The Journey Back To Acute Care

Perhaps you are a new Graduate RT or you have been practicing in the Pulmonary Function Testing lab, Homecare or Patient Education side of respiratory therapy for some time and are looking to get back to the acute care setting.   The last acute care experience dates to when you were a student.  The process carries a sense of excitement and anxiety. You keep your certificates up to date, and try to attend networking sessions.   Despite submitting multiple applications, you have not received a single call for an interview. There is a sense of frustration and doubt that we all have experienced at some point.  Major Canadian cities are saturated with recent graduates and new RTs compete for casual positions which tend to offer limited shifts per week but expected an open availability.  More part-time and full-time positions are available in rural hospitals but fewer postings show up.  Should you move to a rural hospital to get the experience?  Should you change provinces? Is this the right career for me?  Before you head into a downward spiral or make any serious decisions, take a moment, step back and breathe.  Just like any career or job, there is a high level of competition.  The journey back to acute care is not easy but it is possible. Recently, I sat down with a colleague who successfully made this transition.

Viral Patel Image Mr. Viral Patel is an RRT in the Greater Toronto Area.  His experience includes acute care, pulmonary function testing at various laboratories, and sleep apnea education.  Over the past few months he has found his way back to acute care.   I asked him few questions to find out more about his experience, challenges and thoughts.


Question 1.  What were your challenges applying for an acute care position without a prior/recent acute care experience?

Acute care is field that requires constant practice to maintain skills that are learned overtime. As you move away from acute care practise these skills begin to fade and our mind loses the “routine-ness” of working in a hospital. That in its self presents a very massive challenge in applying for acute care position.  Furthermore as you move away from acute care the more knowledge you tend to lose. Acronyms that you were so used to in clinical such as “TVR, ECMO or CHF” you have to think about what they are and how they affect our practise. As such, most places prefer someone who has had recent acute care experience. Can you blame them? Absolutely not, their first priority is to get the best possible candidate for the job and patients.


Question 2a. What were some areas that you had to improve to increase your chances of getting an interview (i.e. skills/knowledge/networking etc.)?

If you don’t work in acute care for an extended period time you begin to lose the clinical skills that are required to be an effective part any respiratory team.  Maintaining certifications such as BCLS, NRP and ACLS are very important to keep your mind asking the right questions when presented with real scenarios.  I had to sharpen up on mechanical ventilation (paeds vs. neo vs. adults), ABG interpretations (what is realistic when dealing normal values comparing to what is taught at school vs. real practise).  Review different types of procedures which are part of our scope of practise: arterial lines, intubations, extubation and smaller procedures such as sputum indications. Brushing up on how they are done really helped.  Keeping an eye open for positions is also key, establishing good relationship with clinical managers and building a rapport to show commitment to the respective hospital.


Question 2b. What resources/recommendations would you share with RTs who are trying to get back to acute care setting?

Class notes, evidence based journal articles, go to your local hospital and get an outline of policies and procedure of common RT related procedures, ACLS/NRP books and of course practice leaders! Even if you don’t work for a hospital if you are a certified SRT/GRT/RRT what harm is there to approach a practice leader to shadow a regular RT for a day just to feel it out?


Question 3. What are some of your challenges now that you are working? 

Definitely getting back in routine of things, knowing where to find appropriate supplies and organizing myself during procedure so that I am not caught unprepared.  Speeding is also something I am working on as acute care can be highly volatile in terms of work load therefore quick safe and efficient work management is key.  Some procedures/equipment maybe only used under special circumstances so taking the time to understand specialty equipment so in the event that I ever do need use them I am prepared.


Question 4. what resources/recommendations you have for those who are now working in Acute Care (after a hiatus)? 

The key resource is definitely policies and procedure that every hospital implements.  They highlight and guide us in implementing our scope of practice such as ventilation of patient groups, arterial line insertions, intubations, extubation, flolan/Milrinone, bronchoscopy and code blue teams.  Clinical practice leaders are an excellent resource for all kinds of information such how to better yourself at specific skills, odd requests from RN’s or patients that you may not have seen in practice so far, or even when dealing with a really stressful day and you need someone to debrief with.  RN’s are your best friends, they know their patient just about better than anyone! If there are specific test results you need or a clarification on patient history you can bet they know the answer.  Lastly RT’s are truly a team driven department and therefore your fellow RT’s are also an amazing resource.  I have been very lucky to be surrounded by a great team who are willing to help each other out above and beyond the call.


Question 5. Any last thoughts?

