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Fluoroscopy of L2 M.U.S.T. pedicle screw placement
Why is the Capnography Reading Abnormal- Getting a True Measure of End-Tidal Volume | Respiratory Compromise: Use of Capnography During Procedural Sedation
Why is the Capnography Reading Abnormal- Getting a True Measure of End-Tidal Volume | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Why is the Capnography Reading Abnormal- Physiology | Respiratory Compromise: Use of Capnography During Procedural Sedation
Why is the Capnography Reading Abnormal- Physiology | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Q&A- Respiratory Compromise | Respiratory Compromise: Use of Capnography During Procedural Sedation
Q&A- Respiratory Compromise | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Strategies to Avoid or Alleviate Burnout | Burnout in the Radiology Setting?
Strategies to Avoid or Alleviate Burnout | Burnout in the Radiology Setting?
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Outcome data | Uterine Artery Embolization The Good, The Bad, The Ugly
Outcome data | Uterine Artery Embolization The Good, The Bad, The Ugly
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MRI Safety & Screening | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
MRI Safety & Screening | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
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Studies into Equipment | Respiratory Compromise: Use of Capnography During Procedural Sedation
Studies into Equipment | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Non-Invasive Ventilation | Respiratory Compromise: Use of Capnography During Procedural Sedation
Non-Invasive Ventilation | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Just Culture Concept | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
Just Culture Concept | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
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Signs of Burnout | Burnout in the Radiology Setting?
Signs of Burnout | Burnout in the Radiology Setting?
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Self Awareness | Burnout in the Radiology Setting?
Self Awareness | Burnout in the Radiology Setting?
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Factors Contributing to Hypoventilation | Respiratory Compromise: Use of Capnography During Procedural Sedation
Factors Contributing to Hypoventilation | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Program Implementation | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
Program Implementation | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
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Clinical Implementation | Respiratory Compromise: Use of Capnography During Procedural Sedation
Clinical Implementation | Respiratory Compromise: Use of Capnography During Procedural Sedation
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What Causes Burnout | Burnout in the Radiology Setting?
What Causes Burnout | Burnout in the Radiology Setting?
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Staff Requirements & Education | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
Staff Requirements & Education | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
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Background to Nursing Burnout | Burnout in the Radiology Setting?
Background to Nursing Burnout | Burnout in the Radiology Setting?
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Review of Abnormal Capnography Readings | Respiratory Compromise: Use of Capnography During Procedural Sedation
Review of Abnormal Capnography Readings | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Why is the Capnography Reading Abnormal- Assess for Equipment Issues | Respiratory Compromise: Use of Capnography During Procedural Sedation
Why is the Capnography Reading Abnormal- Assess for Equipment Issues | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Overview of Respiratory Compromise | Respiratory Compromise: Use of Capnography During Procedural Sedation
Overview of Respiratory Compromise | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Clinical Workflow for PET/MRI | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
Clinical Workflow for PET/MRI | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
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Patient Education PET/MRI | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
Patient Education PET/MRI | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
assesscervicalchaptercontrastdiabeteslymphMRImrisneuroendocrinenodesNoneoncologypatientpatientspelvicperfusionphysicianreferegimenresumetreatmenttumors
Q&A- Risk in All The Right Places | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
Q&A- Risk in All The Right Places | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
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Capnography Waveform | Respiratory Compromise: Use of Capnography During Procedural Sedation
Capnography Waveform | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Introduction to Respiratory Compromise | Respiratory Compromise: Use of Capnography During Procedural Sedation
Introduction to Respiratory Compromise | Respiratory Compromise: Use of Capnography During Procedural Sedation
anesthesiachaptercliniciancrnainterventionalmajorityMedtronicNonepresentationslides
Research and Literature | Respiratory Compromise: Use of Capnography During Procedural Sedation
Research and Literature | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Transcript

Alright let's have some fun. Take some pictures..

okay second why is my camp nog raphy reading abnormal now let's look are you

measuring a true sample of the patients and tidal volume so again we have some of these campin ography waveforms here and in the yellow blocks I'm gonna play it again we're gonna play it again in the back we're gonna look at the

hypoventilation again nice square waveform but you tell the patient take a deep breath and all of a sudden you see the amplitude go up so just because we see little boxes yeah the patient's breathing but are they really taking a

full deep breath this is the patient that you got a baseline on and they were normal and now you started your procedure and now your values are like 28 29 guess what the value probably didn't drop in their blood

it's just a probably not exhaling as well did you flip them prone are they on their side you follow did you change something with their airway so now looking again at the classic hypoventilation okay this is somebody

who is taking deep breaths so we have our normal waveforms here on the top okay that would you hopefully you'd see before sedation and you know what you might see that drop off a little bit during your sedation is at the end of

the world no because you're watching trends every now and then you might tap them on and say okay take a deep breath but you know that they're still ventilating right but if we start to see examples of partial airway obstructions

or complete airway obstructions that's when we want to intervene on the bottom I included the hype optic hypoventilation this is what we see a lot of you see some squiggles and you're like okay airs moving in and out but how

come my numbers aren't adequate that's where you're like are they effectively exchanging are they emptying out their full tidal volume and you give them an Ambu bag breath or you stimulate them and you are you give them that chin lift

and they take that big deep breath and that's what you see is the actual waveform going up that's more of a representative sample and you got to be careful with that they get too much co2 retained again the sedation gets worse

and they may eventually stop breathing from that so look at this waveform here we have an amplitude of five we have us reading to five and a bunch of these square little boxes that's an example of somebody who is making some effort but

are they effectively ventilating not so much so this is the patient that you again you give a you know good breath open the airway stick an oral airway in or do something to stimulate them and then you see that you're like now I'm

ventilating appropriately so looking at another troubleshooting this is really common in the IR Suites from what I seen and I'm sure you guys have seen as well is co2 re breathing so patients are exhaling and what you're seeing here

notice how the baseline in that waveform is not returning to zero so patients are exhaling and then they're inhaling exhaling inhaling they're not clearing the carbon dioxide that they're exhaling out so how

is this happening well what do we do to pee like you guys are working in environments that are certainly not pristine we are flipping patients over there on their side they're draped so we have this beautiful little tent of

oxygen don't even get me started on the combustion cycle right but we have this beautiful Lake draping of a tent and patients are exhaling and where is that going so the last thing we want is somebody who's potentially going to be

hypoventilating then rien hailing carbon dioxide because not enough fresh gas flow so this is also patients who are just shallow breathing right they're inhaling exhaling and they're really exchanging

mostly dead space or this is someone that you put the oxygen mask or maybe you start with a nasal cannula and then you want to increase their fio2 so you put a mask on but you forget to plug the mask in instead of a nasal cannula it

happens right or the oxygen mask gets unplugged or the tubing gets runned over or the connection because it's like a mile away gets disconnected these things happen but if you see a waveform like that these are things to start to think

about right what's going on where my patient is rebreathing carbon dioxide so first we're gonna look at physiology do we understand the physiology of our patient and what our patient is trying to tell us second are we really

assessing an effective ventilation are we really assessing the adequacy of ventilation so instead of just skiing square bumps on our monitor are we seeing something that we saw the beginning of our case or are they

hypoventilating are they not effectively exchanging so that's the second thing we

is my cap nog Rafi reading actually I want to back up a little bit here do I want to back up no I don't I don't want to back up so um let's look at the first

question why is my cap nog Rafi reading abnormal so let's first talk about physiology so a question I get a lot of times is sue the patient comes down for a procedure to the floor I put a sample line set on

them I plug them into the monitor and I'm getting a value of 28 29 30 why are my values abnormal anyone ever see this is anyone still awake okay so there's a few reasons the patients that we are dealing with generally aren't

healthy right I mean sometimes I go to work and I get chest pain I'm like can I just be in an ambulatory gallbladder room today because the patients that are coming from down to IR are sick what their physiology is sick too so we have

Krebs cycle we take oxygen in right it circulates to ourselves it participates in aerobic metabolism we get the byproducts of heat and energy and we get carbon dioxide as a by-product carbon dioxide really diffuse about diffuses

into our blood travels to the lungs and gets exhaled where we measure it so let's talk metabolism really quickly so if someone has a fever if their metabolism is ramped up you think they're gonna be producing more carbon

dioxide yes let's say they're a little hypothermic maybe they're gonna be producing a little bit less you see it for sure in the car patients who are cardiac arrest that are cool to status post cardiac

arrest right those values go way down normal physiology normal physiologic response somebody comes down and they're mildly hypoxic they've got pneumonia or some sort of VQ mismatch and they're hyperventilating to UM debeso

compensate for their hypoxia do you think there's co2 values gonna be a little lower at baseline yeah so these are the patients that you're seeing right so we have reasons that patients could be hyper cap neck like metabolism

right somebody who's in pain someone who's developing a fever early stages of sepsis they may actually have a little bit of a higher value somebody who's sedated or hypoventilating may have a higher value and when we talk about

perfusion is the blood moving round and round is that circulating co2 coming back to the core do we have increased cardiac output with continuous constant ventilation and certainly we can we're gonna look at equipment issues next and

the same goes true more probably in your cases of the hypocapnia patient so someone who is not fully exhaling someone who's in bronchospasm or a COPD or you're not getting that nice square waveform you're only getting some of the

mixed gas ventilation that they're exhaling rights and the conducting airway is mixing with the alveolar gases someone's a little hypothermic someone who's been NPO for 24 hours right it's the opposite of carb-loading right so

you kind of throw them into a little bit of like acidosis you know they're kind of not burning carbs for fuel are they gonna be producing as much carbon dioxide not so much right so when you're coming so when

patients come down to you and you put them on the monitor consider these things so ventilation perfusion gradients so we have what we call our VQ matches and our body is designed beautifully right so when everything is

working great it works great so the way we ventilate all of our lungs owns is very closely matched to the perfusion of all of our lungs ohms so by me standing up here I'd like to think I'm pretty healthy if you did a blood gas and you

put me on one of those filter line sets right now you would hopefully see a gradient that's very small the normal gradient between a PA co2 on a blood gas so the level of carbon dioxide on a blood gas in the arterial blood and what

you see when I fully exhale into the monitor should be between two and five millimeters so these are your patients come down healthy physiology you put them on and you get a value of like 32 then you

could assume that if they were healthy two to five millimeters okay their blood gas would probably like 35 for POC to everyone follow now does any of our patients read the physiology tech books textbooks no they typically don't so

when you have patients come down they may have shunt right so they may have we have our little airway here a and B you're out like picture them as lungs and lung a is blocked so we have no ventilation going to lung a but blood is

still chugging through right so blood is still going through the pulmonary circuit so we're gonna have Patapsco a dia depending on the size of the shunt is this the end of the world are we gonna cancel the case no but just being

aware of the patient's physiology would explain to you why I put this patient on this and I'm getting a value of 30 you follow and it's not the end of the world you document 30 and you monitor for trends as you're going along with your

sedation same thing goes through with dead space dead spaces were ventilating but we have an area of the lung that is not being perfused pulmonary emboli other circulations some medications hypovolemia shocky patients same thing

the VQ mismatch not the end of the world it's part of the patient's physiology maybe part of the reason why they're down there just being aware of these things though so the technology works right our equipment works if just amazed

it's picking up something that we don't connect all the dots on physiologically that sometimes confuses us a little bit so I hope that clears up part of it so when we're monitoring capnography certainly ventilation is what we think

of first and it's important co2 being expired by the lungs that's what we're looking for but if we back up and look at the physiology of carbon dioxide production in the body we are also inferring that

it's being metabolized and being created from Krebs cycle and aerobic metabolism and that we have perfusion occurring okay I'm sure if some of us have seen in our you know nursing careers patients who are kind of peri-arrest and

the capnography kind of drops off it's like a poor man's swan you're watching cardiac output drop in real time because carbon carbon dioxide is not being delivered to the lungs so when we're looking at our patients when

