Okay, you are the evening shift respiratory therapy supervisor. You have bypassed a general therapy position. You are in charge of the place now, okay? You've been called to assess a patient by the name of Phil Brown, a 57-year-old male. Age and gender will always be relevant, okay?
Age specifically because if we were dealing with a two-month DNA... we've weeded out a lot of respiratory conditions, right? So age and gender are always relevant. Who was admitted into the hospital earlier in the day complaining of mild respiratory distress. It's nice to know what they came in for because if it is lung related, this is going to be a precipitating factor in the way things go.
So mild respiratory distress. He's currently on two liters a minute. So we've got him on oxygen, 28% oxygen because that's what a two liter per minute nasal cannula is. and is still in mild to moderate distress. So just the oxygen's not fixing things. The doctor would like your assistance in evaluating his condition and helping with his treatment regimen.
Which of the following would you assess to best evaluate Mr. Brown's cardiopulmonary status? This is not just lung. This is heart and lung and anything that's related to that.
Select as many as you consider appropriate in this section. Let me tell you what I do. I never read this bolded part. I'm really bad about this. I just let my eyes cool down and look at the options and if it's a long list.
I make the assumption I can pick as many as I want to. If it's a short list, I'm assuming it's only one, and sometimes I screw up. Because sometimes the list is long, and they tell me choose only one, and I've already in my mind started picking what I think I want, and I've made a mistake.
So always read this. We can select as many as we want. Now, we're rolling into information gathering. Here's where I want to talk about this.
Real life. If you were in the hospital in clinicals, say you're working in the emergency room, and they ask you to come evaluate a patient and give recommendation for treatment, if you walked into the room, looked at the patient, and saw they were in respiratory distress, would you ever say, holy cow, I need a set of electrolyte stat? That makes absolutely no sense, does it?
Okay. So these clinical simulations, they lay out a list of options. And when we are presented with a list, we like to start at the top and work our way down to the bottom and picking what we think we might need.
Well, that's not real life. We don't have a list. So we're going to approach this information gathering and we're going to go through the list potentially two times.
The first time we go through the list, we're going to think quick, easy, and cheap. Okay? We want to do quick assessments like vital signs and breath sounds, something that's quick that gives us a lot of data and that we don't spend a lot of money. Okay?
Because it's first time through, we're assessing to see if we have an emergency situation on our hands. if we do have an emergency situation on our hands, we're going to stop and treat. We're not going to waste our time getting electrolytes and chest x-rays and that kind of stuff.
Okay, so two times through information gathering. First time, quick, easy, and cheap. If we don't have an emergency situation, you can go through a second time getting relevant data.
Okay, so here we go. You get to choose as many as you want, quick, easy, cheap. Breath sounds, are those quick, easy, cheap? Yep.
Okay. When you click, read what it says. Okay?
Because in real life, as you're listening to breath sounds, you're putting that in your brain and you're using it with everything else. So read. Diminished in the basis with crackles in the right upper lobe. Do you need bowel sounds? No.
But you know what to do with the bowel sound if you had it? really the only reason we are ever going to need bowel sounds is if we're worried about a diaphragmatic hernia and we accidentally hear about bowel sounds in the chest okay we're not assessing for bowel sounds okay but I pick them sometimes because I go really fast and when they line these up they put bowel sounds on the top and breath sounds right underneath it and my brain sees the B it sees the word sound and I click before it actually hits my brain that I just click bowel sounds. Okay? Don't go that fast. They like to stack up EEG and ECG together like that also.
You're wanting an ECG, but you've accidentally hit EEG because it looks the same. Be careful. All right?
So we don't need bowel sounds. Respiratory rate, is that quick, easy, and cheap? 22. Heart rate and blood pressure?
Let's click easy cheat. 110, 110 over 75. CDC. It might be quick if we've got some kind of point of care testing that might can do that, but it's not cheap.
That comes with the cost, so not yet. I'm not saying you can't have it, but not yet. Chest x-ray, that might be quick if you've got somebody right there in the emergency room, and a lot of times you do in larger facilities, but it's not cheap. Let's wait.
Gag reflex. Do you think you want to gag the patient? No.
Babinski. Probably not. That's typically more of a neonatal thing.
Color of the lips and nail beds? They're cyanotic. Now remember, take that with a grain of salt, but it could indicate hypoxia.
Chest configuration. How does the chest look? That's quick, easy, and cheap, right? They have a barrel chest. Tenth.
It's quick, easy, and cheap. They're febrile. Urine culture. Number one, I don't know if that's relevant and it's not quick, easy, and cheap.
