1998 OPEN FORUM Abstracts
Respiratory Therapists in the Emergency Room
Mr. David B. Morgan, RRT, RCP
Today's Respiratory Therapist can offer a lot of diagnostic and treatment options to emergency medicine and trauma surgery house staff in the emergency department. Of course many RT departments make arrangements for coverage for intubated patients in the emergency room, but we feel a better solution is to assign the therapists to the emergency room as a full time assignment. Coverage for the critical patients is then at the department on arrival.
National Asthma Education Prevention Program guidelines call for spirometry to be performed in the diagnosis and management of airway obstruction. Adult patients are evaluated by peak flow measurements taken before and after bronchodialator therapy Pediatric patients have been set up with a mechanism by which nebulizer rental for home therapy can be initiated in the emergency department and for some patients this avoids a 23 hour observation admit just because a nebulizer broke at night or on a weekend.
Patients are evaluated for hypoxia by pulse oximetry and for obstruction by peak flow measurement. The guidelines for evaluating reactive airway disease as published by the NAEPP are taught to the residents rotating in the emergency room. If the patient improves from three treatments or less discharge planning from the ER includes aerochamber training and metered dose inhaler technique instruction. The patients are to measure their peak flow daily and record it in the diary provided. We advise patients to bring this diary with them on their first follow up appointment with their primary care providers and ask their PCP to recommend an action plan and any continued care based on their response to therapy.
Interns and residents have classes presented to them from faculty on the use of anti-inflammatories and antibiotic therapy for respiratory infections. From the RT staff the interns get bedside instruction in the evaluation of peakflow and hypoxia. This is not a simple topic to get across especially since the evaluation of subjective dyspnea is probably one of the most complex of differentials. Patients can then be reevaluated by the RT to determine the response to oxygen or bronchodialator therapy. A patient that remains under 50% of their predicted peak flow is then evaluated for a continuous medication nebulizer.
The addition of CPAP machines to treat congestive heart failure has also increased the interactions of RTs in the ER. We have also placed downs flow generators in the ambulances in our community under guidelines from the emergency services medical director. When a patient receives CPAP in the field with 100% oxygen via a nasal mask by paramedics and then are transferred to our facility, they are transferred to a bedside CPAP machine without incident. The RTs from the ER were also instrumental in training the paramedics in the initiation and evaluation of CPAP.
The presence of RTs in the emergency department can facilitate questions we haven't begun to ask. Is there any role for heliox in the treatment of acute obstruction in the ER? If a severely dehydrated patient requires intubation, should peep be started right away or after the first liter of fluid is given? Point of care testing, should it include lactate in the ER setting? Can an end tidal carbon dioxide tester be used as an evaluation of the effectiveness of compressions in CPR?
The 44th International Respiratory Congress Abstracts-On-Disk®, November 7 - 10, 1998, Atlanta, Georgia.