they first come down we first want to establish a baseline value we want to put on a monitor have a patient take some nice deep breaths full ventilations not just one but a few you want to you know have them take a few and look at

their other vital signs their mental baseline status and we're gonna look for trends in their carbon dioxide value so if someone starts off at twenty nine I don't care that they're not 35 to 45 which is textbook normal this person may

not have the stimulus to breathe if I let too much co2 accumulate so we're really looking for the trends okay now somebody will say well how much of you know how much should we look for 10 to 20 percent change from your baseline is

somewhere where you want to start paying attention to what's going on okay maybe like titrating your sedation or just being a little bit more cautious with how much more sedation but again it's more important to look at the trend

value behavior of your carbon dioxide than it is the absolute numbers themselves so first you having a problem let's consider the patient's physiology

so I actually work mostly in

interventional radiology in CT and ultrasound which is actually on a different floor that where we have our cath lab and I our stuff upstairs so that I our doctors are each going between two floors and one of my biggest

concerns is when we're doing moderate sedation the nurses are down in CT and ultrasound it doesn't matter how many comorbidities the patients have the aasa' is always three or less because they want to justify doing it downstairs

with just one nurse and the procedure list and I just and then you have somebody who obviously needs to be having anesthesia involved and now the anesthesiologist or the nurse anesthetist they get a circulating nurse

with them and I'm just wondering is there a cut-off that anesthesiologists or nurse and necess use for saying okay the a SA when it's this you have to consult with an anesthesiologist before you proceed with a nurse just giving

sedation that's a great question and that's institution unfortunately that's one of those things that is like institution dependent policy and procedure politics finances you know sometimes you'll see patients who really

are in a sa three four or four and a half that are made to be an a sa to write you know so they could be done during off-hours without anesthesia unfortunately it's a symptom so the organization's ever sit together and say

let's look at this globally for the patient safety and if we're doing sedation in this scenario we should still have somebody there who's trained to do the backup for that person I can't speak to your organization's policies

because I don't know them I know that they recommend catalog' Rafi I do know that the avenues to look at would be the Joint Commission in the anesthesia patient safety foundation you know for guidelines and again guidelines are just

that they're guidelines they're not mandates especially you know when institutions develop policies procedures protocols and such I do know on the third bullet down is we have a whole implementation project that we've rolled

out so one of the questions in addition to technical questions we get is how do I go to my institution and kind of change practice a little bit and usually the question is like implementing capnography but it it's a three-part

series that we did on how to implement change in an organization who are the stakeholders who are the champions who can you really talk to that would create change and whether it's the chief of anesthesiology is the person who's your

roadblock or your best friend is it the VP in nursing is it the safety committee you know cuz it takes one adverse event one Sentinel event unfortunately sometimes to change culture it takes more than that I know I know we're

trying a little at a time though but think it was a great comment in question was just made in our institution anesthesia kind of hit at this because the nurses were concerned about what she was just saying and so they worked with

the directors of like IR cath lab the medical directors to you say let's come together and figure out you know if it's a four it doesn't mean that every four needs to be you know it can be given sedation can be given by nurses but at

least get an assessment or things like that and in our institution nurses are able to if they feel like they needed anesthesia consult they can do the anesthesia console it doesn't mean they're gonna have anesthesia but

anestis you can tell you what to give and what not to give mm-hmm but that's that's what they're trying to do they have done for cath they're doing it for IR too and that is I forget them term for it but that's a team collaboration

and so and I must said where we work we actually screen the charts ahead of time because we have some really remote places and some not as remote and it's like the litmus test you know somebody with a BMI 55 is not going to be done

down the street they're gonna be done where emergent resuscitation is right upstairs if needed and same thing holds true like in our institution like anybody can call a patient safety stop meaning like I don't

feel comfortable with this let's not go forward and and again the procedure lists are another list of those champions because procedure lists they care about their pain you know they don't want to see adverse outcomes and

they're so focused sometimes on what they're doing that they kind of black you blank out on some of the peripheral factors and no one wants to see something bad happen on their watch so the procedure lists can be

instrumental in getting better monitoring or advocating for advanced levels of care or at least support for the nurses to have there's another question in your experience are the waveforms the same as far as a

ventilated patient versus a non ventilated patients have you seen any discrepancy in the actual performance that waveform itself yes and no okay so so I'm ventilated patients somebody who's really hyper dynamic I mean I've

seen like you could see sometimes their heart beating you know like just some of the little fluctuations or oscillations for the most part no difference if the non-invasive ventilation patient is getting monitored really right where the

gas is being exhaled like right here you may see some other you know and somebody is intubated so if there's secretions you might see like a little you know blip and such but when things are perfectly working the way they should be

working in both the intubated patient or the patient with an artificial airway versus not the waveform should be spot-on but if you're not seeing that is it a COPD or is it somebody who's got you know bronchitis in there yeah if

you're not seeing that full square waveform the question should be why not is my equipment not working good question great questions did the sign-in sheet make its way I know the spiral bound notebook is over

here but please do make sure that you put your name your email address and you'll be emailed because so you could fill out an evaluation and make sure that you get c e for attending this opportunity today I hope you guys

enjoyed it I hope you took something out of it I hope this just wasn't the basics for you today I hope that there was some value added in to coming today please do hang around we'll be here we'll be in the exhibit hall I know that there's

going to be many more events that are have this afternoon but the rest of the team will be here and we really do look yeah I love working with nurses that are providing sedation's I feel like you're the you're my people you know but you're

the people that are doing this day in and day out and you really are that that patient safety advocate and I feel like when I speak to a roomful of people that you guys go out and teach your precept ease and create change that's going to

impact patient safety so thank you for your attention today and thank you for attending [Applause]

gonna talk about is now you know where

you fall on the burnout scale we've gone over some of the signs if you have found out that you are either on the way or already burned out what the heck do I do with that information should I just quit nursing and hopefully the answer is no

because we all love what we do we just have to figure out how to reconnect with that okay again these are all the slides with a lot of stuff on there but I want you to have the information for you and your peers so

number one is set boundaries knowing when to say no okay I've been working on this burnout and my over stress or whatever you want to call it for three and a half years and I'm still struggling with how to say no I'm not in

a store key way because that will get you in trouble but just to be able to say you know what I'm done I'm saturated I can't take on one more project unless I get rid of one okay no shame in that set boundaries on your commitments both

in and out of the workplace I had someone say to me the other day when I told them what I was presenting on oh I'm not burned out in my workplace but I'm burned out at home same rules apply it's still burn out and you're still

gonna take it out on someone else not meaning to you're not trying to hurt anybody but you're going to because you're past the point of stress okay process your emotions and this was a tough one for me so that's why I had

asked earlier what do you do to de-stress you have to have a way to process them okay especially after a taxing shift I would love to hear every single one of you say if you lost a patient in a very traumatic way like a

code that didn't go well or you just found out that paracentesis patient that you've known for twenty years just passed away whatever it is that you have a debrief but I know we work in a hospital where you have to go oh I'm so

sorry mr. Jones died okay are we taking care of next and you don't have a chance to process that I will warn you I am NOT a journaling person I have never done a journal in my life I find it waste of time I've always thought it was stupid

or I would do one page and never come back to it I have started committing to journaling not every day but if I had a day where something was bugging me my drive home because remember I said if you spend your whole drive home

chastising yourself for how you handled something what I then do is go home I don't like writing in a book I rather do it on my computer and I don't even save the document it's just the act of putting it down on paper okay and where

it little later if we have time we can do a journaling exercise just to show you how I do it but I will literally write down what happens how I felt and I have to be honest with myself and

that's not always easy because then I feel bad for feeling some negative emotions but you have to acknowledge them to deal with them and then think about how I could have handled that situation differently then I erased the

document and walk away and I let it go and I have found it to be extremely extremely helpful and as I said I'm not a journaling person this is not my thing but it's been a way for me to get it down out of my head out of my heart on

paper move on and I've noticed that I'm having to journal less and less so I'm considering that a success okay put yourself first so I said this to someone the other day as I was trying to get my presentation ready and they looked at me

and said I have five children when the hell do you think I'm gonna be able to put myself first between working full-time and this person is going to school and five children when the hell can I put myself first I'm like okay do

you get a shower in the morning she said yes I said make it three minutes longer and stand there under the hot water doing some deep breaths and relaxation it may be fifteen seconds here fifteen seconds there but you've gotta find

those times for you and it doesn't mean you don't love your children it doesn't mean you don't love your job but as I said if you don't decompress you will implode or worse explode and you'll end up hurting

somebody by making a mistake because you're emotional because we already taught had the lecture this morning which was so timely I didn't even realize when we put this talk after that one how timely and connected the two

presentations would be okay and again manager stress we've talked about this a little bit okay exercise is definitely a strategy to get rid of some of that stress for those of you that enjoy the exercise please go ahead I find a

torture I still do it because I know I need to and it's the healthy thing to do but for me it doesn't make me feel any less stressed if it works for you though great as I said everybody's gonna be different I like to so that's my thing

so I find when I am really overwhelmed I will literally go in and make a pot holder do I need another flippin pot holder no but by the time I'm done with the pot holder I feel better

so you got to figure out what that is for you and broaden your network get involved and that's what I love about this conference somebody said it in a presentation the other day and I don't remember who it might have been Kathy

but they love coming to this convention because it reaffirms that I love what I do I'm passionate about what I do so in that busy moment I go back to I love what I do okay so the way I think of these conventions of what I love the

most about them and I always love to make sure we have at least one presentation that and I call it the pull on the heartstrings moment that AHA of why I do what I do and for me this year it was the Johanna Poe lecture about rad

eight and making a difference in other countries could you imagine being in a country that had 60 million people and didn't have a cat scanner so for me that was the moment in this convention but I love coming to these conventions because

I'm able to fill that cup that I can draw on for the next year or in this case now just six months if you come see us in Ohio the other thing I want to point about out about broaden your network and this

takes courage is sharing your struggles with your co-workers now it doesn't have to be everybody we all know we have that co-worker that would just laugh in your face if you told them you were feeling burned out but I'm hoping every single

one of you has at least one co-worker that would understand and want to help you with it partner with that person because there are a few people in my job that I have shared it with and they can tell when I'm starting to get there

because they know me and they'll just say turn around take a few deep breaths go get a coffee come back and it's amazing how much I feel better after just recognizing the emotion even if it was negative it doesn't make us bad

people and then get back to work so try and partner with your group and that's why I suggested taking this presentation bringing these burnout surveys back to your job and do it as a group if you guys all find out that

you're at the same spot even if you're on the lower end of the scale guess what you want to stay there okay so as I said I could probably do an

new data of the Emmy trial that came out last year our ten-year results saying

that after ten years after ten years women who wanted to retain their uterus they looked at them in ten years three-quarters of those women were still very very satisfied and also were still able to retain their uterus so ten-year

data came out randomizing people for uterine artery embolization versus hysterectomy of the women who chose you to an artery embolization ten years later they were still very happy so I tell my patients that this is what you

should expect that you will have symptomatic improvement in 12 months around 85 to 95 percent of the patients are pretty happy there is a entry intervention rate it is not zero and it can be higher than ten

depending on what kind of Imogen is seen ahead of time and that we know that dysfunctional uterine bleed tend to do a little bit better than bulk type symptoms and that's partly because of subjective nature of that so this is one

of the patients that I treated when I was in in Virginia and Riverside and she's a former miss Brazil and she came to see us with what she also called reversed cycles like she would bleed more than she would not and she was

wearing depends and it took everything to just coach her out of the car to come inside to do a consultation because she was so afraid that if she got out she would be sitting in a pool of blood and she had an MRI showing what looked like

a eleven point seven centimeter fibroid she had embolization and that was her six month follow-up MRI to the right which looks like a very impressive result they don't all look this way which is why I save this image something

that looks like a normal uterus now I for the persons that I told to hold your high horse here is the time okay so what happens if I want to have a baby because these are the things you remember we're being ambassadors for this procedure we

need to be having the answers for the things that are our friends and family members are going to be asking us so if you want to have a baby I would say that the data that informs us as to what to do with you is still very weak but the

only randomized prospective trial that we have out there says that you should actually have myomectomy and a Cochrane review was also done and it still says that there's very low level evidence suggesting that myomectomy may be

associated with better fertility outcomes as opposed to UAE but more research is needed and we still require more research so at the very least what I have to do and now you feel compelled to do is to send my patients to see

someone who is a fertility specialist in consultation so we can make this decision together so if your poor surgical candidate if you have the gazillion fibroids and if you've had surgery before a hostile

abdomen and the patient says you know what dr. Newsome there's nothing that you can tell me ever to say that I'm going to have surgery then we're going to be doing something else that is not surgery okay the other thing that your