Blood gases, we might want them, but it's not quick, easy, and cheap. We've got to do the Allen's test, then we've got to stick, then we've got to hold five minutes and then we have to run it. There's nothing quick about that.
Smoking history, just ask them. Forty pack years. If it doesn't say they have quit, assume they're still smoking. Peak flow.
that's typically in asthmatics that we're wanting to assess where they are they have a personal best so probably not lactic acid level is a blood drop so we've gone quick easy and cheap okay now we need to go back up this list and make sure we don't have an emergency so we have a person with a smoking history that's febrile and has a barrel chest kind of sounds like it could be copd right potentially cyanotic or potentially hypox hypoxemic because we have cyanosis tachycardia, a little bit of tachypnea, blood pressure's okay, diminishing base sounds, crackles in the right upper lobe. Does anything about this feel like an emergency to you? Like, do you need to stop and do something right now because they're going to die if you don't?
So we probably have time to go back through here and pick relevant data. Now, the reason I want you to do quick, easy and cheap first is let's say that you had a person in distress and you just went down the list and ABG was the first thing and you picked ABG and you got something that said not performed. And so you go down the list and you click heart rate and the heart rate is 20. Do you see if you had done quick, easy, and cheap first and saw that the heart rate was 20 and the blood pressure maybe was 40 over 20?
That's an emergency situation. Do we need to have drawn an ABG? So this is why you want to do quick, easy, and cheap first, just to make sure your patient is stable. If they are stable, go back through a second time and get relevant data. They're stable.
Let's go get back through there and get stuff we might need so we can figure out what's going wrong. Do you want bowel sounds to figure out what's going on? No.
Want a CBC? okay because they've got a fever right and fever sometimes means infection and with the CVC we can get a white blood cell count at 16,000 they've got an infection as a respiratory therapist you love the CBC because it gives you red blood cells and hemoglobin and hematocrit it tells you about oxygen carrying capacity okay so that's a great thing to get so now we've got an infection on a COPD patient that's febrile would you like a chest x-ray because that infection could be a pneumonia, right? And with those breath sounds, diminished in the basis and crackles.
So we have hyperinflation with Bullis disease. So that's indicative of COPD and a consolidation in the right upper lobe. Want to gag him now?
That's still rude, isn't it? Babinski. So babinski is a reflex that we use typically on neonates. If you're going to do a babinski on an adult, it needs to be an adult that has a head injury. Okay.
They don't have a head injury. So babinski is not relevant. Urine culture.
Okay, sometimes people say, well, that can tell you if we have a kidney infection or a urinary tract infection, and yeah, it probably could, but do you see all indications here with that chest x-ray and breast sound changes and the history are leading us towards an infection in the lung? So that's probably not something we want to do. Nothing has told us about anything about him having problems with his urinary system.
Do you want a blood gas? Might as well see how he's doing. Okay, on the credentialing exams, your blood gases on a COPD patient, as long as your pH is above 7.30, you're happy with that.
Okay, so I know this is 7.32 and it's not spot on normal. It's okay. It's okay for a COPD patient. So you should be happy with that. PAO2 though for COPD because he is a chronic retainer.
should be between 50 and 65, right? So if we're asking ourselves what's wrong with this blood gas, he's hypoxemic, right? And then all that's left is lactic acid level. So we have all of this to look at, and we have several things wrong, but what do you think we need to do first? Because this is how you should take a Cleanse Sim.
You have all this information. In real life, you would have all this information standing at bedside and you'd have to decide what to do because the patient's not going to hold up a poster board and say, A, give me oxygen, B, intubate me, C, give me a breathing treatment. You don't have multiple choice in real life. Don't give yourself multiple choice now. What do you want to do with this patient?
What's one of the first things you want to do? What is something you could do really quickly and fix one of these situations? Would you give them oxygen?
Absolutely. Okay. Was he already on oxygen? How much?
Two liters a minute, right? And his PO2 is 40. Okay, so that two liters a minute isn't working. If you forget, here's this show simulation history, and you can go all the way to the top and read everything. You don't have to write stuff down because it gives it to you. All right, so we're on a two liter per minute nasal cannula.
Where do we need this PO2 to be? At least what? 50 to 65. 50 to 65. So what are we going to do? Tell me what you want to do for this patient.
Yes, they need more oxygen. What device and what flow? We definitely, don't we want to give a precise FiO2 because they are COPD-er?
Okay, I'll go for that. So if you say a precise FiO2 and we're already kind of 28% right now, what's your thought? Oh, okay.
So we are already using that then. Yeah, we're on a two liter per minute nasal cannula. Go up to...
I mean, you could change it to an air entrainment mask. I forgot. Okay, an air entrainment mask like a Vinnie mask.
