator. The offer that was made me at TSRC last summer was not the first one that came for this position, but it was the most intriguing for many reasons. As I considered if the risks of leaving a well established and comfortable position for what I was not sure what were worth it I made inquiries of a few of my associates in medical sales. One inquiry went out informally to several of the long experienced clinical people in what I still call Respironics. Initially no one knew what the Hayek RTX was. Then I heard back from an old timer with the company and he remembered the Hayek Oscillator, which is an older less functional version of Dr. Hayek's RTX and what he said stayed with me. "It is a good device, but hardly anyone knows about it, and it will be a missionary sell". The more I learned about BCV and the more I thought about the other technology changes I have witnessed in my career, I was so sure that I had to take the position. I still feel that spreading the word about BCV is more than a job. It is a calling. So just like a missionary I am bursting to spread the word. In what I get posted here I hope I can do that to some additional degree. Am I biased about the benefits of BCV? Well    I have to disclaim some conflict of interest when I speak about it, but I honestly know that for what is indicated it is in most cases a better way and produces better clinical results more quickly. I say it all the time and feel it to my core: In my over 30 years as a clinical respiratory therapist whose main practice was critical care I have never seen any single device or therapeutic intervention that offers the same potential of altering the clinical course of patients with cardio-pulmonary compromise than BCV.