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RTSO

Summer 2013

Airwaves

www.rtso.ca

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www.rtso.ca

RTSO

Airwaves

Summer 2013

President's Message from Rob Bryan A-EMCA, RRT, AA Greetings and on behalf of the RTSO Board of Directors, I would like to welcome you to another edition of the RTSO Airwaves. I would also like to take this opportunity to thank Dave McKay and Elizabeth Biers for all their hard work putting together another fantastic issue. I hope everyone has had a chance to read the special edition of Airwaves that kicked off the new membership year, as well as highlighting the RTSO strategic plan for next 3 years. If you have any questions regarding the new membership program or the strategic plan, please feel free to contact the RTSO head office and one of our Board of Directors will be very happy to follow up with you. At this time, I want to extend my congratulations to Christiane Menard, Angela Coxe, the CSRT Board of Directors and all of the CSRT staff for putting together a world class meeting and education forum in Niagara Falls on May 30th to June 1st. The CSRT education conference and trade fair was filled with fantastic speakers and entertaining events that left everyone there filled with fond memories and some new friendships. I would also like to acknowledge Jim McCormick and thank him for his work with the CSRT Executive as he ends his term as outgoing president and welcome Jessica Cox from Newfoundland as the incoming president of the CSRT. Next year, the CSRT forum in Montreal will be an event of celebration, as it will mark the 50th anniversary of the CSRT and the profession of respiratory therapy in Canada.

Over the last 3 months, the RTSO has been very busy working on several initiatives to promote the profession and assert our position with key healthcare stake holders in Ontario with regards to our efforts to provide professional advocacy and continuing education. The RTSO has put together a very robust membership portfolio for the next membership year which will include enhanced programs and liability insurance to all the RRTs in Ontario. The new RTSO membership platform starts July 2013 and will deliver an array of value ads including professional and political advocacy campaigning around lung health strategies and expanding the role of the RRT in the “out of hospital” setting. To enable a better chance of success, we are strategically partnering with the Ontario Lung Association (OLA) and the CSRT to promote this extension of our expertise in healthcare delivery. The RTSO is also working collaboratively with the OLA and our provincial respiratory therapy educational institutions in an effort to provide a broad range of CME programs utilizing high fidelity simulation labs and workshop-based programs for our provincial evening education series and fall education forum. Our main professional advocacy for the new membership year is with regards to the role enhancement of the RRT in the community. The RTSO is working closely with the CRTO and OLA with a goal towards establishing a formal

RTSO Airwaves Summer 2013

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President's Message from Rob Bryan A-EMCA, RRT, AA role that will be recognized by the Ministry of Health and Long Term Care (MoHLTC) as well as developing a list of services provided by RRTs in the Community Care Access Centres and Family Health Teams throughout the province. Our primary care and community respiratory care advocacy committee is headed by Dr Mika Nonoyama, John McGrath, and Stephanie Rotella.

Board of Directors with the RTSO for their time and dedication and donation of prizes for the penny auction. The success of this event would also not have been possible without the generous donation to the advanced practice bursary programs from Drager Canada, Smith’s Medical Canada, Trudell Medical Canada, Romlex International Ltd., and The Avery Professional Group.

The other hot topic of interest that the RTSO is following is the clinical workload measurement and statistics collection project by the Canadian Institute for Health Information (CIHI). The RTSO has continued to be engaged in this topic for over 3 years since our initial meeting with CIHI, the MoHLTC, and our leadership committee that was hosted at Mackenzie Health. Since then the RTSO has been involved in two feedback surveys with their consultant providing our local perspective. CIHI has taken the initiative to re-evaluate the workload measurement system used by RRTs to ensure the system is reflective, accurate and robust in capturing RT workload especially as our practice continues to evolve in this new era of healthcare delivery. CIHI has also asked for RRT representatives from all areas of practice across the country to submit their CV and intention to participate in this national project. Those from Ontario will provide our provincial perspective. The CSRT is engaged in this endeavour as well, providing our national perspective and the RTSO has been identified as a stakeholder with CIHI in providing updates and ongoing communications to RRTs in Ontario as this project evolves.

Further, I would specifically like to acknowledge and thank AbbVie (formally Abbot), manufacturer of Sevoflurane, for sponsoring a new advanced practice bursary program to support RRTs in their pursuit to become Anaesthesia Assistants with advanced certification. The RTSO RRT AA bursary fund was launched at our fundraiser with AbbVie generously providing $20,000.00 over 3 years. This money will be offered as two $5000.00 awards to be given out this fall and one $5000.00 award for 2014 and 2015. This program will help grow and sustain the number of RRTs in the field of anaesthesia care by providing financial support to those interested and enable them to achieve their career goal. Please refer to the special notice in this edition of the RTSO Airwaves regarding the application process for this award. There is a very tight timeline for applicants with a deadline targeted by the middle of September with an announcement of the award at Inspire 2013, the RTSO fall forum.

And now to some great news!!! More funding opportunities have become available for respiratory therapy driven research, academia and advanced practice training. It is my pleasure to inform the membership that the research and academic committee is growing and expanding. The annual research and advanced practice fundraiser was held at Silver Lakes Golf and Country Club on July 5, 2013. The event this year saw an increase in registrants by 25% and raised $30,000.00 (after expenses) for research and advanced practice bursary programs. I want to say thank you to Stephen Laramee for all of his tireless efforts in making this event a huge success. I would also like to thank the entire

As you can see, these are exciting times for the RTSO. Your colleagues, who volunteer their hours for the advocacy, educational needs and growth of the respiratory therapy profession in Ontario, continue to do an exceptional job for all RRTs. If you are interested in volunteering with the RTSO, please contact the our head office at [email protected] On that note, enjoy the summer and another great edition of the RTSO Airwaves!

Rob Bryan

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The Annual Research and

Advanced Practice Fundraiser

July 6, 2013 Silverlakes Golf & Country Club

Top left: In anticipation of a great day of golf; Middle left: Stephen Laramee and Rob Bryan President RTSO in front of the prize table; Lower left: tournament winners "The Smiths Medical" foursome with Rob Bryan behind them and Stephen Laramee to the right; Top right: putting on those immacuate greens of this perfectly manicured course: Lower left: speaking of manicure, Gloria Bello and Dr. Mika Nonoyama enjoyed a day at the Spa before rejoining the golfers for a delectible dinner. Thanks to everyone who made this day possible (see Rob Bryan's message for further details)


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Thank You To Our Contributors

Lucy Bonanno MBA, MA, CAE, CHE

Management's Corner Page 38

Carol Columbus

Opening Doors on Dead-End Streets Page 9

Michael Esterlis, RRT

Mode Comparison in One Lung Ventilation A Call to Research Ventilatory Strategy in One Lung Ventilation— Does Volume Control Ventilation Result in Hazardous Pressures Attributed to Acute Lung Injury? Page 30

Elizabeth N. Harvey

Advocacy in Action for Respiratory Therapists Promoting Lunch Health in Ontario - An Immaculate Reception Page 6

Jane Heath, RRT CRE

Lucky 7 Page 40

Ana MacPherson, MASc, CRE, RRT

Spotlight on Ana MacPherson Page 34

Dave McKay, RRT

A Breath of History in Time Page 10

Suzanne McVety, RRT

Regional Respiratory Rehabilitation Program Page 19

Ginny Miles, RRT

New Smoking Cessation Program at the Royal Victoria Regional Health Centre Page 15

Ray Milton, RRT

Welcome to Kingston General Hospital Page 22

Jenna Muirhead


Executive Director, Summerville Family Health Team Manager of Respiratory Therapy, Bluewater Health, Sarnia

Lakeridge Health Regional Respiratory Rehabilitation Program Smoking Cessation Program Royal Victoria Regional Health Centre

Clincial Leader - Respiratory Services Kingston General Hospital Photo contributor for Advocacy article

Mika Nonoyama, PhD, RRT


Derry Thibeault, RRT

Welcome to Kingston General Hospital Page 22

Charge Respiratory Therapist - Critical Care Kingston General Hospital

Front Cover Photos: - Left: Michael Esterlis and friends; Right: Ana MacPerson and friends RTSO Airwaves is a publication of

and may not be copied or duplicated in full or in part without prior permission.