I don't disagree with that. But give me an FIO2 because if you set that up, you have to choose an FIO2. We could do like maybe like 50 in this case and see.
We only have to scoot this number from 40 to 50. And we're already on 28%. Oh, you want to do like 35? Yeah, go easy with it. Either increase your nasal cannula, maybe three or four, or maybe go up on your FiO2 a little bit.
But we don't have to do a big jump because we only have to move this 10-tor for it to be normal. Okay, we've got a plan. Now let's look at our choices.
So always decide what to do because as a therapist, you have to decide what to do. Nobody's going to tell you sometimes. Alright, so here we go.
Docs want your recommendation. Select only one. So you said oxygen. So let's weed out. I like to get rid of the noise so I can just pay attention.
Like we don't want to not do anything because he's hypoxemic. That's dumb. PEP therapy at 2. That's not oxygen. So we're throwing that out. So now we've got three different oxygen choices.
Now we said 35% so that is there. A 10 liter per minute simple mask is about 50%. What do you think about that? Maybe a little too high.
A six liter. Yeah, it's not specific and it's 50%. And that seems like a big deal. We only got to push it 10 and six liters per minute on a nasal cannula is about 44, 45%. No, it's too high.
Yeah, probably so. So just a general increase. Does that make sense?
You knew to do oxygen, but now you have to rationalize it with the disease process. And we did this on the TMC. We talked about this kind of stuff.
Now you're just having to choose for yourself among options that are still oxygen therapy. This is more like clinical practice. Okay, done.
I don't like done. I want the physician to agree with me. I want that validation. I want that pat on the back.
Done. Okay, if it just says done, just assume you're right unless they tell you you're wrong. Okay, they do this a lot on the exams. Done, noted, so just assume you're right.
All right, 30 minutes later, here's his ABG result. 7.25, CO2 of 68. PO2 of 50. Now let's not rush into this. A lot of people rush and say, oh my goodness, I put them on too much oxygen and I knocked out their hypoxic drive. I need to go back down to where I was.
The only way you can knock out a hypoxic drive is to bring the PAO2 above 65. Did you do that? No. you did the right thing. And just like real life, sometimes we do everything correct, but the patient just gets worse despite our best efforts.
And this is exactly what happened here. The patient just got worse. Okay. So don't back off of your oxygen. Now on your credentialing exams, when you have a COPD patient, as long as their pH is 7.2 or higher, you need to try a trial run of BiPAP.
Okay? We don't want to intubate them and start that mess. We want to just see if we can get them over this hump with noninvasive ventilation. So we're going to try a trial run of BiPAP.
Yep, I've really already told you what we need to do, right? So you look down here, and we're putting them on noninvasive ventilation. We're going to help them ventilate.
We're still going to kind of support that with oxygenation also. Okay? Dr. likes that.
All right. An hour later, the patient is in severe respiratory distress. Watch your adjectives. When your adjectives get more severe, your treatment is going to need to be more aggressive. Okay?
Severe respiratory distress. And now here is your AVG. So my question to you is, is the BiPAP working? No.
Are we going to keep going with it? No. What are we going to do?
put them on the vent, right? And before we put them on the vent, we're going to have to intubate them. Intubate and ventilate.
Now, let me show you something really tricky. You said intubate and ventilate, and it's right here on top. Roll through the rest of these just to make sure, because here's why. If C4 had been up here in C1's place, if C1 and C4 were switched, if you were thinking intubate and ventilate do you see you might have looked at intubate and just clicked without reading the rest of it read every single thing because they do that also they put the wrong one first and the right one second because people take the test fast i fall for that sometimes okay so we need to intubate intubate and place on the vent doc agrees so we're probably putting them on the vent we really haven't talked about initial vent setting so let's do this now Title volume, 6 to 8 mLs per kilo of ideal body weight.
Okay. Respiratory rate. Everybody teaches something a little different.
I teach my students anywhere from 10 to 16, maybe 12 to 16. Some programs teach up to 20. Okay. We need a normal respiratory rate. Okay.
FIO2. should be the same FiO2 you had them on prior to ventilation, as long as what you had them on makes sense. Okay. Now, mode.
Mode doesn't matter as long as you have a mode of ventilation that supports an adequate minute volume. Like if you're having to decide between a SIS control or SIMV. there's a school of thought that says if we're going to wean we need to be in a mode we can wean in so let's go ahead and put them in simb there's also a school of thought that says okay let's let them have complete rest and just initiate a breath and that's assist control when it comes down to it when you're picking vent settings the worrying about SIMV versus assist control, don't let that be your deciding factor.