MRA safety is one of our top priorities in our unit we have set up MRI zones zone one being the patient waiting area

zone two is where they change and they get screened zone three is where our control room is and anyone who passes by zone three has to get screened our pet MRI injection room is actually inside zone three and zone four is an MRI

scanner itself we assess risk in our patients for their implants we were iterate to them the importance of bringing their implant card with them just so it's easier for us to assess the compatibility of their their implants

with MRI right now we have the capability of scanning cardiac pacemakers and defibrillators it just needs more coordination with our in-house cardiology service and the implant representative rest assure

expanders and aneurysm clips are so contraindicated inside the skin we tell our patients to remove some items that they are able to remove such as dentures hearing aids piercings and prosthetics if they have it as for radiation safety

we observed the concept of Alera or as low as reasonably achievable you know before we inject the patient with the isotope we keep them comfortable we give them blankets we give them the pillows and we tell them

after they get injected that they are radioactive so we try to limit our exposure to them after they get the injection now we try to keep our distance from them and we have shielding lead shielding within the pet MRI area

now we have lead shield syringes available for the nurses use and we have dedicated a hot hot bath room a hot room and radio pharmacy we Ritter we give these puppies this injection card to the patient after they get the scan and we

were either a to them the importance of this card we have the stories from our patients where after the after they scan gone home and they passed through the tunnels or the bridges that they actually have been pulled over by the

police because the police have very sensitive radioactive detectors there was one patient who may have forgotten his card may have lost his card and he got pulled over and the police had to call our institution to confirm that he

really did have an isotope injected we

physiology knowing that we want to measure true ventilation let's kind of dive deeper into the equipment issues so looking at some studies here this is a

study that compared the different techniques for interfacing capnography with adult and pediatric supplemental oxygen masks in really the main finding of this study was regardless of the measuring device that was used this

signal for the of the entitled carbon side it varies as the oxygen concentration varies especially in very high levels so levels and adults that are less than 15 if you have a good location of your sampling you're going

to get a pretty accurate sample of your carbon dioxide but what this study found is an extremely high flow rates and that's adults greater than 15 liters per minute and in Pediatrics greater than 8 liters per minute that's when you're

gonna start to see some data quality decrease and I'm gonna tell you a little secret if you have an adult that's on 15 liters per minute and you're having oxygenation issues your problems are bigger than that okay no one should

really be on that much oxygen right you know there's a certain point where you have to change the ventilation or maybe they have a perfusion mismatch or they need peep or they need some other physiologic intervention camp Nagato

masks they provide really stable measurements without significantly breathing with commonly used oxygen flows and these are capnography masks that were designed for that not the rigged up ones that we sometimes you'll

have creatively used in the past and because and if you've seen some of the masks coming by some of because of the open design the carbon dioxide measured with the High Flow oxygen rates if we need to use higher flow rates you make

it artificially lower readings a greater again greater than 15 liters per minute and they may not reflect adequately like that gradient may be much bigger than compared with lower flows so using a standard o2 mask the one we pick up off

the shelf in combination with our you know nasal oral scope monitor can provide us with really good monitoring because it's going to be right close to the patient where they're exhaling but you have to watch the risk of patients

rebreathing okay so this is a little bit of a change in practice because we've recommended this for a long time now you put your sampling line on you use your regular oxygen but just by doing these studies we've found that

patients are rebreathing carbon dioxide more than we thought just something to be aware of you're looking at your baseline and if your monitor is calibrated appropriately and I've been doing

for 15 years and I've never seen a Capon ography monitor you know when you turn it on and it calibrates itself where the baseline was not zero okay so usually it's something related to the patient rebreathing and such so again food for

thought this is just the comparisons okay so when we have patients that are breathing I know it's a little hard to see from the back so we're comparing the end tidal co2 concentration between devices and at our supplemental oxygen

rates as we're going up on our flow rates so with patients that were normal ventilating their co2 on a blood gas was 39:39 on the monitor so very very little change and that's actually true for the cap one mask the oxy mask and the

different capital lines that's what they looked at they looked at for when they went up to five liters per minute 38 plus or minus point five 38 plus or minus point seven and then no change for the capital line the two different

capital lines so again nothing's statistically significant as far as using five liters per minute and same thing with ten liters per minute with normal ventilation really no change in the monitoring from no oxygen to oxygen

where you start to see some changes in normal ventilation with using all four of those the cap one the oxy mask and the capital lines very very little difference even at 20 but when you looked at the regular oxygen mask that

wasn't designed for it that's when you see the statistic differences and certainly the same goes true for patients who are a hypoventilating and hyperventilating to using the proper equipment again with normal flows and

even higher flows you really don't see a whole lot of changes and this is just a this in a graphical form here so we have patients with a simple mask on the first column cap one and then the oxy mask and you can see the simple mask between no

flow and flow there's a difference in our siege of co2 readings where the cap one and the oxy mask not as much of a difference right and then the same things when we I'm sorry I'm the right when we

turn the oxygen on and the flow rates go up minimal difference in the concentration that we're monitoring there so careful attention to positioning the mask where the mask is located on the patient the inspired

concentration of carbon dioxide and the waveform itself right the quality of the waveform should be looked at very carefully and then looking at the location the gas sampling should be right over where the patient is exhaling

right you want to avoid having any distance between the two of those which I know can be a challenge in the environments that you're working in so

now let's look at non-invasive ventilation and I know about like five

percent of the patient population that you are seeing is on some form of non-invasive whether they're on by level ventilation or continuous positive airway pressures right so see if HAP using to stent the Airways open and

maintain a pro a Peyton airway and improving oxygenation but BiPAP and patients that need co2 elimination right need help with the by level support so there's a lot of questions that come up when we give

these talks I'm like how does capnography work effectively with these different technologies of non-invasive ventilation and especially because more and more of our patients are requiring these so we're gonna look at some of the

comparisons of co2 capnography data from three different sample sites and remember I showed you that picture so that picture I showed you with the patient wearing the sampling line with a nasal oral scoop and then there was the

mask sampling port and then there was the port on the ventilator circuit distally so that's what we're looking at here so the diamonds that go I wish I had a pointer I don't have a laser pointer I'm sorry but across the top the

diamonds represent our end tidal capnography values from one liter all the way up to eight liters so as the props are as the pressures go up for CPAP they were monitoring leak rates and what they found is the cat nog rafi

values across all of those were pretty accurate when we're monitoring right here the squares and the diamonds represent the mask sampling port and the the ventilator in the circuit distal to the mask and as you could see that

quality of our monitoring goes down as we progress okay to use yes but just know the limitations of your equipment right and again this is the same thing for our BiPAP Dave data are by level ventilation we're seeing again

across the top if we're sampling right at the airway we have pretty consistent readings but then they start to fall off and we look at the other devices that are further down the downstream what we're seeing here is our end tidal

measurements again with CPAP data and what we're looking at is the patient leak so there's always leaks right when we have these devices on and that's a question well sue if I have a leak how accurate am i okay so now the red is our

nasal oral scoop and if you look at the red graph all the way across depending on the leak rate pretty consistent values right the charcoal color is the mask sampling port and that's pretty consistent probably until about like 10

right until our patient like leak rate 10 liters per minute coming out of that mast and then that value starts to fall off and even more so even further distal down our circuit when we're sampling from the circuit at the past the mask

that's the cream color pretty accurate when there's a minimal leak but as the leak goes up that falls off pretty significantly and the same holds true for our by level ventilation pretty similar distribution here with the

patient leak and the sampling so when we're using non-invasive ventilation yes it's accurate and yes it's accurate we're using high flows and yes it's accurate if we have a huge leak only if we're sampling right where the patient

is exhaling so now I hope that clears that up with the patients that are getting supplemental pressure support with your sampling and you know in those just whatever it can sample from the mouth and the nose right at the source

of exhalation has proven to be the most reliable out of all of the different sampling devices so third evaluate your

do anesthesia for some of our cases mostly to our pediatric patients but we are also capable of doing it through the adults they need some anesthesia clearance patient is asked to be NPO

after midnight we have equipment available that are MRI compatible such as the monitors the IV pumps and the anesthesia ventilator machine when we set up the the patient inside the scanner we have to be wary of the lines

the table does move in and out during the test we don't want any of those IV tubing's get snagged we've done pretty good job in securing these lines usually by taping it on top of the coils after the pet MRI with

anesthesia is done they go to the PO 70 anesthesia care unit for recovery and I

culture concept so the single greatest impediment to err prevention in the

medical industry is that we punish people for making a mistake we should learn right we should really learn so what comes to mind when you think about it the term just culture right she's being able to

report something and not having having punitive actions from that Lane free fair open and honest trustworthy supportive nice place to work yes so two nurses select the wrong medication from a dispensing system

one dose reaches the patient causing him to go into cardiac arrest and the other is caught at the bedside before causing harm do we treat these nurses in the same way no we should but oftentimes we don't right

right right so an active failure versus more the latent failure right so upon further investigation it showed that the two vials that these nurses pulled were very similar the vials was very similar to something that wears a different

medication so we needed some separation from pharmacy so so a little systems intervention right in our Omni cells so and maybe you know maybe there's some human factors that were involved there too that you know one nurse caught it

and the other one didn't but rather than punishing we need to work on consoling and supporting and look at the system and find what's happening what's going on what's the root cause a nurse loses custody of yet an unlabeled specimen but

chooses not to report the incident at a fear of discipline do we fur grit forgive the breach given the nurses fear no no so we really can't but we shouldn't come down on her like a hammer you know or on them doesn't have

to be heard on them because this can actually be a sentinel event if if you have to go back and get another sample that's a set a little bit so that's a Joint Commission never event so that that's not that's not a good thing plus

it's an extreme inconvenience to the patient and also we're opening that patient up to further harm because we have to get another sample so you have to ask why did the nurse behave this way why did she choose not to report it

honest honest disclosure without fear of retribution that's an important characteristic of the just culture hmm yes it does doesn't it that's an excellent point thank you very much for

sharing that excellent point certainly she said that you also have to look at leadership because a lot of times leadership has favoritism so you've got to work on the favoritism so it has to be fair and that's also part

of the just culture and that's a very good point as a learning experience and we're gonna cover some of that too so we have a radiology team that defends skipping the timeout on the basis that no adverse event occurred

so do we condone this no no no so we we don't condone it and it is it is a Joint Commission requirement but and although this incident didn't end in an adverse event we could certainly see where it might so again we need to engage our

leadership we need to engage people at the bedside including our physicians as to you know why we blew right through the timeout so a fair and just culture is is a culture that refers to values supportive model with shared

accountability um it's also an integrated pattern of individual and organizational behaviors based upon shared beliefs and values that continuously cease to minimize patient harm that may result from the processes

of care delivery so culture is the outcome of how our organization responds it's the outcome so if we have a just culture we will have people who will report those events those near misses and will work and not hide them and do

what's right that's why we need it because if we don't have it only two to three percent of errors would be reported most hospitals would be unaware of what errors they had health care workers would report only what they

could not hide and airs as viewed by hospital workers and the media are indicators of carelessness which is not true in fact it's farthest from the fact