Editor - Dave McKay, RRT Layout/Design - Elisabeth Biers

Opinions expressed in RTSO Airwaves do not necessarily represent the views of The RTSO. Any publication of advertisements does not constitute official endorsement of products and/or services.

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Special Announcement regarding The

Anaesthesia Assistant Advanced Practice Award

Thanks to an unrestricted educational grant from Abbvie (formerly Abbott Laboratories), the RTSO is able to offer a $5,000 award for the Anaesthesia Assistant Advanced Practice Award to be presented at Inspire 2013 RTSO Clinical Education Forum on October 19, 2013. The venue is the Michener Institute in downtown Toronto. The application deadline has been extended to September 16, 2013. Further information, including the application form and the full instructions are located at www.rtso.ca under the Research Committee/Funding/AP Awards tab.

Advocacy in Action for Respiratory Therapists, Promoting Lung Health in Ontario An Immaculate Reception Dr. Mika Nonoyama Elizabeth N. Harvey Photos: Jenna Muirhead

Submitted by

What is it like to have a lung condition in Ontario and what can be done to improve the prevention, diagnosis and treatment of lung disease in the province? Those were the questions being asked, and answered, when the Ontario Lung Health Alliance hosted its Breathers United reception in a packed-to-the-rafters members’ dining room at Queen’s Park on May 6. The reception was organized to give Members of Provincial Parliament the chance to meet constituents who have lung disease, as well as their caregivers and health-care providers, and to hear the primary message of the Breathers United movement – that Ontario needs a comprehensive, coordinated plan to address chronic lung disease. More than 25 MPPs attended the reception, where they mingled with representatives from the Ontario Lung Health Alliance’s partner organizations and more than 150 Breathers United members and lung health champions from every corner of Ontario. Ontario Lung Association president and CEO George Habib welcomed guests on behalf of the Alliance and urged MPPs to take the important Breathers United message back to their caucuses. The crowd listened to messages of support from the Minister of Health and Long-Term Care, Deb Matthews, opposition health critic Christine Elliott and NDP health critic France Gélinas.

Group photo at Queen's Park - the Ontario Lung Health Alliance Lobby Day on May 6th 2013. Pictured from left to right are Dr. Mika Nonoyama, Stephanie Rotella, Dilshad Moosa and Michiko Bishop (daughter of Dr. Nonoyama).

Helping to spread the Breathers United message were about a dozen respiratory therapists! Mika Nonoyama and Stephanie Rotella from the RTSO board joined the effort as did Sara Han, provincial Primary Care Asthma Program coordinator and Diane Feldman from the Lung Health Help Line. Diane Michaud from Niagara Health System and Lise Carriere from Southlake Regional Health Centre travelled to the event with patients from their pulmonary programs. Other health professionals in attendance included respirologists, nurses and pharmacists.

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Advocacy in Action for Respiratory Therapists, Promoting Lung Health in Ontario An Immaculate Reception Dr. Mika Nonoyama and her daughter Michiko Bishop with the MInister of Health Deb Matthews

Helping to provide a face to lung disease were individuals living with COPD, asthma, lung cancer, pulmonary fibrosis, pulmonary hypertension, cystic fibrosis, alpha-1 antitrypsin deficiency and other chronic lung diseases, as well as people who have had successful lung transplants, and some who are listed on the donation waiting list. You can see more photos from the event in the “Breathers United at Queen’s Park” album on the Breathers United Facebook page www. facebook.com/BreathersUnited Spreading the Word Riding on the success of the Breathers United event at Queen’s Park our Past President, Dr. Mika Nonoyama, met with her local MPP, The Honorable Michael Coteau, Minister of Citizenship and Immigration on May 24th 2013. During this meeting Dr. Nonoyama provided an education about the RT profession; related the

extensive burden of lung disease; and stressed the importance of a Lung Health Strategy in Ontario (together with Elizabeth Harvey from the Ontario Lung Association). We encourage other RTs to meet with their local MPPs to spread word about the important role of our profession and promote Lung Health in Ontario.

Dr. Mika Nonoyama with her own MPP Michael Coteau during a meeting on May 24, 2013 to advocate for lung health.

To learn more about the Breathers United movement and how you can get involved in advancing lung health in Ontario (including how to meet with your local MPP), contact Ontario Lung Association’s Provincial Manager of Government Relations Elizabeth Harvey at [email protected] or 1-888-344-5864 x279.


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Opening Doors on Dead-End Streets Submitted by

Carol Columbus,

Manager of Respiratory Therapy, Bluewater Health, Sarnia This article has been reprinted with the permission of Fisher & Paykel Healthcare

Respiratory Therapists at Bluewater Health in Sarnia, Ontario, Canada, were struggling with a patient transferred from another hospital. After several hours trying all known options, they turned to a recently demonstrated humidified nasal cannula called Optiflow. Within 90 minutes, the patients was sitting up, smiling, and solving a crossword puzzle. Background Bluewater Health in Sarnia, Ontario, Canada, is a 250-bed hospital with a 16-bed Critical Care Unit using Drager V500 ventilators. Armed with budget approval for a high flow device, respiratory therapy manager Carol Columbus, requested an in-house Optiflow demonstration. She was impressed with the high flow nasal cannula’s straightforward connection to their existing ventilators and how easy it was to use. The local Fisher & Paykel Healthcare representative left a sample cannula, along with a heated circuit with Carol along with instructions for use. The Challenge that Opened the Door A respiratory patient, who had spent a full day at a rural hospital with no success, was transferred to Bluewater Health in Sarnia. After trying a variety of devices over two hours, Bluewater respiratory therapists were running out of options and sought advice from respiratory therapy manager, Carol Columbus. The decision was made, with the patient’s consent, to try Optiflow for the first time. “With other devices, the patient had been on 100%, sating at about 89% to 90% and even lower in many instances. After an hour and a half on Optiflow, we had the patient down to a FiO2 of about 70%,” explains Carol. “The patient said he loved it,” explains Carol. “It was just so weird because he was very ill and then in no time he was doing a crossword puzzle and answering the phone. He was free to eat, drink and do all that stuff.”

Early success leads to further applications Encouraged by further successes with similar patients and when weaning a tracheotomy patient, the focus soon moved to extending the use of Optiflow. “We have three intensivists on rotation in our unit and they’re quite happy with the results’” explains Carol. “The ICU nurses are very positive because they’re seeing results; they’re seeing that patients are enjoying it and it’s doing what it’s supposed to do.” “BiPAP masks are really labour intensive. When patients have a mask on and they feel claustrophobic or they’re air hungry, they’ll rip their masks right off. They’re certainly more receptive to a nasal prong,” says Carol. “Optiflow has given us another option before intubation and because it fits our existing equipment, it hasn’t required a big investment,” explains Carol. “When we don’t have to ventilate patients, we’re probably decreasing length of stay and decreasing VAP rates as well.” Beyond the Critical Care Unit Carol is now talking with local homecare providers about using Optiflow with Airvo (Fisher & Paykel’s compact integrated flow generator) when patients could be discharged to home if higher flows were available. “There might be some expense involved, but there is a considerable expense involved in keeping them here in the critical care unit to provide that effective oxygen therapy,” explains Carol. In addition, Carol can see benefits in a standalone unit in the Emergency Department that could be moved to other areas as required. She is also exploring the potential for pediatric applications. As is often the case, necessity has opened the door to a new path. For Bluewater Health, it is leading to a new world of oxygen delivery with Optiflow.