Either one is correct as long as you have an adequate minute volume and adequate oxygenation. Okay, so all these numbers. Okay, here's what you don't want to do. Never go to calculate tidal volume first. Do not do that.
That may waste time. Weed out with something easy. okay I like to weed out with rate a lot of times if it's volume ventilation like I'm okay with the rate of 12 but I'm not okay with the rate of 8 really okay so I'm gonna throw out to not looking at it again I don't personally like 18 I think I'm gonna throw it out but but I might can come back and look at it but right now I'm gonna weed it out and I'm gonna weed out 20 and I just because I teach my students up to 16 okay well I've weeded out that one that I've we did them all out okay Now, if you, what did you get taught and it's not wrong, what did you get taught to set your respiratory rate?
It's 12 to 20. 12 to 20 is what you got? Okay. Okay. So let's do that. If we were going 12 to 20, you would say, okay, you wanted to keep 18 and 20, right?
You still throw out two? so now you've got between one three and four okay let's do that so the next thing let's go to fio2 and see if that helps us weed out 40 40 40. well that didn't help us very much let's go to title volume don't calculate yet don't calculate yet 600 we said we get got rid of two 600 700. Now, let me just ask you, when was the last time you saw somebody truly on 700? Right.
And if you did, they were probably, yeah, if you did, they were probably really tall, weren't they? Okay. So we're probably not doing 700. Would you agree?
Okay. So now we have this one, three, and one. And 12. rate of 18, 640, PEEP of 5, pressure support of 10. Now, they might both be right, right?
So here's what you have to do. You're going to have to make a determination. Which one do you want? And think of a backup. This keeps you from getting click happy, okay?
You think of the one that you're going to pick, but if they give you a physician disagrees and you have to choose again, you need to have a good, strong backup ready. And before you click that one, have another backup in place that you can rationalize. Always think one step ahead, but what if they tell me no?
Okay, so I need to ask you what you want to do. You want 18? A rate of 18? 12. You said 12? That's what I would say.
I'm seeing... I'm seeing... Okay, I'm seeing some head nods.
So I'm going to click this, but if it gives us a physician disagree, we have a backup, okay? We don't have to be perfect. We have to be competent.
But the doctor likes it, and so now we don't have to worry. 30 minutes later, 7.3256, PAO 262. That's a perfect blood gas for a COPD patient. What are you going to do?
Yeah, leave him alone. Doc likes that. And now we go up, which of the following would you recommend for his continuing care?
Select only one unless directed. So you have to go back to how we're going to take care of him. What's wrong with him?
What's wrong with him? He has COPD, but what else is wrong? Fibril, chest x-ray changes, white blood cell counts.
He has an infection. So out of these four, what are you going to do? Treat with antibiotics.
And he's got COPD going on, so probably nebulizers are not a bad thing, right? Because we've got some inflammation and probably some bronchospasm, so good. All right, five days on the vent. He successfully weaned and extubated. After extubation, his PaO2 on room air has been between 40 and 50. We don't like that, so he had a starter 2 liter per minute nasal cannula, and now his SATs are 90 to 92, which is good.
Four days after extubation, his chest X-ray shows scattered infiltrates, hyperinflated lungs, and a flattened diaphragm. Kind of looks like COPD. He's to be discharged in two days and Doc wants your recommendations for his respiratory care after he returns home.
So this is not information gathering, it's just what do you think is best for his care when he returns home. Do you think a nicotine patch might be good for him? He has a 40-pack year smoking history and you have to assume he's still smoking. Would you like him to stop smoking?
I would hope you would, but what are you going to do about that nicotine addiction? because it's a real thing. And he's not going to be able to quit cold turkey because of that nicotine addiction.
So can you offset that nicotine addiction with a patch? Okay, diaphragmatic breathing exercises. And sometimes they throw something on here. I'm like, I don't know if they think that means what I think that means. I'm gonna skip that for now.
Because I just don't know. aerosolized bronchodilators. What do you think about that? He's got COPD. Okay.
Do we want to get him enrolled in a smoking cessation program? Yeah. How about an oxygen concentrator at two?
Yeah, because we don't want to, he's on two now. We don't want to send him home hypoxic. Good.
Restrict fluid intake. Minimize your fluids. We don't have really any reason to, right? Nothing has been told that we do.
Purse-lip breathing. Yeah, if he hasn't figured out how to do it on his own when he gets into distress, we need to coach him to do it because that prolongs the expiratory phase and minimizes air trapping. Usually they figure it out on their own, but if not, we can teach him. Do you want to do IPVB at home daily? No.