burned out so if you chose not to do the survey you can certainly go through this and see how many

you can say yes on so are you constantly sick and tired do you ever find yourself struggling to keep your eyes open even when you're out with friends or is it getting harder to get out of bed than it used to be physical exhaustion is one of

the earliest warning signs of burnout but don't we all attribute it to the stressful day that we just had that we're busy with the kids we're taking them to soccer we're taking them here I don't have children but I have very sick

elderly parents so for me it's the other way but when I was feeling exhausted I just I'm just tired it's busy it's busy but it can truly be one of the first signs that you're getting past stress and into burnout so burner can also

cause physical symptoms including headaches insomnia stomach upset weight loss or gain and it can make you more susceptible to illness do you have those people in your department that are always flippin sick do you wonder if

maybe they're burned-out and that's why they're always sick it's a really good question I was talking to the people I currently work with and even though I happen to work at a phenomenal organization right now and it's the best

job I've ever had it's still stressful I was shocked out of the 12 of us seven of them said they suffered from insomnia seven I think that's higher than usual so we had that conversation of you may be starting to burnout you may need to

help you know pull back a little bit so it definitely is an issue so if you're constantly sick or tired and I'm not making a joke on that one even though I could please seek out medical attention to find out if there is a medical reason

maybe your hypothyroid your vitamin D is low because surprisingly most of us are there may be a medical reason that you're always exhausted but if you've ruled that out it may be that you're going past stress into burnout warning

sign number two and I love this one because I can come up with every single day where I feel just a little underappreciated but this is warning sign number two and I love that cartoon is that not adorable

and yes stress can kill you it's easy to feel underappreciated on a given day what we do we do so much stuff all at the same time and most of the time our patients and our supervisors don't even see

what we do let's be honest we do but we're so busy doing it we don't feel all the good that we do if you start to seriously feel underappreciated you need to kind of take stock and why am I so upset

is it me am I having some issues is it I don't have good communication with my supervisor is it an issue with my coworker and maybe I need to sit down with them and work on our relationship it's okay to say no to extra assignments

I know that's a tough one no is the hard word for me those of you that know me yes I am the chair of the Planning Committee I am also one of the master faculty they teaches the review course to study for your certification exam

I'm also the state chapter president I have a hard time saying no I get so passionate about getting involved that I realize I'm under a mountain I learned how to say no ask Pauline we were at a meeting the other night and they asked

someone to step up and do something and my answer was I'm sorry but I have to say no I have to figure out how and when I have enough it's okay to do that you just have to do it professionally and not snarky which as you can tell by my

personality I sometimes have troubles with I did say no I was very proud of myself I waffled a bit but I said no and yes and it's a hard thing to do especially when you want to help okay do you spend your drive home chastising

yourself on how you handled a certain situation I know I sure as heck do so I'm in a couple of slides I'm gonna share with you how I process that information and I'm finding it's being very helpful in moving me down that

burnout scale okay sign number three dreading going into work I just love the guy over on the right I had so much fun with these people okay nobody wants to work on a holiday or a weekend but if your stomach is getting tied up in knots

when you wake up going oh crap I have to go to that job again it's probably a sign that it's more than just stress okay but we don't want you to just soldier through this is your body's Way of

telling you this is not just stress this is abnormal okay now it's gonna happen to all of us some days granted if I had to work that next day or after I worked my 21 hour shift do you think my stomach would have

been in knots getting up absolutely but it shouldn't be consistent okay I loved the third one if an unsupportive nurse manager or co-workers from hell do you have any of those are making your work life a living nightmare it might be

time to look for another job I'm being honest for me that was it that was my solution I was so uncomfortable in the situation I was in feeling like I wasn't getting the support even when I shared with the person that I would realized

how burned out I was I got no support for my well-being and for my marriage it was time to find a new job but it doesn't have to be if you have a supportive group you can come back from it and stay in a job that you love it is

possible okay so if you're not ready to leave the do job try picking up a new skill or taking a class so let's say you always work in IR maybe you go to your boss and say hey can I start picking up a few shifts in CT just to do something

new to challenge myself with a new task it's a great way to refresh that passion for what you do without leaving the job if that makes sense okay our fourth sign does anybody remember what that blow-up guy was from airplane I love Tim so

warning sign number fours you're going through the motions okay so here's my question were you inspired and motivated after nursing school where you went into your shift and you were so excited to go in and take care of that patient and I

can tell you after I got that leadership job I went in everyday all excited on how I could make a difference but do you see that now you're almost trying to avoid the interactions with your patient and you may not and I hope you don't but

there have been times even now as I'm healing that I'm thinking in my head I just wish this patient was shut up please be quiet and then I have the other side you know the devil and the angel

and then the angel goes Lauren take a deep breath it is not your patients fault you're having a bad day you love what you do go back to that take a deep breath and go back but it happens it happens to all of us and it's not that

we're bad people and that we don't care anymore we just we're overstimulated is the best way I can describe it okay all right and our last sign is that you're becoming insensitive to your patients and the the situation I just just

described and it admitted to which I can tell you is an embarrassing thing to have to admit but I admit it you you can absolutely become insensitive to your patients how they're feeling what they're going through this meta port

I've done seven of these today I'm frustrated I want to go home I have a headache I don't feel well but you forget that for this patient this is life-changing probably in the last week their life has been turned upside down

with a million procedures and new diagnoses so it's taking that deep breath and refocusing okay so if you can and that happens take that deep breath try and take a break which I know is hard some of us don't even get lunches

but even if all you do is I've actually turned around and faced the corner and done three deep breaths and my staff because I've shared with them the struggles that I'm going through if they see me facing the corner they just let

me be because they know I just need five seconds to compose myself okay burnout is not a moral failing I struggled with this a lot because I kept thinking like that okay so now we're

relationship do you have with your emotions are you that person that just shoves it inside and ignores it for

another day a lot of times I admit to that but it's gonna blow up at some point in it so you have to be able to recognize what emotions you're having even if it's negative I already shared my example of

thinking why won't that patient just be quiet I need to concentrate on my charting negative emotion I hate to admit that I had it but I had it it's okay I'm human recognize it and then act on it not in a

negative way but in a positive way so that makes sense okay and self-awareness simply put to be self aware is to know yourself as you really are it's a continuous journey of becoming more and more comfortable with the true essence

of who you are and just a few tips quit treating feelings as good or bad this one I struggle with every day when I have a negative feeling about a co-worker or a patient I feel guilty instantly but I have to learn that that

doesn't make me a bad person it was an inside thought I didn't shout it out to the world and hopefully it wasn't in my body language recognize that it happened take a deep breath and start over and start looking around what is the ripple

effect of your emotions okay I happen to be one of those people that feed off the emotion of whoever I'm with so there are certain people that I work with if I work with them I can guarantee you I'm gonna be cranky by lunch because there

are more of that negative not inappropriately negative but just less the fun to people to be around I end up acting like them by lunch where there's a few other people including someone who be happens to be sitting in the audience

that I work with when I put myself in her room I am happy all day long we may be stressed we may be working our tails off but we are having a good time while we do it so can you always pick your coworkers no but if you do have any say

in that it does help to figure out who makes you a better person and who brings you down okay lean into your discomfort this one was a very very tough one for me if I'm having a negative feeling I really just need to recognize it accept

it and now I'm gonna act differently than I would have if I did it by instinct okay let's see feel your emotions physically which I don't like in the workplace I tend to do that more in my journals later because I know in

the workplace I've got to be more professional no one pushes your buttons do you know what pushes your buttons yes you do and unfortunately your co-workers know how to push your buttons too okay keep a journal like I said I'm not a

general person but it has been helping me don't be fooled by a bad mood you can turn it around but don't be fooled by a good mood either cuz if you're someone like me that feeds off the energy of the room you can change it around regardless

because I've been having a great day until one person walked in the room and that's it I'm a crank now so you have to be careful with that and visit your values I've had to do a lot of self inspection I guess you could say over

the last few years on what I think is important if that makes sense okay so

some of the contributing factors to hypoventilation well certainly will we give sedation we give you know a benzodiazepine we give other medications we combine those with opioids right that

decreases our responsiveness to elevated co2 levels but we also have muscle relaxation certainly in patients with obstructive sleep apnea history undiagnosed or undiagnosed they lose their muscle tone in the airway patency

kind of diminishes very very quickly and they also have a decreased response to hypoxia all again creating that perfect storm of an adverse event waiting to happen and even patients that have don't normally have obstructive sleep apnea

can have it under our sedation so the key signs and symptoms you know clearly respiratory rate is one that we monitor but we also want to monitor the quality of ventilation right one look at patients tidal volumes and how much

they're expiring with each breath we want to look at their sedation scores whether you're using the rasp score or any of the other standardized scores spo2 less than 90 for at least thirty seconds that's pretty significant

hypoxia especially if somebody's on oxygen and hopefully you would detect somebody who's deteriorating much earlier than that but that certainly would be a terminal sign before they became bradycardic and you were pulling

out the code card but certainly using capnography you could tell breath by breath right instantaneous looking at those waveforms and look to see if the patient is not only taking enough breaths per minute but are they

taking quality ones so let's look at a little bit of a case study here we're gonna kind of look at this case study throughout so this is Jane Doe she's 39 years old she's being worked up for a nonspecific abdominal pain they've ruled

her out for gallbladder issues and appendicitis and they want to do an upper endoscopy in a colonoscopy she's treated with chronic pain medications gabapentin and oxycodone and she's had some surgeries in the past no allergies

to anything so concerns with this patient so what risk factors does this Jane Doe have for during for at risk for respiratory compromise during sedation possibility of undiagnosed OSA be a bio t mass index obesity high risk

comorbidities medical condition or advanced age there's more than one right answer so just make mental note here and these are the correct ones so she potentially has obstructive sleep apnea she does have an elevated BMI and she

has medical conditions she's sick acutely and she has pain medications as part of her chronic therapy so now let's look into solutions so again with our case studies after we give her some versed and a hundred Mike's of fentanyl

the patient develops the following pattern on the monitor so what should your first step be in this scenario nothing because her pulse oximetry is normal be stimulate the patient to take a deep breath perform jaw thrust and

place patient at a sniffing position to open the airway give a reversal agent or D intubate the patient good B you guys are all anesthetists now we have a bunch of positions open at Yale if you're

turned the mic to my FA which she will be speaking about program implementation staff education requirements clinical work form and review some case studies

Thank You rose and good afternoon ladies and gentlemen I'm Rafael Donna I'm one of the regular genders at Memorial sloan-kettering I'd like to thank you now because I don't know later I might pass out because just a nervousness if

that possible let me know later okay I would like to acknowledge Pyrrha she's trying to leave now she's have to go back to New York thank you for helping us to make this presentation possible and Renee

he's here he's our clinical radiology director he's very supportive of us and thank you too Larisa Sanchez our nurse leader and Erika leer and are in for making this giving us opportunity to present before