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A

Breath History in Time submitted by Dave McKay RRT

First and foremost, I must make my apologies to Professor Stephen Hawking and his work, A Brief History of Time, for the title. I’ve often thought that medical history, specifically the history related to respiratory therapy, had some really unique stories as well as a few curious personalities and characters. As such, we at the RTSO Airwaves have developed this new regular feature (when we have time and space) to look at some of the more relevant figures and events in our history in hopes that they might offer an interesting read. - D.M. By the end of the 18th century, many methods of “artificial respiration” as it was termed had been developed, trialed and discarded. Several parties, particularly the Royal Humane Society of England, a major participant in the resuscitation movement that was evolving throughout Europe, supported the use of a bellows as a means of respiratory inflation. This means was eventually refuted and discarded due to its lack of control and its inability to meet the characteristics (specifically size and weight) of individual patients. As well, it became apparent that there were undeniable risks associated with the use of positive pressure. For the next century, debates continued and devices were developed by various physicians, back-room mechanics and inventors alike. Most of these strategies focused on utilizing negative pressure and successful attempts were first described by Scottish physician Dr. Jack Dalziel in 1832. Even Alexander Graham Bell made an attempt to create a functional mechanical device by fashioning a metal jacket to a hand-operated bellows to create a vacuum that would facilitate breathing. Bell developed this posttelephone invention in the 1880s in the aftermath of his infant son’s death. It was reported that he had succumbed to respiratory failure and Bell was wrought with the frustration that nothing could be done. What Bell would later realize is that his device was a forerunner to one that would combat the challenges of the polio epidemic in the next century.

independent of human kinetic energy transference. In other words, pumping a bellows was no longer necessary. As such, in 1918, Dr. W. Steuart of South Africa was able to produce a sealed wooden box that operated by a variable-speed, motor-driven bellows. By all facets, the iron lung was born albeit still a very rudimentary technological apparatus. For the next decade, research and development continued throughout the world to establish a viable system to support ventilation. In 1926, the Consolidated Gas Company of New York launched a committee to research resuscitation in an effort to improve the safety standards for its employees. Upon the recommendation of his father who sat upon the committee, the company approached Dr. Philip Drinker and his colleague, Dr. Louis Shaw to lead their endeavour. Drinker and Shaw had already spent that past two years investigating artificial respiration so the $5,000 provided by the committee only enhanced the capability of their research.

Philip Drinker was born in 1894 in Haverford, Pennsylvania and spent much of his youth on the campus of Lehigh University where his father was president of the school from 1905 to 1920. He went on to graduate from Princeton in 1915 and following that returned to Lehigh for post-graduate studies in chemical engineering. After service in the army and two years working in industry, he took a position with the Harvard University School of Public Health, the first of its kind in the United States. He later Many attempts at encasing a patient within a wooden became an instructor in public hygiene. box and utilizing negative pressure to ventilate them continued during the latter parts of the 19th Because of his work with air analysis, ventilation century but the advent of electricity finally provided and illumination, Drinker was later approached by an ability to develop a device that could operate the Rockefeller Institute for Medical Research who 10


A bReath of History in Time offered a position to investigate and develop resuscitation methods following electrocution and gas poisoning. Drinker gained considerable knowledge and made several advancements during the 2 years he spent in this position which then allowed Consolidated Gas to quickly step ahead in its endeavour when he finally accepted their offer. With the financial backing provided by Dr. Philip Drinker Consolidated Gas, this partnership better enabled Drinker and Shaw to achieve their goals. During their experimentation, Drinker and Shaw would place an anaesthetized cat paralyzed with curare in a sealed iron box with a neck collar so the head was exposed to atmosphere. This enclosure would create the necessary environment that would allow the use of rotary blower air pumps (vacuums) that could apply rhythmic positive and negative pressure changes to the chest wall of the cat without varying the pressure at the mouth. The experiment was successful and proved that a controlled pressure in a sealed environment had the capability to induce artificial respiration despite the lack of any effort made by the test subject. As a result of this discovery, the relationship with Consolidated Gas proved fruitful and because of their outcomes and achievements, Drinker and Shaw received an additional $2,000 from Consolidated Gas which then allowed them to focus their development on a device suitable for human use. The achievements of Drinker and Shaw also proved to be timely as the world was facing an ongoing nemesis, that being continued outbreaks of poliomyelitis. Although the inventors viewed their technological breakthrough as a measure of

support for any respiratory illness, it became and will forever have an immediate relationship to the random polio epidemics that began in the second decade of the 20th century and lasted well into the 1950s. These outbreaks became a well rooted fear amongst populations across the developed world and the hope of a viable system that could support ventilation was at the forefront of desire for every community that experienced an outbreak.

Drinker's Iron Lung Several revisions of their device continued and as a result, several technical objectives were met. These included adaptation to a variable population – infants to adults – of all sizes and an ability to regulate the rate and depth of ventilation as determined by that body size. As well, it needed to function on a long term basis and cause no harm to the patient. Finally, on October 12, 1928, Drinker and paediatrician Dr. Charles F. McKhann put the device through its first clinical use when an eightyour-old girl suffered respiratory paralysis resulting from polio. Unfortunately the child died as a result of pneumonia 122 hours later but in those hours, she was able to talk, eat and sleep with minimal respiratory distress. It appeared that despite some notable deficiencies, the Drinker Tank Respirator had proven that morbidity due to respiratory failure could quite possibly be averted. The public quickly and affectionately nicknamed Drinker’s creation the iron lung. In 1931, as a result of sheer demand, a self-taught inventor of medical equipment developed his


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A bReath of History in Time own version of the iron lung. John Haven Emerson was born in 1906 as the son of a physician who acted as the Commissioner of Health for New York City. He never completed his secondary school education but he possessed a mind near genius regarding applied mechanics and technology. At the age of 22, while employed as a janitor at Harvard University, Emerson bought a machine shop from the estate of a local inventor signifying the first day of a career full of invention but also the beginning of a lifetime filled with humanity. In the spring of 1931, Emerson visited the Children’s hospital in Boston and had his first encounter with Drinker’s respirator in full operation. Many of the staff members made issue with the difficulties that the device offered when attempting to provide patient care. John Haven Emerson Emerson was asked to remedy some of these weaknesses and after some thought approached Drinker regarding his ideas for improvement. Drinker subsequently cast him aside having no interest to hear what Emerson had to say. With the encouragement of his father, Emerson instead acted on his own accord and upgraded Drinker’s design making it quieter, lighter, and more efficient mechanically and financially. With a price tag of $2,000 to $2300, the cost of Drinker’s tank respirator in the 1930s equated to the average price of a house. In 1931, spread of the polio epidemic raised demand for tank respirators and Emerson met this challenge by providing a product that could be easily manufactured, could surpass the clinical needs of most patients and offered at a more reasonable $1,000 cost. Further, Emerson devised a method to utilize a flexible two-layered leather diaphragm in placed of the blower pumps used by Drinker. This offered a significant noise reduction when comparisons 12

were made. Other project enhancements included an improved cylinder-like design with portals that permitted access to the patient, improvements to the pressure gauge, easy access systems that better enabled opening/closing the unit and a bed that could slide in and out of it. Two of the more important enhancements included a function that permitted respiratory rate variability as well as emergency hand-operated capabilities in the event of electrical power outages. By this time, Drinker had had a signed agreement with Warren E. Collins, Inc. for over two years which Emerson's Iron Lung provided the company exclusive rights to manufacture his device. Emerson’s movement into the market and the patent infringements perceived by Drinker and Collins caused them to take legal action against Emerson. However, Harvard University intervened and offered a proposal that asked Emerson to withhold commercial advertising of his new design for a 2-week period so that discussions with Drinker and Collins could be held to dissuade the pursuit of legal action. Two weeks later, Emerson received a letter that discussions were still ongoing and he again received a similar letter three weeks after the first. Both offered no release from his nonadvertising agreement. Shortly thereafter, Warren E. Collins, Inc. announced the release of a new model with advanced modifications. Every one of these modifications was simply one that had been developed and incorporated by Emerson. Harvard finally released Emerson of his commitment but at the same time asked that he offer no public disclosure of their previous agreement. Emerson countered by asking Dr. David Edsall, the Dean of the Medical School, whether the university was utilizing the development of these devices to save lives or as a means of financial gain. Without a satisfactory reply, Emerson ignored the ongoing threat of lawsuit and continued to manufacture