Bed rest? Like, rest as much as possible. Don't get up, don't move very much, stay in bed as much as possible.
we need them up and active and taking good deep breaths so not at rest now the only one that needs to go back and you tell me what you want to do diaphragmatic breathing exercises or not here's what I do if I'm not really sure I ask myself how I feel I've done on this and so far I think I've done pretty good so if it's right I'm gonna give up a point or two I'm willing to do that because I don't have to be perfect I just need to be competent okay let's not do it we'll see what happens All right, before discharge, you're talking about how to clean his equipment. Which of the following should you recommend to help him ensure that his equipment is cleaned adequately? E3. E3.
So, can vinegar, three parts. So, water, one part vinegar, clean towel, the air dry. All right, noted. Okay, now I'm going for the grade. Now you don't get to see the grade after each one.
You're going to take 20 consecutively. You don't know what's really going on behind the scenes, but I'm going to show you after each individual one. So here we go.
You got 31 out of 33 correct. Minimum passing was 25. Okay, we're not even perfect, but you were just off by two, but you only needed 25. You got six points with this one clinical simulation. Nobody keep track of these for us.
We got six points in the bank. So are you upset that you weren't perfect? You did really good. Now, my question to you, it's 4 o'clock.
This is officially the ending time and you are more than welcome to leave if you want to. If you want to stay, I'll stay with you. If you want to leave, that's fine. I'll be here at 8.30 and I'll go over it today for those of you that want to stay and then I'll come in at 8.30, I start at 9.30 tomorrow. If those of you need to leave now and want to catch it in the morning, I'll be here at 30 minutes earlier.
But if you want to stay, I'll just hang out and just stay on. If you want to leave, goodbye. I'll see you in the morning.
I'm sorry. And we can just log in tomorrow morning, the same connection? Yeah, the same link and everything. If you want to come in 30 minutes early, I'll do that, Quinson.
If you want to come in right on top of the hour, I'll be here. Okay, perfect. Thank you for your help.
You're very welcome. All right, thank you. Thank you. Y'all staying with me to the very end?
Okay. All right. Close your eyes. I'm going to pick a new one, but if you see what I've picked, you're going to know what to do.
So close your eyes. Don't look. Okay.
We are ready. Opening scenario. Read it the first time to figure out what's going on. Read it the second time for relevancy.
Okay, you're the supervisor again at 300 Bed Community Hospital. You've been paged to the neurology floor. Okay, neurology. This is going to be a head injury or neuromuscular disease.
Alright, 26 year old woman. Okay, so 26 year old, Renee Sanders, who's just been admitted with complaints of numbness in her feet and generalized muscle weakness to the point that she has had difficulty standing without assistance. starting we're having problems with the feet now it doesn't say like that it's moving upwards but it does say it starts at the feet right or at the ground and there is there a neuromuscular disease that goes from ground to brain Guillain-Barre right and that's how you remember it ground to brain I'm not saying that it is but I'm saying that that should flash in your mind okay She also states that she had the flu last week.
Well, that's a little bit further thought process into Guillain-Barre. Guillain-Barre follows recent viral events. She had the flu, which is typically a viral event.
The patient is 5'3", 160 centimeters tall, and weighs 125 pounds. All right, the doctor wants you to assess her status, which of the following would you recommend? Select as many as appropriate. So this is information gathering. The first time, quick, easy, and cheap. Okay, so you tell me with what you can see, or you don't have to say it. You can just hold up fingers. What do you want? Okay, vital signs. Okay, normal, 98, pretty much normal. She's a little tachypneic. Herring Brewer Reflex. If you don't know what it is, don't pick it. It's a stretch reflex. We don't need that. Generalized muscle tone. Neuromuscular disease neuromuscular. Would it be a good idea to look at our muscle tone? because if she's having muscular weakness, that's going to show in the tone. It doesn't mean that she has muscles. It means that the muscles might not be working. Are they flaccid, the tone of the muscle, not the buildup of? Want to check for clubbing? quick easy and cheap right it's just looking to see if she's clubbed it's not gonna hurt anything if we don't need it the worst this kind of stuff does is just gives you zero points these don't hurt you because you didn't spend any money and there's no harm to the patient blood pressure okay whoops sorry I didn't mean to do that but that one was right also all right blood pressure is 110 over 70 Deep tendon reflexes are a good thing because reflexes have to do with neurological responses, nerve responses. So level of consciousness. MIP. That's not quick, easy, and cheap. We might need them, but it's not quick, easy, and cheap. Cough effort. Yeah. QT is the amount of shunted blood or I'm sorry, cardiac output. So that would be like an echo. So that's not going to be cheap. Tidal line, we might do that, but it's not going to be quick. Bowel sounds, vital capacity, maybe, but it's not