Don’t be discouraged if you are just out of school and without a job and don’t be discouraged if you need to go out of the province to practice.  Follow up with HR after applying, build a good rapport and always have a positive attitude.  Always be eager to learn and adapt to changing circumstances.  A few of my colleagues jokingly remind me that I am not a student and I don’t have to do everything everyone says but I tell them all the time I am building experience. The way I see it the more you see and do the more comfortable you become.


Thank you Viral for taking time out of your busy schedule to answer my questions.

To view a list of his qualifications, education and experience, visit his LinkedIn profile at .

Farzad ‘Raffi’ Refahi


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Influential People In Respiratory Therapy: Dr. Mika Nonoyama

There are many people contributing to the field of respiratory therapy. In my journey to learn more about this field, I have reached out to few individuals to discover more about their experiences and the types of activities there are currently involved in. Today’s post is about Dr. Mika Nonoyama.

Mika Headshot

Dr. Nonoyama is a Respiratory Therapist, Health Clinician Scientist, Associate Professor, Advocate, Scientist and Researcher.  I have read her articles and posts in variety of platforms and mediums. I wanted to learn more about Mika, her ongoing contributions to our field.  She was kind enough to take time from her busy schedule to answer my questions:


Question 1: What attracted you to the research side of respiratory therapy?

A few reasons. I loved the idea of coming up with a question and going through the process of answering it. Especially once all the data has been collected and it sits in front of you – it’s almost like an exciting mystery where the results could go any which way despite the hypotheses. The other main reason is because of my mentors, in particular my PhD supervisor Dina Brooks who is a fantastic leader and doing such amazing research.

Question 2. What does a typical day look like for you?

In theory my job is 40% research, 40% teaching and 20% service (volunteering). But depending on the time of year it will change…every day is different. During the teaching term much of my time is devoted to the preparation and ongoing upkeep of the courses (at UOIT). I spend once a week at SickKids doing research with the front-line RTs and collaboratively with other researchers. I also do other research that brings me into the community setting. I have many students (undergraduate, graduate and RT) who help with the initial parts of the research projects while I oversee the processes. My service involves volunteering at various places like the Lung Association and within my University. I love this aspect of my job also because I am able to network and learn about the work these organizations do. I have to mention my day also involves being a wife and a mother of school aged children!


Question 3. Who do you collaborate with on daily basis?

My three research themes are 1) paediatric respiratory therapy; 2) long-term mechanical ventilation; and 3) rehabilitation and chronic respiratory disease. For each of these themes I have different collaborations. The first are my collaborations with SickKids, but I also have connections with folks at CHEO. I collaborate with a large group across the country of health professionals for long-term mechanical ventilation – we call ourselves CANuVENT. My main mentor there is Louise Rose. For the rehab and chronic lung disease I also have various contacts but much of my collaboration is with Dina Brooks.


Question 4. What are some of the sources of gratification/satisfaction and challenge working in this area?

Gratification – seeing the end result of your research projects – usually publication. Though this can be a challenge because it takes time and patience to write and have a paper accepted. I also love to see the look of recognition and understanding on students’ faces when I teach them. My goal is usually to help them experience so they can apply it when they enter the work force…would be nice to see them once they are in the work force! The main challenge for me is finding the time to do it all…


Question 5. What were some areas/knowledge/skill sets that you had to work on to improve in this role?

There is the usual education but more importantly is the desire to learn and do things outside the box. Trying something that interest you and makes you somewhat uncomfortable can lead to wonderful things. I also believe that volunteering your time is essential. I found my success came once I figured out what interested me and what I wanted to do (seems simplistic I know). Once I had that vision I put things in place to make it happen. Having great mentorship to help along the way is key too.


Question 6. Any interesting projects you are working on right now?

One of the most interesting (and challenging) is trying to streamline various respiratory therapies in the paediatric ICU at SickKids. As you know there are many aspects to RT – intubation, weaning, extubation and everything in between. We are working step-by-step on this, extubation readiness being the first. It’s interesting because the research questions come from patient care, involve the care practitioners and are applied back to patient care. Since I don’t practice anymore it’s wonderful to be a part of the practice side of things.

Question 7. Where do you see the future of Respiratory Therapy?

I do hope RT becomes a degree-entry-to-practice. Since most students have a degree already it seems to make sense. It would also help get RTs more within the University system so they are able to interact with the peers they would practice with e.g. nursing, PT, OT, MDs. It would be great also if many RTs would seek graduate degrees and step into the primary investigator role within their institutions.


