RCP: 421 Comprehensive Narrative: Reflection

Autumn Cooley, SRT

Le Bonheur Childrens Hospital: 160 Hours

Goal:

After completing the clinical internship at Le Bonheur Childrens Hospital, the senior student

will be able to demonstrate clinical application of knowledge and skills of an entry-level

respiratory therapist, as relevant to care of patients in critical care pediatric settings.

Learning Outcomes:

After completing the six-week clinical internship the senior student will:

1. Apply effective patient assessment and diagnostic techniques to assist the patient care

team in providing interventions in response to the patients clinical needs.

2. Formulate plans of care that derive from patient assessment, patient medical history, and

diagnostic study data to recommend appropriate therapeutic interventions.

3. Demonstrate competent clinical application of basic and advanced therapeutic modalities,

as applicable to the patients clinical presentation.

4. Collaborate with patients, patients families, and other health care professionals of the

interdisciplinary team in educating the patient/family on relevant therapeutic modalities

to ensure patient safety and improve patient health outcomes.

Throughout my clinical internship at Le Bonheur Childrens Hospital PICU, I

progressively gained new knowledge, reinforced prior learning, and gained hands on clinical

experience necessary to demonstrate clinical application of knowledge and skills of an entry-

level respiratory therapist. I not only learned from my preceptors, physicians, and other

interdisciplinary health care members, but from the patients and family members as well. During

patient assessment, I reinforced prior learning of the anatomic and physiologic differences of the

pediatric patient. The tongue is proportionally larger, taking up more space in the oropharynx,
therefore any swelling will occlude the upper airway and impede ventilation resulting in hypoxia.

The trachea is more narrow and easier to collapse due to immaturity of tracheal rings making any

swelling an elevated risk for airway occlusion resulting in an impedance to ventilation and

oxygenation. The epiglottis is proportionally larger and U-shaped, making intubations more

difficult to perform due to decreased visibility of the trachea. While assessing the patient, it is

imperative to quickly note signs of respiratory distress and begin treatment to minimize the

incidence of hypoxia. The first sign of respiratory distress is tachypnea (> 35 breaths per minute)

and is usually secondary to a decrease in compliance or increase in airway resistance leading to

an increased work of breathing to maintain adequate gas exchange and oxygenation. Hyperpnea

is noted in hypercapnic patients such as: metabolic acidosis, fever, and septic shock in attempts

to blow off excess carbon dioxide levels. Hypoventilation is usually secondary to metabolic

alkalosis, diaphragm paralysis, and CNS disorders resulting in hypercapnia due to an impedance

of carbon dioxide removal.

I reinforced prior learning of high frequency ventilation (HFV) and its advantage of

delivering small tidal volumes with high respiratory rates (>150 bpm) at relatively low pressures

to reduce the risk of barotrauma. HFV is indicated in patients with respiratory failure that does

not respond to conventional mechanical ventilation as evidenced by PaO2 <50 mmHG on a FiO2

of > 60%, decreasing SpO2 <90% despite increase in FiO2, PaCO2 > 60 mmHg accompanied by

acidemia pH < 7.25. The high frequency rates are defined as hertz, as 1 hertz is equal to 60 bpm.

To increase the removal of CO2 during HFV you will decrease the Hz which is the opposite of

CMV in which you increase the rate. The main driver for oxygenation is the mean airway

pressure as the alveoli remain open continuously allowing for adequate oxygenation. Many

patients with conditions such as pulmonary hypertension, meconium aspiration syndrome, and

congenital diaphragmatic hernia showed the greatest improvement in oxygenation when inhaled
nitric oxide (i-NO) was combined with high-frequency oscillatory ventilation. The i-NO diffuses

into smooth muscle cells of vascular walls causing vasodilation by activating guanylate cylase

and increasing levels of cGMP. HFOV improves lung inflation allowing increased delivery of i-

NO to pulmonary circulation thus decreasing intrapulmonary shunting. General Practice

Physician, Dr. Gangu, helped reinforce prior learning of methemoglobinemia resulting from NO

coming in contact with blood and binding to hemoglobin to form nitrosylhemoglobin. The

presence of oxygen causes nitrosylhemoglobin to become oxidized and is toxic to the body in

which the patient may develop pulmonary edema, lung injury and death.
I was successful in improving clinical skillsets of capillary blood gas sampling and

arterial line sampling by reinforcing prior learning and gaining clinical experience performing

the techniques. Capillary samples are adequate in assessing pH and PaCO2 but are not reliable in

the assessment of PaO2 and should be monitored by pulse oximetry or transcutaneous

monitoring. Pulse oximetry utilizes light absorption to calculate the saturation of arterial

hemoglobin. Transcutaneous monitoring heats the skin surface beneath the electrode, allowing a

faster diffusion of oxygen through the skin to be measured by the thermistor sensor. Arterial line

sampling is the most accurate in determining the amount of oxygen dissolved in the plasma.

PaO2 is the driving pressure for tissue oxygenation, not the total amount of oxygen present, thus

a higher PaO2 will lead to a higher driving pressure which causes more oxygen to attach to

hemoglobin.
I could not possibly include the countless learning opportunities that I experienced during

my clinical internship at Le Bonheur Childrens Hospital, but my perception is that my overall

progress far exceeded my original expectations. I not only achieved the learning outcomes

provided in the learning contract, but I also reinforced knowledge from prior learning about

disease processes and the appropriate treatment regimen specific the clinical presentation of the
patient. I gained new knowledge of several therapeutic interventions not listed in the learning

contract such as extracorporeal membrane oxygenation, inhaled nitric oxide, and surfactant

replacement therapy. I can perform therapeutic interventions and modalities as an entry-level

respiratory therapist due to gaining 160 hours of clinical experience. It is also important to note

that I experienced exponential growth in professional development by pushing myself to adapt to

the heartbreaking and unpredictable circumstances that are frequently witnessed in this

profession.