A bReath of History in Time his machine as it had been readily accepted by the American Medical Association and demand was high. A few months later, Collins entered a suit against Emerson for patent infringement. In an attempt to avoid public disfavour, their attorneys proclaimed that the suit was not about royalties but rather in the interest of public safety. However, their suit did seek a 10% royalty on the sale of each of Emerson’s machines as well as a fixed-pricing agreement which certainly raised a question of their interest in public safety. During the proceedings, Emerson representing himself presented a counter argument that each of Drinker’s patents had already been previously published by others thus discharging Drinker’s claim that each of his patents were original. Since any patent is only offered to an original or unique idea or invention, the court dismissed Drinker’s suit and each of his patents were declared to be null and void. The court also saw the benefit of multiple manufacturers should a severe epidemic or pandemic arise. As well, it understood that competition stimulated technological advancement while also controlling costs for the buyer. Shortly after the conclusion of these proceedings, Drinker and Collins discontinued their production. Despite the success of Emerson’s product, demand was still not met and unfortunately, like so many locations across the globe, polio was not forgiving in Ontario. In 1937, an unexpected development during the epidemic of that year was the number of bulbar cases of paralysis which impacted both breathing and swallowing and led to much higher mortality rates. Consequently, needs began to rise and mechanics at the Hospital for Sick Children in Toronto gathered parts that they could find within the hospital to assemble 27 homemade iron lungs. This project was financed by the province at a cost between $650 and $700. Similar events occurred in hospitals across the world. The J.H. Emerson Company continued to make their device for the next four decades with heightened production occurring during the epidemics of the early 1950s. However, by the middle of that decade advancements in endotracheal and tracheostomy

tube design had facilitated the return to positive pressure ventilation thus creating a reduced need for negative pressure devices and a reduction in production thereafter. Emerson finally ceased to manufacture their iron lung in 1970. Resources: Emerson, J.H. (1978). The evolution of iron lungs. Retrieved from http://www.polioplace.org/sites/ default/files/files/Evolution_of_Iron_Lungs._for_ PP.pdf Griscom, S. (1933). Paralysis and profits. Retrieved from http://www.disabilitymuseum.org/dhm/lib/ detail.html?id=953 Harvard School of Public Health (n.d.). Philip Drinker, polio and that “damn machine”. Retrieved from http://www.hsph.harvard.edu/news/centennialphilip-drinker-polio/ The Massachusetts Foundation for the Humanities. (n.d.) Mass moments: October 12, 1928. Retrieved from http://massmoments.org/moment. cfm?mid=295 The Museum of Health Care at Kingston (n.d.). Respirator (iron lung). Retrieved from http://artefact. museumofhealthcare.ca/?p=216 The Virtual Museum of the Iron Lung (n.d.) Retrieved from http://160.109.101.132/respcare/ ironlung.htm Photo Credits: Drinker Iron Lung. Retrieved from: http://www. childrenshospital.org/research/polio_gallery/images/ photo91.jpg Philip Drinker. Retrieved from: http://www. polioplace.org/people/philip-drinker-phd Emerson Iron Lung. Retrieved from: http:// artefactspei.weebly.com/iron-lung.html John H. Emerson. Retrieved from: http://www. polioplace.org/people/john-h-emerson


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New Smoking Cessation Program at the

Royal Victoria Regional Health Centre Submitted by

How does an airplane relate to smoking cessation? Indirectly, it does. In effect, if one of these passenger planes crashed every day and all 120 people aboard succumbed to the injuries that they received; it would represent the number of Canadians that die each year from smoking related illnesses. (I must credit for this analogy to Dr. John Oyston, founder of Stop Smoking for Safer Surgery).

Ginny Miles RRT

means being advised to quit at every visit to a health care practitioner in addition to focused counseling and pharmacological support. The majority (70%) of smokers say that they want to quit. Having a health crisis and coming into the hospital is often an opportune time for that desire to be fulfilled, and it is also where and when the smoking cessation program at the Royal Victoria Regional Health Centre takes action. It is very fortunate for the patients at the RVH that their hospital recognized the value and benefits to fund this important cessation program while also believing in the positive outcomes that such an investment would provide. The program that we have developed is based on the Ottawa Model for Smoking Cessation (http://www.ottawamodel.ca/ en_main.php), which has been a hospital- based model proven to increase abstinence rates.

One aircraft crashing daily, with all 120 passengers dead 45,000 per year

The Ontario Ministry of Health and Long Term Care (2005) states that smoking is the primary cause of premature, avoidable death and disease in Ontario. In fact, 16,000 Ontarians unnecessarily die each year as a result of tobacco use and related illnesses. In Canada, tobacco use is responsible for six times more deaths than murders, alcohol, car accidents and suicides combined. You might think that would inspire and engage people to stop smoking and health care professionals to do all that they can to help patients accomplish that goal. However, this health risk is often ignored. Smoking is an addiction and needs to be treated as such, which

The Ottawa Model is based on five systems wide evidence based activities: 1) Identification of the patient who uses tobacco 2) Documentation on the chart 3) Strategic advice to quit 4) Offer of pharmalogical support and counseling 5) Follow up in community. Patients at RVH are identified as tobacco users and documented on the admission assessment. They are advised to quit by their physician, nurse, respiratory therapist, physiotherapist and every other health care professional that comes in contact with the patient, in a helpful, non judgmental manner. Patients know why they need to quit, so instead of a lecture, we offer pharmalogical smoking cessation aids and motivational counseling. Upon discharge, we attempt to refer them to a community program and/or Smoker’s Help Line, and an automatic


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New Smoking Cessation Program at the Royal Victoria Regional Health Centre phone call program that contacts them at intervals of 3 days, 2 weeks, and then every month for 6 months thereafter. If they experience difficulty or require further information, Smoker’s Help Line follows upwith a call. We are approximately

Dr. Andrew Pipe, one of the program’s founders and I was convinced this was an important intervention. Anyone who has listened to Dr. Pipe’s lectures is immediately a convert. Working with a like minded committee with the same belief at the RVH, we finally were able to initiate a similar program here in 2012.

8 months into a ward-by-ward staged implementation and plan to evaluate if the program increases abstinence rates at 6 months. Based on the Ottawa Heart Institute’s success rates, we are expecting a similar 11% increase after a year of full implementation. The ultimate success, of course, is complete and final cessation, however, success can also be defined as increased staff awareness and participation and/or moving a patient from a precontemplative to a contemplative stage of change. All in all, staff and patients recognize that smoking cessation as a program is the right thing to do in a health care institution.

I graduated from the Respiratory Therapy program at what is now the Michener Institute in 1980 and started my career as a staff RT but have eventually along the way gained experiences in management, sleep medicine, COPD education and Asthma Care. I have also acted as a clinical educator and coordinator. Along this path, I have never said no to an educational opportunity and, as a result, have received certifications in polysomnography, asthma/COPD education, clinical education, inter-professional collaboration, smoking cessation counseling and a degree in Health Administration.