Question 8 – Any recommendations/thoughts/suggestions for students and RRT who are interested in getting involved in the research side? What are the steps involved?

Though generic my answer for question 5 really is the advice I would give. Figure out what area you would want to research and find who is involved. Get in touch with them to see if you can start the collaboration. I am always happy to hear from anyone to chat about things also.


Question 9- Any final thoughts?

I do love what I do and feel very lucky I am able to do it.


Thank you Mika for sharing your experience, perspective, and giving us a better understanding of the research side of the respiratory therapy field!

To see a full list of Dr. Nonoyama’s educational background and research collaborations, please visit

Mika Nonoyama image

Image source: Google Scholar


Farzad ‘Raffi’ Refahi

July 16, 2017

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Resources for Bronchiectasis

At the beginning of my career I was more focused on few respiratory conditions and diseases such as Asthma, COPD, Cystic Fibrosis and Acute Respiratory Distress Syndrome.  With more experience, I am more exposed to variety of conditions that directly and indirectly impact the respiratory system.  In my journey I have realized that bronchiectasis is a common condition which I did not pay much attention to as I viewed it a “secondary consequence” or complication.  This condition involves abnormal widening of airways.  In my attempt to better understand this condition, I searched the web; Here is a list of great resources that will help you review this condition:


The Lung Association:

British Lung Foundation:

European Respiratory Society:

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Duty of Care

On June 14, 2017, CBC’s World News reported that “5 people, including Michigan health chief, charged in Flint water probe”.   The investigation follows the poor quality of water in Flint where more than 100, 000 people were exposed to high levels of lead.

This topic may not be related to respiratory health but does speak to our accountability and actions as individuals with power and influence over other’s health.

Take the time to review:
-CSRT’s Standards of Practice at and

-CRTO’s Stands of Practice at

– CBC World News

-CNN-Flint Water Crisis Facts


Farzad ‘Raffi’ Refahi

June 14, 2017

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Working In A Multi-Generational Workforce


I was given the chance to share my thoughts and views in the Leadership Forum of Canadian Society of Respiratory Therapist in the 2017 annual conference.  I spent few months studying and preparing a list of recommendations to remind managers of ways to improve their workforce (relating to different generations).  In this post however, I will share some advice for employees, staff and students.

As you know, there are several factors that influence the characteristics of individuals such as gender, cultures, politics, race and ethnicity, educational background, age and many other factors.   While individuals are grouped in various categories so they are better understood, each individual is unique.

Check out this quick chart with the list of the recent Generations:

Cohort         Veteran


Baby Boomer Generation X Generation Y


Generation Z
Age* 74-92 57-75 36-56 17-35 7-21
DOB 1925- 1943 1942-1960 1961-1981 1982-2000 1996-2010
*Age in 2017

Veterans grew up during wartime and scarcity.  In order to survive and be successful, they had to be make calculated decisions, and had to work hard at their job.  Change was associated with risks, which they may have not recovered from.   Thus calculated decision making and royalty was the key to success.  There are few existing biases and negative stereotypes out there which include Veterans being out of touch, Baby Boomers being workaholics, Generation Xers being slackers and Generation Y being demanding and disloyal.     I hope that by explaining the experience and mentality of the individuals from different generations, it would lead to better understanding, empathy, and communication between people.   I like to promote a culture of respects for everyone (regardless of their generation).

Baby Boomers are stereotyped as being workaholics.   Just like Veterans, working hard lead to success!  While Baby Boomers also had to work in a hierarchical structured workplace, they may not fully agree with this Top-Down structure.  They enjoy having more options and more influence in the decision making.

Generation Xers are stereotyped as being Slackers.  This generation cohort grew up taking care of themselves as both their parents were working.  Keep in mind that there was an increase in divorce rates.  It is not surprising that Generation Xers grew up being resourceful and independent.  In addition, this generation was introduced to computers and access to information.  They watched as corporations failed and had to laid-off staff.   With a lack of full trust in institution and organizations, Generation Xers are careful in their relationships with organizations or employers.  Generation Xers are resourceful, calculated, and may not be dedicated to a single employer/organization.  This generation values work-life balance.

Millennials (Gen Y) are stereotyped as demanding and disloyal.  Just like Generation Xers, Millennials are cautious about their relationship with organizations and employers.  Grown up with instant access to computers, technology and information, this generations has higher expectations.  Unlike the experience of Generation Xers, the parents of Millennials provided a lot of options to them, and included their children in more decision making.  Thus, for Millennials and Generation Z, sharing their thoughts has been a normal part of their life.