quick. All But do you see, we're going to come through here. We're at the end. Come through here. Do we have any type of an emergency present? So we can go through this a second time. Anytime you're dealing with a neuromuscular disease, you want to get spontaneous pulmonary mechanics. You need a baseline. You need to see, even though she looks like she's doing good, let's just see where she's at. Because if it's neuromuscular, those pulmonary mechanics may deteriorate. So MIP, negative 60. That's good. Tidal volume, that's part of it. 400. That's a good tidal volume. and then vital capacity 2.3 it's a great bottle capacity also really anything for the most part over over about 1200 is going to be a good bottle capacity want that 1.2 liters or 1200 milliliters so once again the bottle capacity okay so do we want is there anything we really have to implement I mean do we have anything to correct But we don't want to send her home, right? She's having trouble walking. So maybe we just admit and monitor. That sounds rational. But that's not there. So based on the information you've obtained, what do you want to recommend? Select only one. Yeah, two. We just, I mean, there's no reason to give her albuterol. That's wrong with her airway. There's no reason to start her on oxygen. There's no indication for it. There's no indication for PEP. There's no indication for IS therapy. but there might be an indication to go ahead and do some further testing because we can diagnose Pion-Barré if that's what we think it is. All right, so now, which of the following lab and diagnostic tests would you recommend at this time? Okay, we need to know where she is now. Everything's normal now. We want a good complete assessment of her cardiopulmonary status, okay? None of these really, except maybe the pulse ox, is going to be quick, easy, and cheap. They're all going to cost money. Okay? So we need a baseline status. Do you think an x-ray to see her lung status would be a good idea? I do too, because neuromuscular disease is going to impact how she breathes, and they may develop atelectasis. So let's see where we start. A CBC. She had a recent viral event. Not that that necessarily changes white blood cell, but we probably should look at that because just to see. Plus it also tells us about our oxygen carrying capacity. Okay. So that's normal. Also chest x-ray is normal. P50. No, that's that point on the oxygen hemoglobin dissociation curve where the hemoglobin is 50% saturated. We don't think that's always a distractor. Physiologic dead space. Paco, people, Paco. seem to know 88 gradient on a hundred percent I'm seeing hesitancy so let's skip it for now ABG okay we'll give it for now FRC that would mean we'd have to take them to the pulmonary lab and do a complete PFT that ends I like it probably a good idea electrolytes Neuromuscular electrolytes alter muscle function, right? So let's make sure she doesn't have an electrolyte problem. That makes a lot of sense. And if you're going to get a CBC, you might as well get a set of electrolytes also. Oxygen consumption is a big metabolic part to see how much oxygen the tissues are consuming. And there's really not an indication for that. She's really not coughing anything up because her chest x-ray is normal, right? And now cerebral spinal fluid protein count. Guillain-Barre, here's one of the diagnostic tests. Guillain-Barre has higher levels of protein in the cerebral spinal fluid. So this is one of the differentiating things for neuromuscular disease. All right, so we're going to get that. It's elevated above normal. This is pretty indicative of Guillain-Barre. So some of this other stuff now, looking at it, you just got to ask yourself, do you want it? As a therapist, some people might want an ABG. I need you to tell me if you would like anything else, and I will click whatever you would like. Now, remember, you don't have to be perfect. We just have to be competent, which we want to be able to pass it. Seven. Okay. And this is where I usually say, okay, now I'm going to stop because we wanted an ABG. And I would have thought myself too, out of all of these, if I wanted something, what I wanted the most would have been an ABG because I'm a respiratory therapist. But it's saying not evaluated. And if I'm not going to be able to evaluate an ABG, I don't know how I'm going to do Paco, people, Paco, because I don't have Paco. Right? and I'm not going to be able to do the A to A gradient because I don't have a PAO2, so that doesn't make sense to me either, all right? So I think we've probably assessed pretty good. Do you agree with that? And really, nothing's wrong right now, okay? We just have a good baseline. So I'm going to go to the next section. Yep, four. See isn't that weird when nothing's wrong and you're like, I don't know what to do because I feel like I should be doing something. Okay, nothing's wrong. You don't have to worry about it. Okay, so here we go to the next section. Eight hours later, oh, she's agitated. She's complaining of shortness of breath. So now it's information gathering. quick easy and cheap first okay pulse and respiratory rate quick easy cheap oxygen consumption ability to swallow you can ask her can you swallow are you having trouble swallowing and she's having difficulty ground the brain see how it's worked its way up if her tongue's not working to help her swallow the muscles of her throat that's quick easy cheap quick easy cheap is what we're doing we look through here breath sounds diminished saps