Ginny Miles RRT

Given the additional training and certificates received from TEACH and my experience teaching patients and staff, I was fortunate to be hired as the Smoking Cessation Coordinator to initiate the program. It has been an exciting and busy journey as the hospital was physically adding approximately 100 new beds, a new regional cancer center, a cardiac care center and a respiratory inpatient unit at the same time.

An important part of my career has also been the I became interested in smoking cessation when I opportunities that I have had to volunteer and started working on my certification as a Certified support our professional associations, the RTSO Respiratory Educator which I acquired in 2008. and the CSRT in addition to the CRTO. If anything, The Center for Addiction and Mental Health these experiences have offered lots of variety and (CAMH), the Training Enhancement in Applied they have never been boring. In fact, along the Cessation Health (TEACH) project, a knowledge way doors have opened that then offered other translation initiative under the CAMH umbrella opportunities. However, I must say that becoming and Smoke Free Ontario had started offering the Smoking Cessation Coordinator and working courses to clinicians on smoking cessation and I with health professionals, patients and their was accepted into the core course in 2006. At that families and enabling individuals in their journey time, I was coordinator of the COPD clinic at RVH. to overcome their addiction has been the most They offered an adjunct day course the following gratifying experience yet. year on the Ottawa Model, some of it provided by 16


The Asthma Society of Canada: Helping Canadians Breathe Easy

Founded in 1974, the Asthma Society of Canada (ASC) is the only Canadian health charity dedicated solely to improving the quality of life for people living with asthma and associated respiratory allergies. The Asthma Society’s vision is one of every child and adult with asthma in Canada living an active and symptom-free life. As the balanced voice for asthma in Canada, it seeks to advance patient self-management, exacerbation prevention, respiratory disease research and access to medications and quality health care for all Canadians. Working collaboratively with health care providers, the ASC helps patients to take control of their symptoms by providing credible and leading edge information and the guidance and education they need to live their lives symptom free. Working with committed partners from civil society and social services, health and social sciences, and with leading research universities, the ASC advocates for better public policy and industry practices on behalf of Canadians with asthma. Additionally, the ASC has many programs and opportunities for people with asthma; helping them live full, healthy and productive lives. The ASC both understands and appreciates the roles of Registered Respiratory Therapists in

asthma care. In its recent publication, Breathe Easy: Self-Advocacy Guide for Canadians with Asthma, the role of the RRT is highlighted. “Registered Respiratory Therapists have been specially trained to help people who have problems breathing. An RRT is commonly found in critical care areas (such as hospital intensive care units and emergency rooms). They can help in stabilizing a patient and giving you medicine when you can’t take it yourself. An RRT can also perform lung testing, and give asthma education.” (Page 22) RRTs are seen as core health-care providers working with family doctors, Allergists, Respirologists, Respiratory Nurse Specialists, and other Certified Asthma Educators and Certified Respiratory Educators. The ASC is committed to helping the public understand the importance of RRTs and the breadth of their scope of practice. The primary work of the Asthma Society of Canada is to provide evidence-based, market tested, age appropriate asthma information, education, management tools and support programs for Canadians with asthma. The Society provides this information directly through telephone, internet, and print, and indirectly through healthcare providers, primary caregivers, teachers, coaches, employers and community organizations. The Asthma Society of Canada also seeks to support strategic research through project collaborations, which will result in an improved understanding of consumer needs and programs. The Asthma Society of Canada strives to represent the views and best interests


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The Asthma Society of Canada: Helping Canadians Breathe Easy of Canadian asthma consumers with other key stakeholders: government, industry, healthcare providers, and community agencies. The Society also engages in and facilitates dialogue and debate on issues impacting Canadians with asthma. The Asthma Society of Canada has a national office, located in Toronto and employs Certified Asthma Educators and Certified Respiratory Educators working across the country. It also engages volunteers in communities across Canada in a variety of ways. One of its core volunteer-based programs is the National Asthma Patient Alliance (NAPA), established in 2007. NAPA is a grassroots group of volunteers from across Canada who either has asthma or has someone in their life affected by asthma. Their aim is to increase patient awareness about how to achieve optimal asthma control and to address the communication and advocacy needs of these diseases. The first activity of this group was to enable patients living with asthma and allergies and empower them with the Asthma Patient Bill of Rights in order for them to understand their responsibility to properly manage their disease and lead a happy, healthy life. The mandate of NAPA is to be the preeminent network of patient volunteers dedicated to leading advocacy efforts, organize education initiatives and build a network of patient volunteers dedicated to improving asthma care and education in Canada. NAPA's mission is to ensure each and every one of the 3 million Canadians diagnosed with asthma has the support and resources he or she needs to enjoy the highest quality of life possible.

asthma education, peer support and research by raising awareness and money through sport and other physical activities. Team Asthma members proudly wear the Team Asthma logo at sporting events across the country to show that asthma doesn’t need to stop anyone from reaching their goals. Asthma Ambassadors are a volunteer team of Canadians who have committed to providing peer-to-peer support regarding asthma for friends, family, co-workers and others in their community whom they interact with on a regular basis. They also volunteer at health fairs and other events to share asthma information. Occasionally they provide comments to the media on asthma issues. The ASC provides Asthma Ambassadors with training, support and resources and gives them access to Certified Asthma/Respiratory Educators. The Asthma Society of Canada does not have branches or chapters. It provides its services directly to people with asthma through two comprehensive, interactive, educational websites - www.asthma.ca and www. asthmakids.ca - as well as through email and the toll-free Asthma & Allergy Info Line, 1-866787-4050, which is staffed by Certified Asthma/ Respiratory Educators. The Asthma Society of Canada would value and welcome any respiratory therapist who would be interested in volunteering with our organization. Those interested can contact our office via email at [email protected] or by phone via 1-866-787-4050.

Two other programs directly involve people with asthma. Team Asthma is made up of Canadians living with asthma and their friends who support 18


Regional Respiratory

Rehabilitation Program I have been a Respiratory Therapist for 27 years and have never regretted my career choice. During my 27 years, I have worked at numerous hospitals, although the majority of the time has been at Oshawa General/Lakeridge Health. I have also had the opportunity to provide respiratory care in many different settings. Each setting has provided different challenges and opportunities for professional growth and development. After graduation, I followed the typical course of most Respiratory Therapists, working in acute care. Even though this work was rewarding, challenging and ever changing, I looked for new learning opportunities. During the years, I have had the opportunity to work in the operating room, an asthma education centre and currently the respiratory rehabilitation program. While thoroughly enjoying each area I have worked in, I find respiratory rehabilitation extremely rewarding. In this program, I have developed a more comprehensive understanding of the management of chronic lung conditions, including rare conditions that were taught in school but rarely seen in acute care. I am also afforded the luxury of a direct educational involvement that helps patients better understand their condition and the steps that are necessary to manage their illness more effectively. Coupled with the rehabilitation component, it is a rewarding experience to see patients improve the quality of their daily life and prevent hospital admissions. Respiratory rehabilitation is defined by the Canadian and American Thoracic Societies and the European Respiratory Society as an evidencebased, multidisciplinary, and comprehensive

intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities. In general, respiratory rehabilitation is designed to assist patients to improve their quality of life through education, exercise and psychosocial support. The word rehabilitation can often cause patients to arrive with a false hope they will improve their lung function or eliminate the need for oxygen. However, while we do tell our patients that while we can’t change their lung function, we do ensure them that they can become stronger and better able to do their activities of daily living. The goals of respiratory rehabilitation include: • The prevention or reduction of exacerbations and need for ER visits/hospitalizations • A better ability to perform daily activities • An enhanced knowledge regarding the management of their lung condition • A reduced level of anxiety and depression • An ability to return to work for some • A better quality of life Every aspect of the program is designed with the intent to achieve these goals. Education is provided in group settings. Each education session builds upon the others. Topics include: lung function, breathing techniques, lung diseases, respiratory medications, inhaled device techniques, managing episodes of illness and/or exacerbation, energy conservation and relaxation, bronchial hygiene, home oxygen, emotions and fears, intimacy, adopting behavioural changes and healthy lifestyles as well as developing an exercise program to sustain health. Gradually the patient learns what is happening in their