I go into my part of the presentation let's say let's do a PET scan into to our MRI team you see the white floating areas over there let's pretend us the normal uptake from pet SDG but if we do pet MRI look what happens yay you see

their smiles it's very very vivid colors our team is very diverse you could see from all we come from all over different parts of the world they are awesome they help us give us this very good images that we're going to present today

the MS Casey pet MRI program planning and implementation took over a year the department have to hire dual modality artis who specifically trained for pet and MRI the cross training of our ends because we all MRI nurses we have to

cause cross train to nuclear medicine and pet department the construction of the radio pharmacy in the MRI suite and the development of the pet amar protocols in collaboration with the bio engineers physicists the radiology

leadership the attending radiologist the radiology leadership our ends and the artis also the compliance with the State Department of Health regulation guidelines very important part of this

all right so now here's what I want to

spend some more time digging a little deeper and talking about our clinical implementations this is where I get why I do a lot of these events and a lot of speaking with clinicians and this is where I'm gonna address a lot of the

questions that I get very frequently about using capnography and hopefully you leave with a little bit more knowledge and some troubleshooting tips so capnography traditionally when it first came out was used on intubated

patients right for establishing that they have a pain airway the endotracheal tubes in the right place and it's staying in the right place and that was placed in line with the endotracheal tube via adapter but now we're using

more and more capnography with patients who are spontaneously breathing and maintaining their own air and we have this breathing patients who are breathing between their nose in their mouth so they've developed

monitors where we can monitor patients who are exhaling through their nose and/or mouth we are looking at is again that non-invasive continuous plot concentration overtime of the co2 concentration that is being exhaled at

any given moment which is going to tell us instantaneously if there's any change in the patient's ventilation it just this is just a blown up view for those in the back saying if some of this can be difficult to see but what we have

here on the left side of the screen is an image and Michaels gonna start to hand out some of these just so you guys could put your hands on them and feel them and touch them because there's a lot of different advices that have come

out even in the last year that I haven't seen yet that I'm starting to see so we brought some samples that you guys can just touch and play with and such but what we have on the left is a sampling a filter line set which delivers oxygen

through in both nares both nasal you know prongs and also samples out of the nose but also out of the mouth and this is important because we all don't breathe just through our nose and mouth right we we we switch breathe Leone

where I'm talking I'm exhaling through my mouth sometimes I have a stuffy nose and I can't breathe through my mouth through my nose so sometimes when we're monitoring these things we can't if a patient is breathing just through one

air you're not going to get an adequate sample we're using capnography and I think it's more important to use capnography in the patients that have their own airway and our risk for losing their airway rather than ones that

already have an airway established and we're using it certainly in our sedation Suites we're using it pediatrics and neonates all the way up through adult right and we're using it more and more to with non-invasive ventilation with

our CPAP and our BiPAP patients that's another question I get a lot and we're gonna dig into that a little bit more but as you see on the picture on the right when we have patience with our non-invasive ventilation there's

different sampling sites that we can use we can have on the top there this patient is actually wearing a nasal and oral monitor underneath the mask there's also a mask port so a port that can be just plugged right into the

and then there's also ports that are on the circuit the mask ventilator connection which is a little bit more downstream so there's three places that you can attach capnography monitoring to and we're going to talk about the

differences with those as we go through here so let's look at physiology so why

two slides and I know you probably could have written these slides for me but what causes burnout specifically in our area so number one long shifts a lot of us choose and have the opportunity work ten or twelve hour shifts which is

phenomenal because you only have to be there three or four days a week but they're long shifts and then god forbid you're on call that night and a cold leg comes in at 5:30 guess what you're staying

so sometimes we end up I broke almost my own record recently and did a 21 hour straight shift before I got to go home and go to bed and thank God I was off the next day because I can tell you by the time I was driving home it was a bit

scary but it happens it's happened to all of us okay and we often find ourselves being put into some people mandatory overtime or like myself I'll get the phone call that the department is short my manager is not forcing me to

come but I feel bad and I want to support my co-workers so I'll pick up an extra shift even though I'm exhausted but I want to be a team player so okay putting others first is the other reason now we all went into nursing because we

care we want we are caring people we most often put everyone in our lives before us let's be honest especially people whose kids I do not have those I only have the furry variety but as a whole the nursing community is

notoriously selfless we feel that it's our calling to help others but do we care do we put enough attention and caring into ourselves and I bet you most people would say no honestly but we because we want to care so much for

others we are more likely to get burned out does that make sense okay I'm gonna have the two girls that I've asked are going to pass out a survey while we do this last slide if you need a pen they'll give it to you

the other two causes that I like is busy high stress environments is it high stress and busy in your department absolutely but we even you know one of the slides that the last presenter did said that errors occur when you are

under what was it under productive or over productive I forget the verbage she used but how many times I've made a stupid mistake because our first case got delayed for two hours and I sat there doing

absolutely nothing so my mind wasn't engaged now that it's time to work I'm not there so both can be absolutely yucky and let's be honest I have some nurses in here that the nurses for a long time there is a lot more technology

and computers and requirements as far as charting now than there ever was so you've become very detached from things but to me one of the most important ones is the fourth one and I know Cathy talked about this a lot in her

compassion fatigue lecture yesterday is that we deal with sickness and death all the time we see those patients that are the same age as us and they're not going to make it another year we see that person or that child that doesn't

survive we deal with that every day okay so my question to you in general as they pass out the stuff how do you distress how do you get rid of some of that give me some ideas on how people do that I was waiting for that that is usually the

number one answer and he said drink which while it is an immediate fix if that is your only decompression strategy you're in for some trouble but then that's guaranteed work for us later so you know that's okay

how else does some some of you deal with stress gardening dancing I love it what you got Cathy whoo she said horizontal adult activity is how she deals with stress okay you know the point is I don't care how you want to deal with it

but you have to deal with it I know all of you must know somebody who is in the field whether it be a nurse a physician and EMT or whatever that their only mechanism to release that stress was drinking or whatever or bottling it up

which could be even worse and they ended up quitting the profession because they couldn't deal with it so bottom line is I don't care how you deal with it but you have to have a way to get rid of it some people like

crafting some people exercise I don't know why the only time I'm the only time I want to be running is when there's a car running behind you no chasing behind me what did you say Johanna mm-hmm oh no I

know why don't give me the nursing answer so bottom line you all have to have a mechanism to release some of that stress so what I want you guys to do if you want to participate you don't have to I am gonna be quiet which is very

difficult for me for the next couple of minutes to give everybody a chance to fill out the burnout survey that you got be honest you don't have to share your answers with anybody it's only it will only help you if you are completely

honest alright so while you're totaling in essence what causes burnout and specifically in our department are you ready for the list I did a a group whole of some of the people that were around me ready staffing schedules long shifts

fatigue excess noise in the workplace no it's never noisy work load time pressures difficult co-workers and challenging patients and Families lack of control in the work environment inadequate resources exposure to toxic

substances what sorry that one made me laugh potential for hostility and violence so basically just about everything we do can lead to burnout if we don't help you figure out a way to deal with it does that make sense is

everybody done with their survey okay so let me tell you why I did this survey in the first place and then we're gonna talk about if anybody's brave enough you don't have to stand up I'm just gonna do a show of hands and see where everybody

fell I first saw this survey I have been interest for 28 years I was a nurse for about 15 years when I decided to go back for my BSN as soon as I finished my BSN I decided I wanted to go into leadership so I went back for my msn in leadership

just as I was finishing that degree a great leadership opportunity opened for me in the organization I worked in to go and be a manager so here I am all excited fresh and chipper felt like I was a new grad all over again

and I can tell you the first five years were absolutely some of the most stress mode but invigorating years of my life I had a very supportive person over me who helped me grow helped me learn how to stand in front of a group

and not vomit in the garbage pail because I can tell you before I started that job I had to have a garbage pail any time I presented but even though it was a stressful work environment I loved it I thrived on it I was that over

engaged person you know I had to force myself to put it away at night because I was just so excited about the idea that even though I'd been a nurse for almost 20 years now I was finally in the position to

help make some changes okay so that director decides to retire damn hip for being so selfish okay so the way the hierarchy was in that department we had our director who is the one that decided to retire and myself and another senior

manager or assistant directors whatever you wanted to call us so it was the three of us director retired one week later my Cove manager got a promotion to director at another facility so it ended up being me

for nine months while we looked for partners now I would love to say that I was able to pull my supervisors but where I worked they were working supervisors 99% of the time they were taking care of patients and in the count

and barely had that 1% of their time to squeeze in to do evals and all of that managerial stuff so there was no way I could pull them so here I was for that nine months thinking oh I'm just stressed I'm just stressed it's no big

deal but I started seeing you know in the middle of this absolutely crazy day the only thing I could think of and this is gonna sound stupid the only thing I could think of doing was a crossword puzzle it was my way to decompress and

get away from all of the stress but I started to realize I was doing them more and more so am i handling my stress or am i getting burned out see what I see where I'm going so we get a new director in and guess what she and I are like oil

and water so for the six months after that was not nice either let's just put it that way so I had a very good friend of mine come to me and hand me a piece of paper very much like the one I just handed you and said please take this

survey I think you're beyond stress I think you're burned out and I'm worried about you and I laughed at her and I actually got a little angry and said I don't know what you're talking about I'm just stressed it's

been a tough year leave me alone well my desk didn't do anything for about three or four days and finally I was cleaning my desk a couple of days later and I'm like you know what she did it out of a place of caring I really didn't handle

that well let me at least take it so I can throw it back in her face and say see I'm not burned out I'm just stressed well I took the survey and the first time I took it I was in that highest category of 60 to 75 I believe my score

was 72 and it was such an aha moment for me now my situation was management and of course it was influenced by a million different things but it doesn't matter if it was management iron nurse Ct nurse pet nurse doesn't matter when you're

burned out you're burnt out okay I had to do a lot of soul-searching I am obviously worse off than I thought meaning very burned out it's here on paper it's black and white I started to get really involved in the topic doing a

lot of research and saying okay now I know I'm burned out but now what what the heck do I do now so that's why I got so passionate about doing this presentation because even if you took the survey we also talked about what

causes it and I'm going for the next few slides they're going to be sometimes that you or maybe your co-workers are burned out so it's not only the survey it's everything but do I have anybody in the room that is brave enough to raise

their hand if they fell into that very high category well thank you for being so brave we did have I think two or three people welcome to my club it's not a lot of fun but you it can improve I promise you it can improve this in my

personal history was three and a half years ago I have since taken the test two more times and each time I am moving down in categories the last time I took it was before we came and I was at risk of burnout I was no longer in the

burnout category so it is possible to come back from that highest category was anybody surprised by where they fell no do we know in our heart of hearts and in our sub just that we are a bit burned out

probably a little bit was there anybody that was lucky enough to get 15 to 18 no signs of burnout oh my god I love you you are my hero I want to grow up to be you there you go that could do it she said she just changed jobs oh my

goodness gracious all right we're gonna toast we're gonna talk about signs of when you're burned out and then we are gonna talk about strategies to alleviate how the heck do I get out of this hole that I've dug myself in because I love

being a nurse and at this point in my life I was actually considering leaving and doing something else I'm like you know what I want to go back to working in a clothing store where I don't have to deal with life and

death issues anymore thank God I didn't because I do love what I do but you've got to do something to get out of that hole so I invite the two people that unfortunately said they're in hi to please email me I will help you out of

that hole any way I can okay so we're gonna go over a few of the slides if you chose not to take the survey that is absolutely fine I have a million extra copies because I didn't know how many people were gonna come if you want to

take a handful back to your department and do it as a group you're absolutely welcome to take them okay I absolutely you will eventually get every single one of the presentations that you got that you saw at this convention including the

ones that you didn't get to see but it's gonna take a couple of weeks so what I'm committing to you is if you want the presentation and the burnout questionnaire now because this is an issue for you I want you to put your

email in my notebook up here when I get home tomorrow I will email those to everyone tomorrow okay because this is something that's important for you and remember my slides are coming up that are so busy you're gonna nod off but I

want you to be able to use it right away if you think this is an issue for your group all right signs that you are

program is the stuff requirements and

stuff education all personnel who works in this department the radiology department have to complete successfully the web-based training for level 1 and level 2 safety MRI training including the housekeeping

and also the hospital staff that comes to the department have to fill up a screening form after doing so you'll be given a sticker placed in the back of your ID and it's good for a year and that serves as your pass coming to MRI

so you don't need to fill it up every time you come in and the initial radiation safety training is given by our safety radiation safety officer in the start all it's on higher and also the best training for RT Sundarbans

course training to nuclear med and the pet department it is important if you work in the radial pharmaceutical area that you know the basic concept of spill management the acronym cares I would like to acknowledge that this acronym is

done or formulated by our nurse leader le carré leer C stands for contains pill and opened the checklist the checklist should be available or posted to all areas where major pharmaceutical agents are administered a s alert the

technologist and supervisor they're very knowledgeable in taking care of the spills our is to restrict the area don't let anyone come in and step onto his areas of spill remove the patient if possible he is to educate the patient

you have to reassure the patient there is no health hazard or nuclear hazard to them yes is to sanitize sanitize the area of spill and record in the medical record is very important but what to do when this bill occurs in the zone for of

the MRI we were prior to going that I would like to show you the how our Rachel active spill checklist looks like this is formulated by Pierre Robson it would take you I would give you guidelines on how to do step by steps in

case of nuclear spill and what to do for spills that occur in MRI so on for first cover the area with absorbable material remove patient from stone for prior to proceeding to the decontamination process contact

radiology leadership they're the one to direct surface contamination within zone four and remember the Geiger counters are MRI unsafe so how we check the Geiger counts you have to use an absorbable material you keep wiping and

then bring it out and measure the Geiger level until you keep doing that until it gets cleared also remember that the MRI magnet is always on so have someone is done guard outside the door so anyone that would need to go inside the room

would have to be scanned again and screen this is our ms KCC clinical

heard the title of my presentation is what we burn out in radiology yes we do just like every other nursing specialty and every other first responder that you

can think of some a lot of the research that I found was for police officers because they have the same give your 110 percent all the time every day on every shift and it burns you out okay so yes we do have it in the radiology setting

but in our case nurses are the fabric that hold the healthcare system together who sees the patient more than anybody else in their stay it's us okay so normally when I give this presentation to a smaller group this is a bit of a

big group so we're not gonna do this as an activity but I want you to just think back why did you become a nurse in the first place what led you to do it anybody brave enough to give me a story cuz if not