for 91 quick easy cheap you can look at tracheal position if you want it's not gonna hurt anything but I don't know if it's really relevant but you can do you want to it's not gonna hurt anything and it doesn't cost anything okay if it doesn't hurt and it doesn't cost it's probably gonna if it won't lose you points the worst it's going to be is zero points. So if you don't want it, we don't have to get it. There's no really reason. You're not worried about a unilateral disease process, right? Okay, you don't have to. That's fine. Okay, so here we go. All we have so far is 115, difficulty swallowing, 91, diminished breath sounds. I don't have enough to say it's an emergency. She's just in distress. Let's go through this again, okay? Relevant data. Like, do you want those pulmonary mechanics again? Because we did them before. Do you want them again to see if they deteriorated? Yeah. Okay. So while I go, title volume was 400. Now it's 250. I'm just going to get the pulmonary mechanics real quick since we're talking about vital capacity while ago was 2.2. We can always go back to the history, but it was over two. Now it's 1.1. Definitely deteriorated. MIP was negative 60. Now it's negative 22. Anything else you feel like you want? I can still do a truncate position, right? Okay, we can do that. Anything else you want here? I skipped some when I was just getting pulmonary mechanics. So we're going back through and getting relevant seven. Yeah. Okay. And that probably, if you look, it's probably everything. And now we got to look at what's going on. We have a blood gas that has deteriorated, but it's not true ventilatory failure yet, because that would be a pH less than 7.30, right? Okay. We have an MIP that's significantly... less negative. We've gone from negative 60 to negative 22. She's lost muscle strength, but critical would be something greater than negative 20, like negative 19. So this isn't quite critical yet. Biotic capacity has dropped a lot, but it's not quite critical yet. It almost is, but it's not. Tidal volume is 250. It's dropped lower. So do you see how when I first took this stem, I was like, man, I feel like they're putting me right on the fence. They're giving me stuff that she's getting worse, and I have all the data that she's getting worse, but none of it says push the button and intubate her and get her mechanical ventilated, right? There's nothing that says pull the trigger on it. But when I come back up here and I see that she has difficulty swallowing, here's where I say, hmm. If you're having difficulty swallowing, you can't manage your own saliva. When you can't swallow your own spit, do you think your airway is compromised? Probably so, yeah. So if your airway is compromised, don't we need to intubate to protect the lower airway? And with the rest of these things right here, if we're going to intubate, let's go ahead and start mechanical ventilation. So the clincher for me... is this right here along with those? I've got an airway compromise, and we're so close to critical. Let's go ahead and get her on the vent. Yeah, Ladies. Now, when we're taking this test, if that first one where it said difficulty swallowing, and then we were like, okay, maybe we go to the next section, because that's almost an emergency situation, will we lose? Will we not gain the other points, or how would that affect the testing? Yeah, you're absolutely right. you would give up the other points that we got here. So that's why going through quick easy, even if you hit something that like the blood pressure was low, don't immediately stop. Go ahead and get your quick easy. You've got to have at least a baseline assessment. And what we had, even though it was difficulty swallowing, We didn't have the rest of it to compare it to. So just saying, well, I'm having a hard time swallowing might not be airway compromised. But when you see it in relation to the muscle strength deteriorating, it then begins to be more of a problem. Does that make sense? Yes. Thank you. Okay. All right. So here we go. Intubate and ventilate is what I think I heard. I think what we kind of talked about. So let me see how I don't read this. Based off of the information, select only one. Yeah, five. Good. You read all the way through. See how they put intubate in place on a 40% T-piece, right? So if in your mind you were saying intubate, ventilate, and that says intubate, you might accidentally click that. You've got to make yourself read it all because this is where we need to go. Patient is intubated. So he's intubated. She's intubated. Transporting to ICU. You're ventilating her with a manual resuscitator. You notice that there is a mental resistance when compressing the bag. So you're squeezing the bag and it's easy to squeeze. but the chest doesn't rise. So anytime the bag is easy to squeeze, but there's no chest rise, there is a leak in that system between giving the patient the air from the manual resuscitator to the lungs. There's some kind of leak in that system. We have to find it. I'm seeing three. and then I saw one. Okay, because one says leak, right? And three is leak. So probably going between these. So let's talk this out. The reservoir bag is that bag at the end of your ambu, and all that does is allow us to give a higher FiO2. So even if there is a leak in that reservoir bag, that just means some of the oxygen doesn't get into the bag, but it flows into the atmosphere. We will still be able to bag the positive pressure in the chest. This won't cause a leak in the