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Regional Respiratory Rehabilitation Program lungs and why these different interventions are helpful on a day to day basis. For example, when patients learn the importance of proper inhaler technique and receive comprehensive instruction, they can apply this information and feel direct and often immediate benefit. These simple outcomes frequently result in buy-in to the program. Education is also provided on an individual basis to address specific patient needs. This education can occur at any moment during the program including the initial assessment, during didactic sessions or exercise, at the end of a session, or even after graduation. The exercise component consists of a combination of stretching, cardio and strength training. The goal of exercise is to improve the patient’s level of strength and conditioning which in time will result in less breathlessness with daily activities, despite lung function remaining unchanged. During exercise, patients learn to apply the new knowledge that they have acquired during their education sessions. For example, while exercising, patients find themselves in situations that cause breathlessness. They can trial utilizing their quick relief bronchodilator prior to exercise to determine if this increases their exercise capacity or they can utilize both diaphragmatic and pursed lip breathing techniques that have been taught to maintain control of their breathing. If they push themselves too hard by moving too quickly from exercise station to another, they are taught to pause and utilize these breathing techniques to regain control of their breathing. This also provides great practice for their everyday life. Gradually patients learn to pace themselves and to recognize when they are pushing themselves too hard. Rather than quitting the activity, they realize that they can pause momentarily, regain control of their breathing and resume the activity. This gives them a sense of personal victory as well as some feeling of control over their illness. Many patients initially say they feel their lives are directed and controlled by their

lung disease and find great benefit when they feel that they have gained some ground against their illness and a firmer control of their life again. Treatment modalities can be explored and barriers addressed and overcome. It is not uncommon to have a patient carry their prescribed oxygen into their initial assessment. The need for supplemental oxygen has been determined, yet the patient is reluctant to use it. This unique setting, where we interact with the patient on a regular and frequent basis affords the opportunity to identify barriers that may exist to its use and directly address them. For some, it can be as simple as alleviating the concerns of using oxygen. Patients often express the concern “they feel they will become addicted to it” or “want to wait to use it when they really need it, to ensure it will work for them at that time”. With discussion, many of these concerns can be alleviated easily. A more difficult barrier is when the patient doesn’t want to wear it in public due to vanity. Over time, we can address the benefits of using supplemental oxygen and often improve the patient’s compliance. As another strategy, we can also allow patients who are reluctant to use their prescribed oxygen to “test drive” it in the gym and actually feel the benefit of using oxygen during activity. They are often quite surprised at how activities feel easier to perform, endurance improves and that they are less fatigued by them. Patients can also be taught their physical limitations due to their lung condition. Work of breathing, resistance and restriction are terms that Respiratory Therapists easily understand from ventilating and weaning patients in the intensive care setting. Just as too high of a respiratory rate on a ventilator of a COPD patient will result in air trapping, hyperinflation, and increased work of breathing, so too will a high treadmill speed cause the patient to breathe at a high respiratory rate with inadequate time for exhalation, resulting in hyperinflation and increased work of breathing. Identifying patients with high residual volumes helps to determine who needs to be monitored

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Regional Respiratory Rehabilitation Program closely during exercise. When the concept of air trapping and hyperinflation is explained to a patient, they recognize that there is a physical reason why they can’t walk quickly and perform strenuous activity. This raises their awareness and helps the patient to understand their limitations and the importance of staying within them. From ventilating an ARDS patient, we recognize the difficulties ventilating a stiff lung. Likewise a patient with pulmonary fibrosis can attempt to diaphragmatic breathe, however, they will be limited in their ability to increase their tidal volume and/or inspiratory capacity. Again, as a respiratory therapist, we easily understand these concepts and can explain to a patient that their inability to increase the depth of their breathing will result in them having to breathe at a much faster rate during exercise. As a result, they start to identify when their respiratory rate is too high which would then cause them to become breathless. This awareness provides an understanding to patients whose lung function may limit their ability to increase their exercise speed and/or perform strenuous activities. We also teach patients that there are times they will be restricted by their lung function and no matter how strong they become or how much oxygen they use, their lung function (whether obstruction or restriction) will create boundaries for them. By understanding their limitations, we can alleviate of laziness and/or guilt. Another situation that can arise during a respiratory rehabilitation session is breathlessness from anxiety or increased shortness of breath due to a change in lung condition. The respiratory therapist’s assessment skills help to easily differentiate between the two and intervene appropriately. From the intervention, patients gradually learn how to manage episodes of anxiety and gain confidence in their ability to do this. Listening to and observing our patients helps us teach them to recognize early warning signs of an exacerbation. Statements such as “it

took me two hours yesterday to strip and remake the bed” can be dissected to find out what is really happening. Patients begin to realize they need to recognize their bodies warning signs and immediately act on them. They begin to take things a step further and go on to determine why they are having difficulty performing their usual daily activities. Are they more breathless than usual? Are they coughing more? Has their sputum production changed? Are their ankles swollen? From here they are able to determine that further medical assessment and intervention is required and to seek help. I can think of many ER visits and hospitalizations that have been prevented by recognizing these symptom changes which had enable patients to receive early assessment and treatment. Respiratory rehabilitation affords a unique opportunity for respiratory therapists to utilize their expertise to augment and improve patient care. On a daily basis, I am required to assess, educate, support, intervene and follow up. I have had the privilege of providing care for the respiratory patient in a multitude of hospital settings. As such, each setting, while completely different, has helped develop, shape and enhance the care I provide today in the respiratory rehabilitation program.

Submitted by:

Suzanne McVety RRT Lakeridge Health Regional Respiratory Rehabilitation Program

Suzanne McVety, her husband Mark and their grandson Garnet


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Welcome to Kingston General Hospital

Above: Kingston General Hospital today as seen from Lake Ontario Right: Drawing of original Watkins building, still in use to this day housing Administrative offices.

Kingston General Hospital (KGH) is a community of people dedicated to transforming the patient and family experience through innovative and collaborative approaches to care, knowledge and leadership. This year we will be celebrating our 175th anniversary. Our place in Canadian history began with the erection of the Watkins building in 1835 but our first patients didn’t arrive until November 1838, when 19 wounded American prisoners were brought to our hospital following The Battle of The Windmill near Prescott. It was a battle won by British troops and local militia from our area who successfully defended the St. Lawrence waterway and Upper Canada. At that time, three years had passed since the original building was completed, but the hospital's commissioners had struggled to secure funding and commence operation. Prior to confederation, Kingston was chosen as the seat of the nation's first Parliament and the hospital was repurposed to serve as its temporary home. From 1841 until 1844, meetings between the provinces of Upper and Lower Canada were held in what is now the Watkins Wing.

Today, KGH is the South East Local Health Integration Network (LHIN) center for complex-acute, specialty care and trauma services and is also home to the Cancer Centre of Southeastern Ontario. KGH serves almost 500,000 people who live in a 20,000-squarekilometer predominantly rural area, as well as some communities on James Bay in Ontario’s north. Care is provided through its Kingston facility and 24 regional affiliate and satellite sites making us the third largest employer in the Greater Kingston area. Fully affiliated with Queen's University, KGH is a teaching hospital which is home to 2,400 healthcare students from 34 universities and colleges across Canada who each relies on us to provide the learning environment they need to become health-care professionals. We are also home to 160 health researchers which helped to earn us the 2011 ranking as one of Canada's Top 40 Research Hospitals. We currently operate 373 inpatient beds with our 3,750 working KGH staff 565 medical staff and 850 volunteers. We treat more than 49,300 people in our emergency department, conduct more than 70,000 cancer center visits and deliver 2,040 babies each and every year. Redevelopment Our $196-million redevelopment project is nearing completion of Phase 1. This massive

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Welcome to Kingston General Hospital construction project includes • Expansion and renovation of the intensive care unit (ICU) from 21 to 33 beds • Expansion and renovation of the Cancer Centre of Southeastern Ontario adding two new radiation bunkers, increasing chemotherapy treatment chairs from 15 to 39, adding a specialized clinic area for pediatric patients and almost doubling the overall size of the cancer center from 54,445 square feet to 91,085 square feet. • Construction of a new, expanded 40-station in-center kidney dialysis unit • A new 25-bed unit for inpatient pediatrics with increased access to a state-of-the-art pediatric critical care unit. • A new 32-bed unit for medicine and inpatient oncology patients to provide. We are currently planning Phase 2 which will include, among other initiatives, expansion and renovation of our Emergency Room, OR and Neonatal ICU.

