Fear of the Ventilator: RT students in the ICU

Like a line of ducklings, a fresh crop of respiratory students obediently follow their seasoned clinical instructor through the corridors of the adult intensive care unit. Dressed in newly embroidered collegiate scrubs without any fading and their stethoscopes fresh from the package, their faces show palpable apprehension from the cutting sound of beeping IV pumps and ventilator priority alarms. Many appear uncomfortable, distracted by unfamiliar sights and smells from every room on the floor. In the neonatal and pediatric units, the climate is even more daunting; with hawk eyed supervisors and the ever present reminder of un-cuffed ET tubes in every radiant warmer. Respiratory students often feel as if they already have a target on their back, so it is little surprise that they have numerous reservations about initiating patient care in a challenging hospital area.

Entering critical care areas for the very first time can be a harsh reality for many a medical student, who too often have never encountered any patients in this vulnerable state; much less been deemed responsible for the needed therapies and care that are required. And while the many variations of oxygen therapy devices and procedures on the hospital floors are vital to the cardiopulmonary learning of these future respiratory therapists; the intimidation of being responsible for an intubated patient on a mechanical ventilator is a steep and fearful learning curve that need more that just a week or two in the ICU.

For those who have survived the academic process and traveled forward into the profession as respiratory care practitioners, we remember all too well our own introduction to the critical care mechanical ventilation clinical sites. That very moment when the learned theory of multiple wave-forms and vent modes is suddenly real and present in the patient’s room; compounded with the placement of multiple medical devices and lines over which we have little knowledge from our specialty. Intubation on a lab mannequin simply does not compare to a real patient in restraints that flinches in pain, or the frustration in attempting to decipher the language of a hurried bedside shift report from the night therapist trying to go home early. Academic respiratory therapy does not exist in a vacuum, and the crossover between a student’s apprehension of accidentally injuring a patient from a lack of experience and becoming confident enough to act without intercedence from the instructor is a bit of a magic act in itself.

One inconvenient truth to remember is that all respiratory students should have a healthy fear of critical care procedures and mechanical ventilation support upon introduction to the process. While choosing the wrong answer on an exam might cause a failing grade, the incorrect tidal volume set on a ventilator could easily cause a pneumothorax or irrevocable volutrauma episode that could cost the patient their life. A healthy amount of respect is already needed for the profession on it’s own; and a student must the potential fear of causing harm to mature into functional respiratory therapist. Unfortunately for the faculty, the true timeline for this crossover is unique to every student; and many not correspond with exams or equivocate to the clinical calendar. Bold behavior does not always mean a reckless act, and a timid student may not be as careful as you might hope. Where is the balance?

All of this begs the question of how instructors can seamlessly lead their respiratory students to the other side of fear that they might be successful as a practitioner. What methods can we employ to aid them in their journey, while still being vigilant of patient care?

First: Relate to them before and after entering the critical care setting that they will see medical conditions and problems they have never before encountered. While a baptism by fire may work well for some, it should not be held as the standard for all learners. While an extrovert might excel with immersion, the introvert might need a different approach. Continue to mention that you once stood in their shoes as a student, and confess to them your own apprehensions that went through your mind during those very first encounters. Respiratory students need to relate to their credentialed instructor as a individual who was once a student, and one who has succeeded in overcoming the same challenges.

Second: Encourage the students to speak with other specialties in the care units, and gain an appreciation for the differences in what they do. Speak to the nurse aids, LVNs, RNs, radiologists, physical therapists, and all varieties of specialties and physicians contributing their patient’s care. In addition, listening to daily rounds is vital to interpreting the language of medicine; even if the subject is at first beyond the student’s scope of understanding. Teaching hospitals are already encouraging this process, as everyone who is today an expert in the medical field was once a beginner themselves without credentials or clout. The team concept of the hospital simply cannot exist without active collaboration from all areas of medical discipline.

Third: Insist your respiratory students have the ability to explain simpler concepts of mechanical ventilation to those without ANY medical knowledge. Often, the language of mechanical ventilation is only spoken among RTs and physicians; and we quickly lose the ability to explain the simple concept of breathing, phases of the cough, or breath sounds to those without a medical background. This ability of simplifying complicated topics is vital for speaking to patients and family members, and it allows the students to reinforce their own knowledge multiple times a day. This act alone will make them a better communicator, and give them the ability to search for methods to make the process more effective. The idea is similar to flipping the classroom, except the student may not hide behind any lofty respiratory terms during the explanation.

Fourth and last: Teach your students to troubleshoot the ventilator, and accomplish this by dispatching them to investigate alarms in the rooms. With your supervision, have the student find the initial problem and give you potential methods to fix the issue. If their assessment is correct, allow them to correct the problems within the scope of their learning. If their assessment is wrong, show them why and allow them to participate in the solution. If a peak pressure is high and inline suctioning pass could correct the issue, allow them to complete the task. If a leak is present, insist that they follow the tubing until it is found and stopped. Point out the graphics during the alarm, and connect them to the immediate condition. Teach the big picture assessment, and allow them to include the entire patient in their reasoning. Cuff pressure maintenance, auto PEEP, weaning parameters, acid base status, spontaneous breathing trials, and sedation issues are only test answers for your student until the tern can be connected to a real life solution.

Be the clinical instructor that supplies your students with the “ah-ha!” moment in respiratory, even if you yourself never had that opportunity. Turn that fear of the ventilator in a true passion for medical problem solving, for that same student might very well be the staff therapist caring for you in the distant future. Does your clinical training give them the best resources and cardiopulmonary knowledge to provide optimal care to all patients? If your answer is not an enthusiastic affirmative, re think your approach with the above mentioned steps.