system, it's just a leakage of oxygen. but your cuff not being inflated properly when we bag the air goes in around and back up so the chest won't rise so this is our true leak in the system so they inflate it to minimal weight I'm not really pleased with that but the problem is no longer present we fixed the issue and now she's in ICU we want vent settings here we go again with all the vent settings so I still like rate to weed out with we just have a few difference in those of what we've been taught and it's not that big of a deal we'll deal with it so do you like 20 with what you've been taught do you like 20 please let this you know I know you like 12 I like 12 to you like 14 not 14 also there's 12 and that's eight, and that seems that's a little bit low. So I think we're caught right in the middle as far as we've got rid of one and five, so we're now right in the middle. Then I usually go to FiO2. Okay, FiO2 is what they were on prior to. If you know nothing about the patient or they weren't on any oxygen, 40 to 60 is a good FiO2. Well, that hasn't really helped us, and really don't even like 60. I'd rather 40 to 50, right? So... probably can throw out 60, but that tidal volume, she was five, five one, five three. She was petite. I have to go back and see how tall she is. Five three. Okay. So that tidal volume is too big, isn't it? Okay. So now we're between two and four. Four fifty and five hundred. So this is where they're forcing your hand and you're going to have to calculate it. Ideal body weight, six to eight mls per kilo. Or if you're chancy, see on a test, especially as a student, I wouldn't risk it. I'd calculate it out if I were you. 5'3 equal to ideal body weight is around 120? 500 looks close. Ladies, do you all agree? It's the higher end actually. It's the higher end. Okay. But it's still 8 mLs per kilo? It's between 6 and 8 still? You know how to run it again. I'm sorry. Take 120 divided by 2.2 and that's their kilos. I got 436 for the high-end. I'm correct. Well, 436 the high-end, 500 would be really high. I didn't do the math. I'm sorry. So it would be 450. I'm sorry. Ladies, what do y'all think? Okay. Let me bust down my calculator. Let me just check it real quick. All right. So 120 divided by 2.2 equals times 6. 327 is the bottom number. Times. 8, 320 to 436. 436 is our 320 to 436. So the higher end. Okay. So that's a little high. Wait, that's too high. That's too high. So we can go back up here and here's 400 with a rate of 20. So we need a first and a second option. You've done really, really good. So don't be scared to make mistakes. Do I have a title line for number five again? Title line for number five was 500. I mean, 400 would be a final decision for me. Okay. What do y'all think about that? Okay, have yourself a backup. If they say no to this, go for your backup. What's your backup if we go here? That would be the 450. Okay. Ladies, what do you think? I'm thinking 450. I'm sorry, what? It was a 6-1 down there that was 400, but I think the PEEP was. With the rate of 18, pressure support of 8, PEEP of 10. Okay. So that's, with that PEEP, it's probably a no-go, right? Okay, so right now I hear the strategy of trying one. If I get a physician disagree, then go into four. And these are choices you're going to have to make. You don't have to be perfect. There's a lot of right ways to do things, and you're not wrong in your rationale. But don't be scared to get a physician disagree because you've got a good, solid backup plan. So are we going to go for one? Okay. That's okay. We have a backup plan. We have a backup plan. And sometimes they do this to say, can you, okay, well, if the doctor tells you no in the hospital, you've got to just, you've got to come up with something else, right? Okay, so we're going four. Okay. We're not getting mad about it. We're setting the patient up on the vent. Seven, four, nine, 30. We're hyperventilating. 95 which of the following would you recommend at this time well they're hyperventilating we don't need to leave it the same right peep doesn't do anything for hyperventilation we can decrease the tidal line by 50 which is what you wanted to do well ago huh when you wanted 400 we don't really ever add dead space intentionally that would bring this up that would work but we don't usually do that we usually adjust minute volume and pressure support changes spontaneous tidal volume but so what do you think out of this option yeah doctor likes that and now we're reading 40 out of 42. So do you see even that, even that, that you were so anxious over a baby about getting it wrong and not liking the options, you parceled through that perfectly, okay? You did a great job, so don't be afraid to be wrong, but be logical about it. So 40 out of 42, you only needed 31. We got nine off of this one, six off the first one, so we're rolling in tomorrow with 15. Okay, we'll see how tomorrow morning does and we'll roll into the next clinical simulation when we really start our day with the higher of the two. Okay. So we'll start straight up. Y'all will start straight up on the 10 o'clock my time, whatever time that is your time. And we're gonna start with clinical sims. We're going to bring this back because this is the most unfamiliar. We're going to start with two in the morning and then we'll go into doing a lot of mechanical ventilation tomorrow. Okay. All right. Thanks for sticking with me. See you all in the morning. Good night. Good night. Good night. You're very welcome. Thank you. Thank you. Glad you like it.