Generation Z receives similar negative stereotype as Millennials.  Just like Millennials, individuals from Gen Z are educated, enjoy instant access to information and opportunities.

To improve communication and to reduce the chance of perceived disrespect between generations, keep the communication style more formal and proper for older generations.  Younger generation is comfortable with less formal communication and in less formal settings.     Older generations value being heard as they like to pass on their knowledge and wisdom.   Younger generation also enjoy sharing their thoughts and ideas despite having less experience than older generations.

Staff, students and employees need to realize that one size does not fit all, and they need to look at things through different lenses.  Everyone is unique.  Each person deserves a chance to work where they feel respected.

This post is meant to be short, simple, and to serve as a reminder.  If you require additional information or have additional questions, feel free to get in touch with me.

Image credit:

Farzad Raffi Refahi  May 18, 2017

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Improved. Part 3. ‘Foot Health’

This is the third part to a series of posts, titled ‘Improved’, aimed to assist with development and improvement of Respiratory Therapists and other Healthcare Providers as individuals and as clinicians.

I share recommendations and advice from Mr. Piyush Jadav, a healthcare professional with educational and work experience as a chropodist.  In my conversation with Mr. Jadav, I asked for any recommendations for clinicians who either work 12 hours long day/night shifts/ acute care, and/or to those who work sedentary 9 hours shifts/diagnostic/patient education.

In time for foot health month, this post is released in May.

Footwear Advice for Clinicians/Hospital Workers

First off, when speaking about footwear; the most important thing is comfort. I have told many patients about what footwear is the best or most appropriate for them. The biggest issue with compliance has to deal with the level of comfort.

When speaking about footwear, at the most basic level there are 3 shapes of “lasts”. A last is the structure on which a shoe is built around.


  1. Straight last
    1. most appropriate footwear is motion control (high torsional stability,  stiff heel counter)
    2. Most appropriate for patients with over pronation, low arch profile
  2. Semi Curved Last
    1. most appropriate footwear is cross-trainer (medium torsional stability, EVA midsole (dual or single))
    2. most appropriate for patients with mild over pronation
  3. C- shaped Last
    1. Most appropriate footwear is cushioning/running shoe/minimalist shoe
    2. Most appropriate with patients with high degree of supination, high arch profile


With respect to hospitals, these same examples can be applied. Mesh/net material in shoes is usually not allowed in some departments due to risk of infection and lack of protection. Shoes that are used for long periods of walking in the hospital or clinic setting should not be used to recreational activity. Footwear that is meant for running/exercising are designed to absorb more force due its high demands.

Look for footwear with either Velcro or laces which provide stability to the midfoot as well as the ankles. Slip on shoes provide little to no support and have a shorter lifespan.

The best time to try on shoes is closer to the evening because one’s feet do swell slightly during the day. This will ensure a proper fit.

Also, try to change socks at least once a day. Try to designate a pair of shoes for work only, allowing them to breathe overnight. This will prevent excessive odour and moisture from building into the shoe. Never wear your shoes without socks, this can harbour excessive moisture and may contribute to athlete’s foot.

A typical clinician/hospital worker can be on their feet for 8-12 hours per day. Standing for long periods of time has been linked increased pressure on peripheral blood vessels. In addition, this can lead to varicose veins or “bulging veins”. Some of the first symptoms may include cramping, muscle aches and mild swelling. An inexpensive option to help with this would be to use mild compression (10-15 mmHg) stockings which may help with relieving symptoms, which can be picked up without a prescription from the pharmacy.

Written by:

Piyush Jadav, B.Sc., D.Ch
Registered Chiropodist

Primary site of practice:
Uptown Health Centre
9325 Yonge St Richmond Hill, ON L4C 1V4
(905) 508 -8876


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Improved. Part 2. ‘Nutritionist’

studio photography of different fruits and vegetables on old wooden table

This is the second part to a series of posts, titled ‘Improved’, aimed to improve the life and work of Respiratory Therapist and other healthcare providers.

I share recommendations and advice from a friend who is a health professional with educational and work experience as a nutritionist.  In my short conversation with her, I asked for any recommendations for clinicians who either work long 12 hours long day/night shifts/ acute care, and/or to those who work sedentary 9 hours shifts/diagnostic/patient education.  I have added relevant resources to some of the suggestions so I recommend that you check out the reference section for additional information.