I'll give you mine okay I'll give you mine I was unfortunate enough to have to be in the hospital at 13 for surgery the hospital I was in did not allow mom to stay overnight put me in a two bedded room

with a spanish-speaking only woman that had just had a hysterectomy and was screaming III all night okay so here I am terrified and the evening nurse came in and said I'm gonna give you a pain shot

and then I'm gonna sit with you until you fall asleep that was it and I know I'm gonna get teary here and there so please excuse me I knew right then and there I wanted to do that I wanted to make a difference so anybody

else brave enough okay what you got Thank You Joanna PO did everybody hear her do you need me to repeat that I do hear a lot of my mother was a nurse and I saw how much she cared my sister was a nurse my father was a nurse or a doctor

there's a lot of that that happens but ultimately it always comes down to now granted you're gonna have those few and far between people and I hope they're few and far between but say they went into nursing because you can get into it

with an associate's degree and make a decent amount of money and it's all about the money there are some in our career and I've even met some that I even to this day I became a nurse so I could meet a doctor

and quit working not kidding I am hoping that that's few and far between honestly most of us it's because we want to make a difference we wanted to help we wanted to show compassion for someone else but the problem with burnout is we get into

compassion fatigue which if you made Kathy Brown's lecture the other day I only made half of it so I may repeat some of what you said but that's where we get when we're burned out okay so that's what we're gonna talk about today

okay the objectives for today it's very simple this is going to be a very relaxed this is not stressful I want everybody to just sit back relax and I want you to reflect and think if taking notes helps you great

but just enjoy this one okay so at the end of the lecture I want you to be able to define the difference between stress and burnout because I can tell you just ten years ago I wouldn't have known the difference so we're gonna talk about

that understand where you are as far as a burnout level and that's the activity we're gonna do you all have an opportunity to take a burnout survey and you will get that I can email it to you if you want to take it back to your

peers to see where you fall on that continuum because no matter where you fall on the continuum even if you're at a low risk you want to stay at a little risk so it's good to know where you are so we're gonna do that we're gonna

describe a little bit about the topic of emotional intelligence I'm not gonna go into it a lot I could talk eight hours on emotional intelligence alone because it happens to be one of my passion but it really feeds well into this so we're

going to talk about what emotional intelligence is and it's one of the few things that you can actually increase and improve and change so we're going to talk about that just a little bit and then I want you all to be able to walk

away with one thing that you can do to alleviate or mitigate burnout okay so

equipment so first when you have a patient that comes down look at your patient look at

the vital signs Mental Status baseline lung sounds baseline ventilation status do they have a blood gas that's on record do they have they been monitored of capnography are you putting them on it for the first time yourself and

putting the sample line on get your baseline breathing get your baseline reading after a few breaths have them take some nice deep breaths look at their baseline waveform look at their baseline values but consider the

physiology it's okay if they come down and they have a low value or a high value because you're looking for changes and trends in the value second look at the effectiveness of your ventilation so that's a problem sometimes people will

come up to me and say you know this stuff doesn't work yeah I put this thing on the patient and I see their chest going up and down but I'm not getting anything in the monitor well guess what you know and I see this in the recovery

rooms and then I go and like well let's go if I'm clinical well let's go look at the patient and the patient is like slumped down in the bed your head is like this and they're snoring I was like well how about we boost the patient up

we prompt the patient's airway open and all of a sudden our waveform improves so look at your patients right look at the effectiveness of ventilation you know do you need to supplement their ventilation all of a sudden you see their waveform

come right back up right and then finally equipment okay it's not it's it's a little cut and dry yes we use capnograph we put capnography on the gas does the analyzing of the gases for us but you need to understand the the

mechanics of it right and using now capnography with different flow rates and with BiPAP and leak rates and different measures of you know different flow rates of oxygen blowing by so look at your equipment what are the

limitations of the equipment that you're using are your connections tight are you sampling right at the airway or are you sampling distal to the airway some of you may not have a choice right you might only have the mask connections or

for whatever reason you can't you if you have a burn patient or somewhere where you can't put something a patient it's okay but just think about the equipment think about the limitations think about the challenges

you may have with somebody you're doing a te eon or you're flipping somebody prone and they're breathing kind of sideways you're looking at the equipment in conjunction with the patient and the challenges you face so I hope that

putting it together in a format of first looking at physiology second looking at the quality of ventilation but third looking at the equipment interfaces and then passing around some of these devices and such kind of helps to take

it to an advanced level and put some troubleshooting and with that we have time we actually have if we have at least five minutes for questions I'm gonna leave this up on the screen and these are some really great resources so

there are plenty of things online they're free there's no charge some things have C II credits affiliated with them the California burden Board of Nursing but the pace website has a ton of information I apologize I don't have

a handout for you but you can come up take pictures of this go online see any of us after at the booth we can show you some of the equipment we could to answer more questions if you have another session you want to run off to but now

we have time for any questions and the microphones in the middle so don't be shy I don't have any prizes like like prices right but I'd be happy to answer some questions

want to look at now third this is the area that I really wanted to get to today did we pass along out no yeah hand me up one if you don't mind

so third let's look for equipment issues anyone in here do yoga a couple hands okay so some of this is from a yoga exercise and it will play into what we're gonna discuss here but on the left here this is an example

of some of there's all different products out there so on the Left we have a nasal cannula that on one side is delivering oxygen and on the other side is monitoring our carbon dioxide so everyone just humor me if you're not

eating take your finger and plug your right nostril and just take a few breaths in and out through your left okay now let's do the other side so plug the other side it's supposed to be calming we do this in yoga anyone having

trouble breathing through one nostril over the other okay I see a quite a bit of hands so physiologically we have deviated septums we have nasal congestion we have you know our blood capillaries getting gorged on one side

you know I know if I sleep on one side I wake up all stuffed up I have to take a nap on the other side to even it out at least that's what I tell myself right but we preferentially breathe through different nostrils so if we have a

patient on a monitor there's only monitoring from one side do you think that's the most effective monitor we can use probably not just take notice right now who's breathing through their mouths because a lot of us breathe through our

mouths especially patients who are respiratory compromise under sedation or are sick and these are the patients we take care of so for monitoring just through the nose are we doing the best job of monitoring we could be doing no

and we found this out I mean there's all different products out there but what we have found that is most effective is using something that is delivering oxygen through both nares but also monitoring exhaled gases from both nares

but also from the mouth and evidence proves us so I'm not just making this up so we're looking at here is a study that was looking at the accuracy of non intubated capnography patients different sampling lines and what we see in the

navy blue on the left is the first is when they had patients just under a mer and then they put patients on a couple liters of oxygen per minute and you can see use the nasal canula with a scoop was pretty

accurate for both those patients who are breathing room air and supplemental oxygen when we look at two different other designs of nasal canula that just had like a little like a little port to kind of hung down the accuracy not as

great okay same patient group but what happens when we add oxygen to those nasal canula they just they dipped in their accuracy so I'm not saying not to use whatever you have you know if you may only have those kind of nasal canula

but just know that you might not be getting a full sample especially if you're adding oxygen if you're just using a nasal cannula port you follow so just knowing the limitations of your equipment so the monitor the little

machine can only evaluate the gas analyzer can only evaluate what's being delivered to it so if the sample line is not receiving an adequate sample it's going to give you an a waveform that is certainly not accurate so we want to

consider a few things are you connecting multiple tubes to get like multiple you know sampling lines together and connecting them with a stopcock yes no I see some nods of heads and sometimes we have to do what we have to

do right to reach the monitor to the patient but if you're connecting those sampling lines is the connector tight I've seen a number of times where I've seen abnormal waveforms and someone stepped on the stopcock that was

connecting two pieces of tubing and then you just correct the stopcock or tighten up the connection and then all of a sudden your waveform improves but also where the sampling port is located on the patient is important so remember

that picture I showed you of the non-invasive ventilation and the person had the oral and nasal scoop on and they also had the port on the mask and the port on the circuit three different locations we're gonna look at that a

little closer but where is the sampling port located doesn't it make sense to have the sampling port located right where the patient's exhaling especially for delivering oxygen and especially if we're delivering oxygen and kind of

higher flow rates right greater than 12 or greater than 8 and P because it's gonna do potentially dilute our samples and these are some of the challenges that when I talk to people that they are bringing to me like it

just doesn't seem accurate when I have patient on oxygen how can I know that it's accurate so that's what we're going to look at a little bit more here so the farther the sampling ports are from where the patient is exhaling the higher

the chance of your sample being diluted and not being completely accurate when you're looking at your exhaled gas and you may see something like this picture here so there's some challenges like I said we can do the exhaled co2 can be

diluted the masks we're passing around some masks here some of the masks may allow for rebreathing so when I started and you know in healthcare and especially in anesthesia and such and providing sedation we used to take a

non-rebreather put on the patient and then cut tubing and stick the tubing in one of the little holes okay see a couple of nods of heads here right we make our own and that's how we monitored air going in now but do you think those

non rebreather czar really allowing patients to exhale fully and to get all that co2 out where it's all that carbon dioxide going you you see the mask fog up right now they at risk for rebreathing co2 absolutely so we're

looking at all these challenges right and do you think that little like rigged up mask design was getting a really accurate sample really close to the airway not so much so and you guys are assuming do you guys do T E's and

things where you're putting mouth guards and patients yes no some their sampling issues with that right how do we sample when someone's working in the airway well there are bite blocks now that are integrated and I think we may even have

some here that we can actually capture an accurate sample so knowing the

what is burnout the description is a broad-based syndrome that develops gradually over time associated with mental and emotional exhaustion but the

problem is aren't I always mentally and emotionally exhausted after a 17-hour shift because I happen to be on call so this is where I really came into the conversation in my own head and yes I talked to myself am I just stressed or

am i burned-out and it is a really good question because stress can be good stress gets your adrenaline going and it gets you in the moment it makes your concentration sharper and it allows you to do a really really good job so stress

is good but when it's continuous stress it can lead to burnout so this is described ascribes the difference as while stress is characterized by over engagement meaning I've got I'm going above and beyond I'm giving my hundred

and ten percent which I've always hated as a saying because how can you give more than a hundred but it fits for this presentation but burnout is characterized by that disengagement of I don't care anymore

okay which none of us want because we all went into nursing because we are carrying people okay the way I like to think about the difference between stress and burnout and this is how I one of the reasons why

