MedicateOH interviewed Larry Wical, a local respiratory therapist who is currently hard at work on the front lines of fighting the Coronavirus pandemic with his fellow hospital workers here in Ohio. We asked Larry to tell us a little about how respiratory therapists are crucial to the battle against the COVID-19 infection as well as share with Ohioans what they can do to stay healthy right now.
MedicateOH: Tell us a little bit about what a respiratory therapist does and what your background is?
LW: As a Respiratory Therapist (RT), our scope of practice is both specialized and vast at the same time. First and foremost, our job is to help patients maintain a normal, healthy respiratory status. We do this through various means, such as delivering a myriad of breathing medications as well as assisting them in various breathing exercises to help more fully engage their lungs. Some patients require these medications and exercises in order to maintain a healthy baseline of breathing, while others require it to pull them out of respiratory distress and back to normal.
When a physician is working toward diagnosing a patient with a specific lung condition, RTs are the ones who administer the testing processes often referred to as pulmonary function tests. When a patient’s respiratory status deteriorates beyond their ability to breathe on their own without some form of support, we are the ones who assist physicians in placing a breathing tube in the patient (a process called intubating) in a safe and controlled environment. Once the breathing tube is placed, RTs are the clinicians who place the patient on a breathing machine (formally called a ventilator – the lay person often refers to this as “life support”) and then use both their experience and a series of calculations to determine the most effective settings to manage the patient. In addition to administering breathing medications and managing patients on ventilators, RTs also draw arterial blood from patients, assist in sleep apnea studies, transport critically ill patients from place to place via ambulance, plane or helicopter. We work in hospitals, long-term care facilities, nursing homes, home health agencies, physician offices and I have had the pleasure of knowing many fellow RTs who have worked as organ donation coordinators, ECMO (extracorporeal membrane oxygenation) specialists, instructors, clinical researchers and even hospital administrators.
As for our background as a profession, we follow a very similar path as nursing in that you must obtain a 2-year degree in Respiratory Science before qualifying for a medical license to practice. And, just like nursing, the respiratory field is trending toward practitioners pursuing bachelors degrees with more in-depth courses in management, care-planning and public health. I went back to school to pursue a Respiratory Science degree, but I have a Bachelors degree in communication and finished my Masters degree in Organizational Leadership in Healthcare Management last spring. I personally have worked in a variety of settings, ranging from national home care companies to a top-level trauma center. Working in healthcare affords you many opportunities beyond just employment. I have had the privilege of using my medical expertise to serve in various volunteer capacities. During my career in healthcare, I have served in a medical mission in Haiti, worked as a medical volunteer for the Flying Pig Marathon on race day and performed medical screenings at the NAACP National Conference. With a little bit of initiative, the amount of reach we can have as providers is almost unlimited.
MedicateOH: Why are you passionate about what you do?
LW: Several things contribute to my passion and motivation as a clinician. The first thing that comes to mind is the Bible verse Collosians 3: 23, which reads “Whatever you do, work at it with all your heart, as working for the Lord, not for human masters.” That really speaks to me, because at the end of the day, when it’s all said and done, I want to be able to look at myself and my contributions to society and feel good about what I did for humanity. If I help a company reach their financial goals in the process, and they spread the fruits of their labors to employees, than that’s even better.
Also, I once read somewhere that whatever we do for a living – no matter what it is – we should strive to be the best in the world at it. Whether it’s tossing pizzas, installing mufflers or giving breathing treatments… do it better than anyone. And that’s a nugget in the back of the head that also drives me. I am a very competitive and compassionate person, so sinking all of my being into caring for others while trying to be the best at it drives me. Am I the best in the world at it? No, definitely not. According to the American Association for Respiratory Care, there are more than 130,000 RTs in the United States alone, and that number continues to grow. I know many RTs in my home city alone that could work circles around me, but I never stop trying to be everything my patient needs.
MedicateOH: Why is respiratory therapy such an important part of fighting COVID-19? What does a ventilator do to assist a patient who’s battling COVID-19?
LW: My specialty is so crucial to the battle against Covid-19 because ultimately, the sickest Covid-19 patients must be intubated in order to ensure their virus is contained to the closed system of a ventilator. Once these patients are on a ventilator, they must be professionally managed by an RT who is skilled in working on patients with debilitating respiratory failure. But, as not all patients are the same, not all patients on ventilators are the same either. There are so many different ventilator strategies that are being used in order to manage these Covid-19 patients. Some require more oxygen or more ventilator pressures, some require less. Some require a gas called Nitric Oxide to attain a certain degree of homeostasis in the pulmonary vasculature, thus helping them move oxygen more effectively through their body.
