The examples below are actual notes from rtNOW respiratory therapists. Patient names and locations have been de-identified.
Patient 1 BIPAP: rtNOW incoming call at 01:42AM from [facility redacted] on
patient that came in with hypoxia and was coughing. Patient was placed on
non-rebreather with saturations at 92% and then had a coughing fit and started to
desaturate even more so placed on V60 BIPAP st16 10/5 85% and saturating 84%
SpO2 prior to calling rtNOW. When I received the call, I switched settings at 01:49AM to
ST 16 16/8 100% to hopefully improve oxygenation and saturations only got 85-87%
with patient achieving rate of 35, VT 350-450, and MV around 14.0. Patient is full code,
labs are being drawn, and patient is still not improving and is still not very responsive. I
told RN to talk to doctor because it looks like we are heading to intubation. She talked
with doctor, and he is planning on talking with family and still waiting on labs. RN was
going to call me back after doctor talked with family or when labs are back. rtNOW call
ended at 02:01AM. rtNOW incoming at 02:42AM call from [facility redacted]
calling back on patient that we started on V60 BIPAP ST 16 16/8 100% and VBG results
were the following 7.38/44/164. I instructed RN to turn FiO2 down to 60% and titrate
FiO2 per saturation if the pulse Ox probe was reliable. The patient was now waking up
and being more alert than prior. Instruct RN to call back if you need any further
assistance or help with transport. rtNOW call ended at 02:46AM.
Patient 2 HFNC: rtNOW incoming call at 2157 from [facility redacted]. The patient
brought into the ER with sob, confusion and Afib with RVR. She is being seen for a
medication reaction, currently being treated for a UTI. She has a history of dementia,
atrial fibrillation, CHF, pulmonary hypertension, and a right thalamic stroke. Oxygen sats
were initially in the 70’s and she was placed on Oxymask. RT now called to initiate
HFNC for increased work of breathing. HFNC placed on 50L 50%. Oxygen sats now
92-96. Respiratory rate on HFNC mid 20’s. BS: expiratory wheezes, increased aeration
after DuoNeb. rtNOW call ended at 2225.
Patient 3 Baby: rtNOW call came in at 2003 from [facility redacted]
regarding baby boy born at 36 3/7 weeks with APGARs of 6 & 7 needing cpap. Patient
on neopuff CPAP of 6 and 60% at the time of call. SATs 96%. Bubble cpap set up and
placed on patient with peep of 6 and 60%. SATs 100%. FiO2 gradually weaned to 21 %.
SATs 91%. Doc ok with SATs of 89% and above. The patient will be transferred to a
larger hospital and will call back if have any concerns before transfer. Call ended at
2036.
Patient 4 BIPAP/ Intubation: rtNOW incoming call at 12:17AM from [facility redacted] Med/Surg.
rtNOW was contacted for assistance with NIV initiation via V60 for increased WOB. At
the time of the video call patient was noticeably working hard to breath with accessory
muscle use and respiratory rates 45-50. Throughout the day patient had been on 3-4
LPM nasal cannula but had a new increase in oxygen demand requiring an 8 LPM
oxymask. Over the last 72 hours since admission (admission date 8/7) RN has noticed
a decrease in mental status and increase in WOB so NIV was requested. RT started
patient on IPAP 10, EPAP 5, RR 10 and 50% and patient’s RR slightly decreased to
35-40, accessory muscle use still evident at this time. Tidal volumes on these settings
range from 400-600 ml with a VE around 20-25. RT trialed CPAP to see if patient would
“synch” or be more comfortable but no change noted. Patient is currently in restraints
and on precedex so I suspect some of the discomfort/high RR is from alcohol
withdrawal which was one reason why patient was admitted. Service notified by RN
staff about concern on mental status and airway clearance. RT and RN talked about
possible need for intubation, and they were encouraged to call back for assistance
when service decided next course of action. rtNOW call ended at 12:47AM. rtNOW
incoming call at 01:41AM from [facility redacted] Med/Surg rtNOW had previously assisted RN
with this patient initiating NIV due to increased WOB. With changes in patient’s mental
status and concern to maintain airway the decision to intubate was made. The
intubation process was started at 02:09AM and the first attempt was unsuccessful.
Patient’s O2 saturation dropped to 60% around this time, so a nasal airway was placed,
and patient was bagged to increase SpO2 to 92%. Multiple attempts at the airway were
attempted between 02:12AM and 02:49AM. Bilateral nasal trumpets were placed
around 02:32AM and multiple strategies were attempted such as a bougie, patient
positioning (towel roll under shoulder) bronchoscopy, cricoid pressure, downsizing ETT
to 6.5 to help insert airway with little success. Around 02:49AM ETT was successfully
advanced past the vocal cords and there was positive color change and bilateral breath
sounds. Patient was placed on LTV RR 16, VT 500 (6-8 ml/kg range 410-547 for 172cm
male), PEEP 12 and 100%. 6.5 ETT secured at 25 at the teeth. Patient saturating 93%
and tidal volumes around 450-500 on the ventilator. Patient awaiting transfer to different
facility. rtNOW call ended at 03:07AM.