I finally realized at what point I was burned-out stress if you get to take a vacation you go back to point zero you're able to rest and recoup go back to work and you're at even level if you go back to work and on five minutes in

on day one you're already back to the state that you were at before you left for your vacation that's not stress that's burnout that was the easiest way for me to tell when it went from stress to burn okay I hear

people laughing okay got a couple of cartoons in here because as you will learn over the next hour I'm a bit of a bit of a goofball in my life in my family we handle stress by laughing we are very inappropriate at

the most weirdest times but that's how we deal with stress and I pulled that into my nursing career in my personality because that's how I do it so hope you like that one okay so burnout NIR or radiology

so burnout has been described as having three core dimensions an overwhelming feeling of exhaustion with compassion fatigue and we're gonna go over that a little bit more in the next few slides feelings of cynicism and detachment for

the job I'm a sarcastic girl by heart this was a tough one for me to figure out where I fell on that am I just my normal sarcastic self or am i a little past that and now I'm truly being cynic it's a tough one and a sense of

ineffectiveness and lack of accomplishment again that's the difference between stress and burnout stress is your overachiever and you're burned-out person is your disengaged okay so what causes burnout these next

so reviewing the evidence in relation to respiratory depression and airway

compromise respiratory depressions been identified in ninety and ninety two claims of which seventy seven percent have resulted in severe brain damage or death eighty-eight percent of respiratory

depression events occur within 24 hours of a surgery or sedation related event and 97 percent of these were judged to have been preventable with better monitoring so where does capnography fit in with all of this with with your areas

well if you're starting capnography monitoring in your procedure and carrying that over into the post-operative or the post sedation care unit or in your own recovery units where you're recovering them before you send

these patients to the floor that could be part of a bigger picture they can continue on the capnograph even monitoring onto the floor and be monitored with that so that they are monitored throughout the entire time so

by starting capnography you may be actually implementing a monitoring strategy that hopefully could be carried through for that patient for the next 24-48 hours if they're receiving pain medications and such so when we look at

some of the factors for respiratory compromise we have patient factors right intrinsically they may have diagnosis that we do not know of like obstructive sleep apnea there hasn't been diagnosed polypharmacy some of the treatment

factors things medications that we give illnesses that they're coming in with or lying in bed developing atelectasis maybe have pneumonia they bring in their own illnesses and then the area of care factors right weather monitoring is

continuous or episodic in nature and certainly the interventions and you take all of these things together in this Venn diagram sometimes that can create the perfect storm for creating an adverse event related to either opioids

or sedative use and how do we monitor for that how do we figure out which patients we need to monitor there's so many complex factors we really need to anticipate the consequences right and monitor appropriately so moving on to

etiology and I keep the slide in here and I know it looks very basic oxygenation and ventilation oxygenation process of getting oxygen into the body onto the red blood cells and transported to these cells for cellular metabolism

and Krebs cycle whereas ventilation is removing carbon dioxide from the body these are two separate physiologic processes and sometimes these terms are used appropriately interchangeably they are

related to one another but they are separate processes we can oxygenate patients with ECMO with passive oxygen APNIC oxygenation High Flow oxygen but can we eliminate carbon dioxide without ventilation and the answer is no we need

to ventilate to get the co2 out and the co2 is a very important regulator of pH so how do we monitor ventilation and

[Music] since all right I like to move around a lot when I present so I'm gonna struggle so if I am ever away from the microphone and you can't hear me just give me a signal or a hand wave or something but because there's so many words on my

slide I'm gonna try and stay right here okay so I heard somebody say when you

workflow for pet MRI upon arrival the patient have to fill out questionnaires the MRI screening for contrast and allergy assessment pet screening form

the RT will review MRI screening for after he checked that the patients at MRI safe and no presence of a Mia Ferris fragments or anything he would give the paper to the RN the patient then will be escorted through the change room and

asked to put on robe and non slip shots this is these are the responsibilities of the nurse in our clinical workflow for pet MRI RN to review pet screening form and contrast questionnaire if patient have to receive gadolinium check

kidney function EGFR below 15 you notify the radiologist except for a of s below 30 you notify the radiologist check for allergies if allergic make sure patients is properly pre-medicated

check for Medicaid presence of medication patches and implanted infusion pumps now also you have to check for patient's blood glucose monitoring I have one but I would but I don't go inside the scanner so I'm safe

check for pregnancy status with pediatric patients we have a special process to follow the iron then obtains blood glucose and record if blood glucose is 70 to 199 we proceed with the scan anything above 200 we follow the

glycemic management with PET imaging flow chart and here's how our PET imaging flow chart looks like it looks complicated by its color coded it's three pages but I would like to show you some key points like the administration

of insulin is also based on the level of BMI you see on the arrow says BMI below 25 and there's another flow chart is if it's above 25 after that the patient will be brought back to the pet designated injection room

remember our pet MRI is located in zone three of the MRI area so prior to that the RT would the screen the patient again the patient would pass through the wall-mounted metal detector and nobody could go into song free without escorted

by the IRT or a nurse you have to swipe your ID to open the door mission when the patients in the hot room are in would obtain the height in centimeters and weight in kilos after that the RN now could do IV access once

secured you call the range of pharmacists that you're ready to inject so we wait until and the FDG dose would come up through the pneumatic children this is how our hot lab looks like the pneumatic tube to your left above is the

shower and we have the hoop to prepare for the dose or check for the dose and the wash station and once the those arrives the nurse injecting and the RT is scanning or the RT assisting just always two artists in one machine in our

MRI Department we have four magnets and only one is for MRI PET MRI it's always two artists in each machine so one RT is assisting you and with the patient so once the FDG arrives we do a patient identification using two patient

identifiers we check the label and the dose if it's correct the FDG then will be injected to the patient once injected we tell the patient they have to wait for 40 minutes during this time we instruct them to stay still not stay

still but limit movement and stimulation and inform them that we have a camera inside that room and the nurses in a and the nurses could monitor them in the nurse's station one RT will set up the scanner and computer

and patient will be screen and wondered prior to so on for so you get wandered twice check for ferrous presence patient then will be positioned on the scanner table by the pet mr technologies it takes 15

to 20 minutes for setup you have seen how the patient is position the whole body is covered by the coils and head is covered by another coil as anybody among he works in the institution who requires time out prior to injection raise your

hand please at ms KCC we do this is done by the injecting nurse and the RT is scanning the RT is reading information directly from the monitor not anywhere in the monitor while the nurse is comparing and listening into the using

the documents on hand this is done to ensure the five rights the right patient the right scan the right area your scanning the right contrast those and rate and method of administration as you all know is either given IV push or by

the dynamic or the injector timeout will be done if patient will be receiving gadolinium once the scan is finished IV access will be removed our artists are trying to remove and inject also so they are capable of removing the IV the

radiation card will be handed to the patient and paste after that patient would be assisted to the change room and discharge there is good thing when you change the patient into the robe and the non-skid

sucks because just in case there's a spill you're not sending that patient into the paper outfit they're not gonna be happy at all now I'm gonna bring you

gets pet MRIs right now our main focus are our oncology patients it helps us

determine the type of cancer they have the diagnosis of cancer assess disease progression treatment therapy and treatment planning and some antecessor treatment response so let's say a lesion is FDG avid and

has low blood perfusion that would help our physicians to us to say what kind of treatment they can give to the patient pet MRI is also good for patients who can tolerate longer scans right now it's a very young modality

there's still a lot of research goes on with this and coupled with that is advantage of research right now we actually in the Memorial sloan-kettering we have started using this instead of FDG we've used gallium 68 of to assess

neuroendocrine tumors who have also done cervical lymph Austin Tiger phim where FDG is injected directly at the patient's cervical cavity and that helps map out the lymph nodes in the survey in the pelvic area this can be used by the

surgeon and see what lymph nodes can be sampled during the surgery we provide some education and assessment before during and after the pet MRI we assess for the patient's allergies we tell the patient's they have to be NPO at least

six hours prior to FDG injection as for our anxious patients they often come pre-medicated and this just comes with some care coordination with their physician the physician would prescribe some low-dose anti-anxiety medications

and the patient would take it an hour before their test as for our claustrophobic patients we what we have done is we let them see the Machine we let we let them feel the Machine we put them inside if they would want to and it

would be up to them if they would be tolerating the scan we assess for their diabetes regimen and my refe will speak more about that later we assess for patients pregnancy status on patients loving to fifty years old process for

their breastfeeding status and screen their implants during the pet MRI we tell them about the coil placement we give them an emergency call bell and we tell them to decrease their movement well being is like although our some of

our patients would say I didn't move but then the image so differently there there's a possibility that the magnet can induce some involuntary twitching after the MRI we tell them that they can resume their

diet they can resume their diabetic diabetes regimen and as if they get MRI contrast they can pump and dump for about 24 hours after the test but if they don't get a contrast they can keep their breast milk inside the fridge just

to help to decay just to decay the isotope that was given to the patient it doesn't give any harm to the baby

questions a question comment I'm

Canadian I work in a Canadian hospital and I would say my hospital has an excellent just culture this is a practice so the other day we had a bunch of unusual things happen to begin with and I made the first error and it was a

medication error I forgot to order chemotherapy page went into the room they filled out their interventional procedure safety checklist and someone checked off all the equipment I need for this procedure as present checked it off

he did a time out in the room completed it the doctor started the case when he got the catheter in the right place that's when they discovered there was no chemo because I had forgotten to order the chemo that was the first mistake and

so we have an RLS reporting and learning system I filled it out etc and my manager was 100% supportive that art Swiss cheese lined up and you know the three things that should have caught it did not so this the safety procedure

checklist failed and so did the timeout but the ultimate one in my opinion and I wrote this in my report was that the doctor should never have started a case if he didn't know everything was ready and my my or

zatia was extremely supportive of everything I did but that doctor still thinks it's my fault that we didn't do the case and you know I'm not a new grad obviously and I'm you know he's wrong and I don't care

I fully own my mistake but he's wrong in that the whole thing was my fault so sometimes your organization will 100% support you but you might have people that are not in the just culture part and they're just looking to blame you so

you know I feel like I've done my thing I've learned I've set arow and I'm changing the situation and so it's important to remember that part of your just culture and and not focus on the people are trying to say it's your fault

to stop you from reporting in the future not really a question sorry no that's alright that's great because I think that illustrates that anatomy of the error in healthcare with that blunt end of the system and the sharp end so he's

kind of stuck in the sharp end isn't he he's blaming at you thank you very much because errors are made and they're devastating not just for the patients they're devastating to a practitioner so I think we have to look beyond the just

culture and there's something called second victim and you need second victim support and I'm trying yet actually where I work to have a program instituted sort of like a Rapid Response Team when an error is made so that you

can have the support and it goes beyond changing a policy or procedure or doing a root cause analysis but you need emotional and psychological support for the practitioner that made that error and came forth to report that error so

just wondering also how many people have a second Victim Support Service at their institution see there very little I think we have to really look at that and look forward and implement maybe something like that I

agree and we are one of those institutions that have the second victim and and that in itself is kind of a it's a topic but absolutely and and that does go hand in hand with that just culture to support because it is very

devastating when you have that air and depending on the patient safety event that occurs you know if it results in a patient death that really sticks with you and also events that we don't just stop there with ours so we have a

psychologist that's on board that talks with our physicians and then we have a liaison in our Employee Assistance Program that's also psychology based for our staff so that they can have further follow-up but even even if it's a

devastating event where there wasn't anything that was done wrong it's just that we were gonna stop that train that was rolling with this patient you know how devastating sepsis can be you just sometimes aren't going to stop

that train and and the patient is going to pass but the practitioners that were involved in that care are are moved by that most recently we had a three-year-old who passed and they had they were septic had a cleft palate and

they had a abscess that had formed after the surgery so you know that can be very devastating we do we pull our practitioners into that and that from risk management we're able to initiate that so we absolutely ask when a serious

patient safety event occurs or one that we can pick up that there's some a lot of emotion wrapped around it we'll ask them how they're doing and then a we can self-refer a person and then EAP we'll reach out to the staff member and

our psychologist we'll reach out to the physician if we if we really feel that they need just a little helping hand so yeah it's a good program I kudos to you to get that started so much for your talk today I just wanted to reach back

to you and ask you how your organization or other organizations support the exposure of those events within your hospitals I happen to be from Vanderbilt University Medical Center and we have been in the national news recently and

so there's been a lot of conversation with my staff and you know you you pull your team together and you have conversations and and the event occurred in 2017 and I'm facing them in 2018 2019 and they're like how come we don't know

these things happen in our organizations and you know there's a lot to learn from patient error and Sentinel events and I'm just curious to learn from you how how do you expose your nurses within your organization to those very private

things that go through risk management can you share with me sure sure thank you that's a great question so we do out of patient safety and risk management we do Grand Rounds and we do one once a quarter and in that way and

we will on some sensitive issues because some of it can be wrapped up in legal if there's lawsuits pending and stuff so you you really can't share some of that and I think that that might be some of it a little bit of the disconnect that

staff have because they may or may not know the players involved which gets to be a little tricky so so time helps but we we do let them know that the event happened here and that's that's the title of our