While others need to lay in the prone position on the bed, which helps change the general dynamics of the lungs while they are being mechanically ventilated and oxygenated on the ventilator. While laying prone, the little air sacs in your lungs called alveoli are more open to being inflated because the posterior lung tissue is no longer being compressed due to gravity. This allows these portions of the lungs to rebound faster and experience an increase in perfusion, which is a fancy way of saying the lungs experience an increase in blood flow to the areas that are necessary for better oxygenation.
When a Covid-19 patient is quickly placed on the ventilator, the recovery process begins immediately. Not only is it safer for the patient and clinician because the virus is contained, but now the RT can begin the journey of putting the puzzle back together. Through a series of chest x-rays and arterial blood samples, the RT can make adjustments to the ventilator to help the patient regain normal ventilation and oxygenation values. As we have seen over time, this turnaround is more often than not a fairly slow and deliberate process. We have learned a great deal of what may work and what may not work from our colleagues in Europe, because the virus hit them hard for several weeks before it started showing up in American hospitals. Even still, there is no “one size fits all” solution in terms of ventilator management. We are still learning more every day.
MedicateOH: Why are ventilators in such short supply currently and what happens when a patient doesn’t have access to one?
LW: Our healthcare system may reach a point where ventilators are in short supply because of several factors. First and foremost, we have an aging population that is very susceptible to a virus like this not only because of their advanced age, but also because of the relative health comorbidities they bring to the picture. A disproportionate percentage of the 65 and up population has heart failure, asthma, COPD and/or diabetes, so we have an older population with disease processes that have already caused significant damage to their hearts, lungs and kidneys. One thing we do know for sure is this virus will hit the elderly harder than most, and it will hit the elderly with preexisting medical conditions even harder. We’re seeing that in the numbers all around the world. While this virus is causing the greatest harm to the oldest patients, it can’t be stated enough that this virus is infecting and killing babies, children, teens and young adults as well.
If a facility has a patient who requires invasive ventilation but has no ventilator, the options are skim. Intubating a patient and then bagging them for a long period of time with a bag-mask valve resuscitation system has proven to introduce too much risk for all involved, because the patient’s own air is exhaled out of the bag into the ambient environment. This poses a massive threat to those nearby as the virus spreads very aggressively in a respiratory droplet and airborne fashion. Once a breathing tube is placed, the patient needs to be attached to a closed-system machine immediately. In the absence of a proper ventilator, there are some brands of noninvasive ventilatory machines that have an option to connect patients with breathing tubes. The tough part is, most hospitals have noninvasive positive pressure machines, but not all of them have machines that are compatible with intubated patients.
MedicateOH: Many patients who lack access to non-emergency care right now are needing to utilize homeopathic and non-traditional remedies to treat pain, such as medical marijuana. What advice would you give to patients who want to incorporate medical marijuana safely and legally into their treatment plan?
LW: My best advice would be for all Ohio patients to continue having a firm, open line of communication with their ordering physician during this complicated time. Not only are we all in this together in combating the virus itself, we are also battling the unintended consequences of the virus, such as anxiety and neurological/neuromuscular conditions that are exacerbated by excess stress. In that regard, if there was ever a time to touch base with your ordering physician to ensure you are managing your conditions as safely as possible, now would be the time. I would encourage patients with weak immune systems to consider using the electronic visits that are becoming more and more popular. This is a great way to get timely, reliable information from your physician without going out in public and putting yourself at further risk of contracting the virus.
MedicateOH: What would you grade Ohio versus others states on how our medical community is doing fighting the Coronavirus infection and why?
LW: In terms of managing a very challenging virus in the setting of a very stressed national healthcare system, Ohio seems to be performing at a very commendable rate. Governor DeWine was very quick to get out in front with all the classical measures that have shown to slow the spread of viruses. He has acted in a very strong, transparent manner from the outset and didn’t hesitate to engage President Trump with requests and demands for his state. He conducts a daily, televised briefing at 2:00pm EST to update the public on the state’s latest Covid-19 developments.