Comprised of former KGH patients and their family members, Patient Experience Advisors are an integral part of KGH’s patient and family centered care initiatives. • Inter-professional Collaborative Practice Model (ICPM) had been identified as a top priority at KGH to transform how care is delivered for the patient, families, and our providers. With the growing volumes and increasing acuity of patients, the need for fundamentally rethinking how we provide care was necessary. The ICPM has redefined the care team model by clearly defining how members of the team will work together in a coordinated and collaborative fashion resulting in a better experience and results for the patient and their family.

Recent Accomplishments • Kingston General Hospital has been awarded ‘Accreditation with Exemplary Standing’ from Accreditation Canada with an overall score of 98.9 per cent • Kingston General Hospital has won the prestigious NRC Picker Innovative Best Practice Award at the 2012 NRC Picker International Symposium on PatientCentered Care. This award signifies that KGH’s approach to empowering patients is unique. Today, KGH has more than 50 Patient Experience Advisors who work side by side with staff at all levels of the organization to ensure the patient voice is heard at every turn.

Working in this relatively small RT community, we have built many strong professional relationships and lifelong friendships. We help and support each other during life’s difficult moments and celebrate the good times together. This sense of community is demonstrated through various events and activities throughout the year. A very notable event is our RT week festivities as it is packed with daytime educational events and evening activities promoting the profession, education and fun. We are joined by other professions for our annual dodge-ball tournament, forming several teams of RRTs, nurses, paramedics and physicians as well as other hospital support staff. A portion of RT

Respiratory Therapy at KGH Our RRTs are a highly dedicated group of professionals with a wide range of responsibilities. At KGH, Respiratory Therapy services are provided via a purchased services model with most RRTs rotating through all areas Another important part of our redevelopment and their time being billed to the departments in plan is the removal of carpet (yes, we had which the services are provided. This centralized carpet!) from all inpatient areas. This project is well underway and to date we have removed service approach has allowed us to remain a close-knit versatile team. over 190, 000 square feet of carpet.


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Welcome to Kingston General Hospital improved work life balance interest grew. Today, all but a few are working this schedule. RT Students We are privileged to act as a clinical site for students from Algonquin College. Teaching and mentoring benefits students and staff alike. First and second year students join us for site visits and 3rd year students stay for their entire clinical year. Our clinical instructor is quite busy coordinating their activities and guiding them through the year as their numbers have grown from 8 to15 over the last few years. Beginning this year, all students will also spend two rotations at our partner facility, Quinte Health Care’s Belleville General Hospital. While at both sites, students rotate through all areas of respiratory care within the hospitals. Tom Fisher and Bill Priestman entertaining in the Main Lobby during the Holidays

week event proceeds are donated to charity. The week culminates in a Halloween party where the costumes and the party are truly amazing. There are 57 staff RRTs who work within KGH Respiratory Therapy Services. As well, we have 4 Anesthesia Assistants and 3 RRTs offsite at the Ventilator Equipment Pool.

With a growing focus on inter-professional education, students are provided opportunities to engage other professions and are also encouraged to take the lead on educating staff and students from other professions. This year students participated as educators in the operating room and in the emergency department.

Pulmonary Function Testing has recently moved to the redeveloped Hotel Dieu Hospital in an effort to integrate Kingston’s Ambulatory Care services to one site. They continue to provide inpatient services at KGH on scheduled days and on demand, as well as acting as an expert resource for the community. The majority of the full timers work four Adrienne Leach, Director of Respiratory Care consecutive 12-hour shifts on a DDNN schedule Services and Director of Professional Practice Allied Health. with 5 days off in between their next set. This staffing model was introduced gradually as staff RT Leadership expressed interest in participating but once staff members recognized that the schedule offered an There has been an evolution in staffing and responsibilities over the last few years. Adrienne 24


Welcome to Kingston General Hospital Leach, the Director of Respiratory Care Services has seen her portfolio grow to include her position as Director of Professional Practice Allied Health. She chairs the Professional Practice Council and leads the home first program which engages the appropriate community resources and aims to provide the right care at the right place at the right time for patients in or destined for ALC beds.

initiatives. In 2012 she accepted a position as Manager of Inter-professional Collaborative Care and Education.

In 2009 Cynthia Phillips, our long time Clinical Leader, had been seconded to lead the Interprofessional Collaborative Practice Model (ICPM) and Patient and Family Centred (PFCC)

Anesthesia Assistants Edwin Aguilar and Paula King

It is certainly a major accomplishment and source of pride to have RRTs leading the way in these important multidisciplinary positions. Above: Ray Milton, Clincial Leader outside the Respiratory Therapy department Below: Ventilator Equipment Pool RRTs Regina Pizzuti, Sandy Fodey and Rosalyn St. Germain

Ray Milton has now assumed the role of Clinical Leader for Respiratory Therapy Services and staff report directly to him. Ray has recently returned to KGH after leaving his staff therapist position to pursue further education and along the way served as Coordinator of the Ventilator Equipment Pool. Regina Pizzuti, a familiar name to several RTs across the province, remains at the Ventilator Equipment Pool and Sandy Fodey, our long time clinical instructor is now there as well, acting as the coordinator for ventilator equipment. As a result, Chris Dunlop has stepped into the vacated clinical instructor position while Derry Thibeault acts as the charge therapist for critical care and Paula King as the charge anesthesia assistant.


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Welcome to Kingston General Hospital Tracey Fisher and Andreanne Bourdeau-Paquette having a little fun in the Kidd 2 ICU

Neonatal Intensive Care The NICU and Labour and Delivery is staffed by one RRT each shift. Staff members rotate through this area alongside two core therapists. Staff members have the opportunity to gain advanced training (intubation, etc...) in order to be designated as a Team Leader. They lead the team during resuscitation of the newborn and support junior medical residents as required. Our Level 3 nursery allows RRTs to perform airway management, invasive and non-invasive ventilation, high frequency oscillation, blood sample acquisition and point of care testing. KGH is also the referral center for high risk deliveries between Ottawa and Toronto. With

Mike Nutall reporting an overnight oximetry

the improvements in technology and medicine, the number of high acuity patients has gradually declined. To maintain skills and competencies, simulation time is set aside each week with opportunities to practice and to receive feedback in resuscitation scenarios. Participants have found that the simulation experience improves communication, coordination and cohesiveness within the resuscitation team. Critical Care KGH operates a 33-bed Level 3 Adult ICU as well an 18 bed Level 2 Stepdown ICU with 5 staff on day shifts and 4 on nights working between both units. As an integral member of the interprofessional team, we manage the respiratory needs of patients with varied acuity throughout the spectrum of their critical care stay. From using some of the most acute modalities available such as HFO, nitric oxide and aerosolized Epoprostenol (Flolan) to applying current best practices to improve patient outcomes, such as daily weaning screens, spontaneous breathing trials and early mobilization. Patient transports and procedures like percutaneous tracheostomy and bronchoscopy keep us busy through most of the

Alicia Wilkison heading out on a transport to CT scan

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Welcome to Kingston General Hospital day (and night in some cases). We identify barriers to discharge and facilitate timely coordination and planning. At this time, we are currently proposing the formation of a multidisciplinary Tracheostomy Team to standardize trach weaning and discharge planning outside of the ICU.