Grand Rounds and we bring those patient safety events but will de identify them quite a little bit and change some of that to protect the practitioners involved and also to focus more on the on the patient safety event and again

focus on the system so on the on the blunt end rather than so much on that sharp end because that sharp end it's sharp for a reason and it could hurt so it can hurt our clinicians describe to me who all is involved in your Grand

Rounds and where that takes place so we have we have a couple of different venues in our Hospital depending on how large we anticipate it to be so we actually have a an auditorium that has the auditorium seating because we're an

academic Medical Center so we have that that luxury we also have some smaller venues depending on what's happening so depending on what the event is we may have outside people come in and talk about that in fact we had the one of the

big things that we're working on right now is sorry the burt behavioral emergency response team so and awareness awareness wrapped around that so one of the things that we're actually looking at is bringing in the the nurse who

speaks from the del noir event to come to the hospital and speak about issues she presented very well very strategically and just to kind of heighten that behavioral awareness that we don't want our nurses to be you know

subjected to that so so depending on what's happening we may pull in outside most of the time we will involve people from our own departments throughout the hospital depending on what the event is so we've we've had some we had a wrong

patient that was they had a procedure done not a wrong patient we had the wrong the wrong procedure was done on the right patient and we actually brought in from ultrasound and from I are including the

physician involved with the case and then a risk management person and made up a panel for people to we presented and then fielded questions now that actually went really well we standing-room-only so okay that was good

so that's some of the strategy that we use thank you you're welcome because we have a computerized reporting and learning system our system sends out a monthly report on just the trends so if we're seeing a rise in a certain

thing and sometimes it's just you know Falls so remember to look at your Falls where whatever but sometimes it's more specific so there have been you know a mixup on this drug in this drug and and pharmacy is doing this to try and

alleviate that and so well it's not everything and it's obviously not any that are illegal it does give you a sort of months a month overview of what kinds of things people are doing wrong and the best part about it is these were all

reported independently so you can it's showing us as people that someone listened to our report and that something's being done about it right very good point and that's some of what we hear too is that these systems allow

you to anonymously submit a report which is fine we're interested in the event we want to hear the the event it's helpful when we have a name because if if I as the MIS managers that's looking at this report if I have a question I'd like to

go back to the person who put the report in to kind of find some more information out but it is not necessary and we're like I said we're more interested in the event but we we to send out a report that kind of aggregates our involvement

but it what our top five reports are for the month but we hear a lot of disconnect that our staff don't hear about what's happening what the report is I put that I put that record in and I don't hear anything about it well did

you give us a name so because the manager the unit manager also sees that and that's why we encourage our managers to use some of those reports that they're seeing as a patient safety during their event during their

department meetings get that word out and what they're doing about it because leader leadership so does do some effect some change but staff might not realize it's connected to the event that they turned in I was just curious amongst us

all who when you get new hires or new employees who talks about what to do you know if there's an air or just the whole process of that because I know the facilities that I worked at nobody has ever done it until the time that it's

happened so what education are we providing from the get-go that maybe change practice further down absolutely so we risk management speaks at nursing orientation for us anyone else do they have just to talk about oh sorry that's

okay Dartmouth Hitchcock Medical Center up in New England and we have an error prevention training class that's required by all new staff but we also have made a huge push that all veteran staff have to go as well and we're like

at 90% it's a two-hour training and it talks about all different types of error prevention and then it also talks about our reporting system we also are starting to look at code lavender if anyone's heard about that but that's the

second victim so we're supporting our nurses through errors and doctors you know technicians technologists but we have a really great just culture I mean sometimes of course it's thought to be punitive but I actually as a nurse

manager do all of the reporting systems for quality and safety for the whole department and we have at 9:30 we have a daily safety brief and everyone from the hospital every department comes and reports out any safety issues and then

oftentimes in real time we're actually getting together with the different parties to say okay what can we do what was the failure we also have a very robust our see a root cause analysis or when we

have something that goes to a report that's pretty serious we will have that we get a lot of people in the room including the people that were involved in it and it's to look at where do we systems failure where is that and then

after that oftentimes we'll do a cap so we'll grab a group of working together to say we need to change our policy or change the standards in which we're working because it's it's not ever proof it's fabulous thank you so much for

sharing that okay thank you all very much I appreciate you coming [Applause]

hopefully you think capnography right so we are looking for in our waveform is a nice square waveform it's a plot of

magnitude of quantity of carbon dioxide concentration over time and that is what's plotted out the baseline should return to zero in between those little square wave forms and the top of it should be a nice flat alveolar plateau

reflecting the alveolar air that has participated in gas exchange being fully exhaled the end of that point D on the monitor here on the bottom right hand corner that is where you get the value of your end-title carbon dioxide

concentration that's where the number on your monitor comes from that is the highest value and that is the end of your expiration of your full tidal volume that's where that digit comes from so here's where I'm gonna need a

little help with the computer playing some waveforms here so first on the yellow box in the upper left hand corner we have an example of what hypoventilation looks like with somebody who was breathing shallow so you see at

first a square waveform right but the magnitude wasn't that big and then you tell the patient take a deep breath and you see that magnitude goes way up so you probably have seen this in your practice when you're taking care of

somebody you're like why is the end-tidal solo anyone see that yeah to have the patient take a deep breath and you might be surprised by what you see so now moving over to the black box in the upper right hand corner we have

classic hypoventilation and this is usually just opioids like somebody's just purely on opioids and they're taking deep breaths nice big tidal volume but they're only taking like 4 of a minute and that's what that waveform

would look like you see the differences here okay now in the purple box again this is one that you probably have seen quite a bit it is an example we have a nice square wave form and then all of a sudden our

wave form just the amplitude decreases and the overall shape becomes that that nice square wave form and this is a patient who's partially obstructing right there exhaling some but there's some flow the monitor is not getting the

full flow of carbon dioxide and then finally on the right hand side lower box we have an example of a complete airway obstruction and this is where we're ventilating and then all of a sudden something has happened whether the

monitor has become dislodged the nasal cannula has moved there's some secretions in the line but that's worthy of checking right because ventilation we can detect immediately and we can check on that before there spo2 other

oxygenation values drop so let's look at

to our case study the first case study is the normal whole body pet MRI the the

image song to your left it's a regular pet MRI the one on the right as you could see it's a big difference there is very vivid image and you could pinpoint the organs they are not to me of the patient this is normal

scan there is normal uptake on the brain the ureters the bladder the kidneys those are normal there's no abnormal uptake or there's no hypermetabolic uptake noted the next case study is a 59

thank you Michael thank you to Medtronic for having me and thank you to the AI a your organization for having me today I seem to be having a little trouble advancing my slides so I'm just gonna get started with my introduction here we go

so I'm here's my disclosures basically I am sponsored by Medtronic to provide this Lunch and Learn for you but I am an active clinician I work actively at Yale as a CRNA and I do provide the majority of my anesthesia in what we call our off

floor locations meaning interventional radiology EP lab GI endoscopy r zh' in the operating room so I understand the challenges you face I do you know the sedation in those rooms myself so I understand the positioning concerns the

monitoring concerns and so I'm really I'm honored to be here today and I hope that I add value to your conference while you're having lunch I won't talk about anything that is off-label use everything I will present today is

evidence-based medicine and had been proven I'm not here to sell you any products or talk you into buying anything I just really strictly clinician to clinician so starting out we only have

an hour and I really want to make sure I get through everything today so I'm gonna ask if you have any questions to please hold them to the end and that's for a couple reasons because if you have a question I might even be covering that

material in subsequent slides and I want to make sure I get through the whole presentation the beginning of the talk is going to be some review material for some of you we're gonna move through the first 30 slides pretty quickly because I

understand that the majority of you are already using capnography and I want to spend the majority of our time in this presentation talking about the stuff that the advanced level the problem solving the troubleshooting and the

things that are really pertinent to your practice so that you have value that is gained from attending this presentation today

interested okay let's look at the

literature so when we look at the AAA say they were the ones that you know they look at a lot of sedation claims and the close claims are what they look at the causative factors of adverse incidents and when they look at sedation

claims that occurred outside the o.r it's sometimes it's been referred to as the wild wild west of anesthesia yeah when you're outside the o.r environment and you're in remote locations the incidence of things going really wrong

increases significantly and I'm sure you guys are no stranger to that right but in remote locations a lot of the claims were judges being preventable thirty-two percent of the time versus eight percent of the times

that that happens in the operating room 62 percent of claims with over sedation as their cause could have been prevented by better monitoring and these are anesthesia providers that are looking at this right and we're seeing the

anesthesia providers have been using capnography and other advanced monitoring as their standard of care for a very long time certainly sedation and claims in monitored anesthesia care these are you

know cases where we're not into baiting the patient very common 21 percent in the specific claims related to Mac anesthesia and again the common denominator here was lack of monitoring or better monitoring could have improved

outcomes so when we look at the professional associations we have UAS a we have the European Society of anesthesiology the Society of gastroenterology nurses and then certainly your organization right the

association of radiology and imaging nursing and what your statement is with capnography it's a RN endorses the routine use of capnography for all patients who receive moderate sedation and analgesia during procedures in your

imaging environments right and and there's certainly there's their statements from many organizations that are all along these lines one of the questions I often get is - well how come we have these recommendations we have

these you know endorsements and such but we're not you know mandated to use it and a lot of that is political there's a lot of pushback from organizations that are gonna come out and say you must use this you know or else they could

strongly recommend things in the anesthesia world it is one of those things that but it's been a long time and I think in time you're gonna see the movement become more strong as far as recommendations go but for now that's

where a lot of the claims are strongly encouraged strongly recommend and such but that means that we should be doing it because the evidence is proven that that it is safer for patients so let's look back at our case study so later in

the procedure our patient develops the following pattern on the monitor you stimulate the patient and position the airway and you have no response what should your next step be nothing because the pulse oximetry is

normal hold additional sedation meds until breathing normalized supplement breathing with a BVM if if required to maintain acceptable and tidal co2 give a reversal agent or intubate the patient well the correct answer would be

to hold additional meds monitor the breathing and supplement the breathing with a BVM see if you can increase the ventilation to maintain acceptable levels well now we're further deteriorating so our same Jane Doe

patient is does not respond to your previous efforts and the end tidal co2 continues to rise followed by a sharp drop in our spo2 concentration despite being on oxygen then the following waveform appears what do we do nothing

decrease our oxygen give a reversal agent or intubate okay I heard some C's what do we want to immediately do she's kind of acutely dropping so yes C would've been correct maybe a slight ago you know before she's really started to

desaturate and certainly that would be correcting the problem but immediately before she decreases her SATs any further becomes any further hypoxic recommendation is to establish an airway

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