It is hard to speak to how all the healthcare systems have fared individually because I don’t have much more than anecdotal information with which to work, but what I can do is speak from the numbers that are available to us. When you take into account that the state of Ohio is the seventh most populated state in the country (11,6000,00), but ranked 17th in positive Covid-19 cases (5,878) and 16th in Covid-19 deaths (231), it’s hard to not be impressed. Larger population density historically equates to more cases and more deaths, but Ohio seems to be a bit of an exception in that regard. In looking at how Ohio is faring in comparison to its neighboring states, one comparison worth noting is that between Ohio, Kentucky, Indiana and Michigan, Ohio has the lowest death rate among those who test positive for Covid-19.
As I sit here today, Ohio has reported 5,878 positive Covid-19 cases with 231 deaths, which represents a 3.93% rate of death from reported cases. Michigan has the highest rate of death with 1,276 deaths in 22,434 cases (5.69%), Kentucky has reported a rate of 90 deaths per 1,693 cases (5.3%) and Indiana’s 7,435 cases have resulted in 300 deaths (4.4%). So just gleaning over this data, it would appear that Ohio is doing a good job compared to its neighbors.
MedicateOH: Why are stay-at-home measures so important?
LW: We are finding that the lessons of how we managed the population during the Spanish Flu of 1918 taught us much of what we need to know in terms of eluding the Covid-19 virus. The unique thing about this virus is that is can be spread in so many ways, most notably by contact and through the air we breathe around others. So when you have a virus that can spread every way imaginable, it’s important to keep to ourselves as much as possible. Once you leave your house, you immediately begin introducing new viruses and bacteria into your life. When you leave the house, you are also spreading your germs and bacteria to others who touch what you touch and breathe the air you breathe.
I can’t stress enough how aggressive this virus is and how effective it is at transmitting. The less you leave the house, the less you introduce your germs to others and vice versa. If we don’t stop passing the virus around to each other, the virus will live long enough to continue mutating and infecting more and more people. Then what started off as a two-week stay home order becomes a month, a month becomes three months and so on. This is how we flatten the curve of transmission, but the curve won’t flatten itself.
MedicateOH: How are hospital workers staying protected? Are more masks still needed and if so, what can Ohioans do to help hospital workers get more? What other supplies are in short supply?
LW: While in the hospital, employees are wearing surgical masks 100% of the time, whether working in the patient care area or not. If N95 respirator masks are an option, many employees can be seen wearing them a bulk of the day, as these masks give reasonable protection to both droplets and airborne viruses when fitted properly. If an employee is giving a form of treatment with aerosol of any sort, it is advised that employees wear at the very least an N95, a full gown, gloves and a PAPR mask if available. Because the virus is so flexible, healthcare workers have to respond by covering all the bases of possible transmission. Disposable masks, gloves, gowns and hand sanitizer are on short supply all over the country, so most hospitals are happily accepting donations of supplies. As a matter of fact, just recently one local college donated all of its ventilators and other respiratory supplies to two different local hospitals. Since colleges are now out of session due to the virus, their rationale was they weren’t using the equipment any time soon anyway.
MedicateOH: Beyond washing hands and following quarantine orders, what can Ohioans do to help themselves and their local community to fight the spread of COVID-19?
LW: Beyond proper hygiene and following the stay at home orders, it is important to remain consistent and vigilant. While it is tempting to bend certain rules, if these rules are bent, it can result in somebody else either getting sick or dying.
This means not allowing the kids to play basketball in the street with other kids, combining trips out if you need to go out. Go to the bank, grocery store and drive-thru to pick up dinner in one trip. It’s not only better for the environment, it greatly reduces the risk of coming in contact with someone else who may be infected. If you must go out, at the very least wear a mask of some sort. While it’s not perfect, it’s automatically giving you some layer of protection against others, as well as protecting others from you. Remember, just because we don’t have the active virus or feel sick doesn’t mean we aren’t a carrier of the virus. And lastly, the hardest one in my opinion, don’t be afraid to speak up and hold each other accountable. If friends and family are holding sizable get-togethers, voice your concerns and use logic and facts to help them understand that there are reasons for why we do what we need to do.
MedicateOH: What hope can you offer to Ohioans who are fearful about contracting and dying from COVID-19?
LW: If we all work together and follow the guidelines set forth – guidelines that have proven to be effective over the years – we will get through this. Right now, self-care is more important than ever. I would encourage people to stay positive, stay active, eat a healthy and balanced diet, keep in touch with friends through the phone or social media, and most importantly continue to encourage and lift up each other.
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