Megan Knowlton and Derry Thibeault in Kidd 2 ICU

artificial airways and also provide support for the NICU/L&D RRT during high acuity events and multiple births. Cardiac Sciences Unit (CSU) This unit treats both medical and surgical cardiac patients and an RRT is available there Monday to Friday (0830 to 2030) on surgical days. Otherwise, the unit is covered by the critical care RRT outside of those hours. Approximately 300 cardiac surgeries are performed annually at KGH and this unit has also recently begun performing Transcatheter Aortic Valve Implantation (TAVI) procedures. A consistent and fully immersed RRT presence in CSU has contributed to a very cohesive and effective team. Emergency Room KGH is the designated regional trauma center in the SE LHIN. The ER RRT on shift is a vital member of the trauma team and also covers the pediatric in-patient areas. RRT responsibilities include advance airway management, invasive and non-invasive ventilation, arterial and venous

We’ve recently added a Mon-Fri Critical Care Charge RRT to be a clinical resource to RT staff, students and to other disciplines. The role includes day to day coordination of activities, supplies and equipment. The charge represents the Respiratory Therapy department and is an active decision making participant within interprofessional committees. Wards A Wards RRT is on each day and night shift. They provide a wide range of services including advanced airway management, respiratory assessment, tracheostomy/laryngectomy tube management and weaning. Along with the interprofessional team, they manage patients with acute deterioration; they are members of the code blue, pink and Rapid Assessment of Critical Events (RACE) teams. They facilitate discharges of complex respiratory patients and patients with RTSO Airwaves Summer 2013

Eric Lam analyzing an ABG in Point of Care Testing

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Welcome to Kingston General Hospital line insertion, O2 therapy, and respiratory assessment. RRTs in the ER are also available to monitor patients during conscious sedation. An Increasing development of medical directives for RRTs and RNs will hopefully lead to greater responsibility, autonomy and engagement of staff in the ER and other areas of the hospital. In May of 2013 the 2nd annual Simulation Olympics were organized and hosted in Kingston. There were 18 teams from as far away as Quebec and Western Ontario with an excellent RT presence amongst the competing teams. The Kingston ER and ICU teams placed 2nd and 3rd respectively. Participants commented that we should all try these events as they offer opportunities to learn and to hone skills, communication and team work in a very positive and energizing atmosphere. Operating Room The are two dedicated FT anesthesia assistants Paula and Edwin in the Operating Room that work staggered shifts, Monday to Friday and share call in the off hours. Paula is the charge therapist and her time is shared between clinical work and administrative responsibilities. She also runs the simulator. In addition, two other RRTs, Jaime Colbeck and Tyler Ladas, at present are working hard to complete the clinical components of their AA training by this fall. Sleep Disorders Lab The Sleep Disorders Lab is staffed by Registered Polysmonographic Technologists (RPsgT) and our department works closely with them for complex respiratory, sleep and home ventilation patients. Ventilator Equipment Pool Established in 1994, the Ventilator Equipment Pool (VEP) is a provincially directed service operated by Kingston General Hospital that provides life-enhancing equipment to thousands of clients across Ontario. Funded by the Ministry of Health and Long-Term Care (MOHLTC), the VEP is the central provincial depot of ventilators

and related equipment for persons of all ages who require these devices at home and who have been approved under the Ministry’s Assistive Devices Program. The three very dedicated RRTs within this office, work closely with those at KGH and with other RRTs throughout Ontario to optimize the discharge of our homebound patients with ventilatory needs and to support them following their discharge. Respiratory care has grown tremendously since the early days at KGH. There are RRTs within our group that has seen our staff numbers grow from 8 to over 60 in a very short time frame. This has occurred along with an equal progression of our roles and responsibilities. Change continues at an even more rapid pace. Although it is not always easy, there is a growing sense of optimism with the current course that we are on. Most RRTs by nature are highly adaptable and are early adopters of new knowledge, therapies and technologies. This will enable us to continue to be advocates for safe and effective change. RRTs are highly valued members of the Kingston General Hospital. Their passion and dedication in providing Outstanding Care Always is readily apparent. Their efforts and expertise benefit their patients and their colleagues alike. As a result, our group derives great personal and professional satisfaction in the work we do and they look forward to the opportunities that lay ahead with our continued growth.

Submitted by:

Derry Thibeault, RRT

Charge Respiratory Therapist - Critical Care Kingston General Hospital

Ray Milton, RRT

Clinical Leader - Respiratory Services Kingston General Hospital

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Mode Comparison in One Lung Ventilation A Call to Research Ventilatory Strategy in One Lung Ventilation— Does Volume Control Ventilation Result in Hazardous Pressures Attributed to Acute Lung Injury? Submitted by Michael Esterlis , RRT

Index of selected abbreviations: ALI- Acute Lung Injury; EBC- Exhaled Breath Condensate; OLV- One Lung Ventilation; PCV- Pressure Control Ventilation; PLV- Protective Lung Ventilation; PRVC – Pressure Regulation Volume Control; VCV – Volume Control Ventilation; TLV – Two Lung ventilation The National Heart, Lung, and Blood Institute – Acute Respiratory Distress (ARDS) Network (ARDSnet) accepts that lung protective strategies such as low tidal volume (VT), plateau pressure (Pplat) goals less than 30 cmH2O, and appropriate positive end expiratory pressure (PEEP) / fraction of inspired oxygen (FiO2) combinations reduce morbidity and mortality in acute lung injury (ALI) and ARDS patients1. One-lung ventilation (OLV) is common in thoracic anesthesia and often presents a patient population with unique challenges.

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Common indications include thoracic malignancies, chest trauma, esophageal disease, mediastinal tumors, transthoracic approach to the spine, and diagnostic procedures such as bronchoscopy, mediastinoscopy and open-lung biopsies. The lateral decubitus position that is required in many procedures involving OLV alters the normal ventilation / perfusion (V/Q) relationship, which is further imbalanced by induction of anesthesia, initiation of mechanical ventilation, neuromuscular blockade, opening the thoracic cavity, surgical retraction and external lung restriction with a rigid bean bag2. Switching from two-lung ventilation (TLV) to OLV is associated with marked increases in airway pressures of the dependent lung, and this poses a risk of barotrauma in preexisting pulmonary hyperinflation3. Increased airway pressures can theoretically increase pulmonary vascular resistance by compressing intra-alveolar vessels and divert blood from the ventilated to the non-ventilated lung, counteracting hypoxic pulmonary vasoconstriction and therefore increasing shunt fraction and hypoxemia4,5. Thoracic surgical candidates further represent a group of patients in whom ventilation-induced cytokine up-regulation produces a proinflammatory state, which renders the patient to increased vulnerability to ischemiareperfusion, and direct tissue trauma6. Despite the unfavorable factors of increased ventilation


Mode Comparison in One Lung Ventilation In a similar study design, Pardos et al8 randomly allocated 110 patients undergoing thoracic surgery with at least 1 hour of OLV to VCV (n=55; 8ml/kg) and PCV (n=55; pressure to obtain 8mL/kg) groups. Participants with uncompensated cardiac disease, asthma or previous thoracic surgery were excluded. The two study groups were of similar demographics, preoperative pulmonary function, and intraoperative characteristics. Sevoflurane (1-2% expiratory concentration) was used as a maintenance agent. PEEP of 5 cmH2O, and RR to target normocapnia were used in both groups. The authors found no differences in intraoperative arterial oxygenation, Pplat or Pmean, but noted significant increases in Ppeak (P