Regardless of the work-setting, clinicians get heavily involved with their responsibilities and may loose track of time and their food intake.  Nutrition can directly impact cognition, concentration and decision making (1).  My source, the nutritionist, suggests: stay hydrated, eat healthier, plan your meals, have healthier snacks, and give yourself time to adjust to healthy eating habits.

Stay Hydrated. Don’t ignore thirst. Drink water. Carry a container of water with you (at your desk/RT department). If you choose to drink other fluids, check out the 2014 guideline by Dietitian of Canada (2). This guideline suggests a daily water intake of  2.2 L for women and 3 L for men (19 years and older).

 Eat Healthier.  Eat more vegetables and fruits.  It also adds more fiber to your diet (just remember to increase your water intake with it).  Limit foods that are high in  calories, fat and salt.  Consider lean meat or alternatives. Check out Canada’s Food Guide for more details.

Meal Preparation. A main obstacle in healthy eating at work is preparation.  Prepare food in advance:  Purchase, prepare and cut your veggies before it is time to cook.  Use slow cookers or pressure cookers to better fit your schedule.  Cook higher quantity of food than needed and freeze it for later consumption (reference 5).  If you don’t have time to prepare a meal and have to purchase a one at work, cut up some veggies and fruits to take with you.

Snacks. No matter how busy you may get, take the time to eat something, e.g. instead of having cookies and chips, cut up some bell peppers and celery sticks. Pair it with protein such as almonds and walnuts. It is better than working on an empty stomach (impacting concentration and overall performance at work). (3 and 5 ).  Also when it comes to shakes, it is better to eat food than to drink it (chewing food improves the transmission of satiety signals).

Habits. Keep in mind that any behavioural change, including improving dietary intake, requires time and practice. Set SMART goals (Specific, Measurable, Attainable, Rewarding, and Timely) .  Take small steps, keep motivated and enjoy!

Thank you to my nutritionist source (anonymous, so her opinions would not reflective of her employer(s) ) .  Also, a thank you to my followers for allowing me to be part of your  personal or professional development and growth.

Resources and references:

  1. Friedman, Ron. What you eat affect your productivity. October 17, 2014. Harvard Business Review.
  2. Guidelines for Drinking Fluids To Stay Hydrated. Nov 27, 2014. Dietitians of Canada.—Know-when-.aspx
  3. 10 Nutrition Tips for Shift Workers. Dietitians of Canada. 2013
  4. Miller, Carla. Changing Your Habits for Better Health. June 2013. NIDDK (NIH).
  5. Canada’s Food Guide
    Limit these:
    Fast and Easy Meal Ideas:
    Planning Tips:
  6. Getting Started: Setting SMART goals.  Alberta Health Services. Mar 2012.
  7. Image credit. Freepik.


[End] [Farzad ‘Raffi’ Refahi HBSc/RRT/CRE. April 02, 2017]


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Improved. Part 1. ‘Personal Trainer’

The Gym
Over the past few years, I have worked in various settings such as acute care, pulmonary function testing and patient education.   My experience varied from working in an active 12-hours long day or night shift in the ICU/ER setting to a more sedentary 8 to 9-hours “office job”/shift in pulmonary function testing and patient education.  I faced different challenges in each setting.  For example, around the 4th month working in ICU/ER, I noticed that wearing quality footwear will have a significant impact by reducing discomfort, and indirectly improving my energy and concentration levels.  On the other hand, during the less physically demanding shifts at PFT, I felt a total body fatigue and discomfort that stems from sitting for prolong periods of sitting down (i.e. reduced mobility and sedentary aspect of PFT/Patient Education setting).  In an attempt to improve the quality of life of my fellow clinicians, I reached to various healthcare professionals to get their advice (which I will share in a series of posts titled ‘Improved’).
In this post, I share the advice, tips and wisdom from a Personal Trainer.  Keerthanan Kugathasan is a personal trainer equipped with latest knowledge from his studies at York University’s Kinesiology and Health Science program.  The following is a summary of his recommendations:

Working long sedentary hours a day can be detrimental      to your body and health. Sitting more than 8 hours a day has been proven to increase the risk of muscular skeletal diseases, obesity, diabetes, cancer, heart disease and kidney disease (CDC.  2015). The spinal cord of the human body also puts up a huge strain, constantly in a curved position while you sit at your desk. This can evidently lead to poor posture when standing and sitting. Large muscles and joints, especially the ones located in the hip/lower region of the body, also tend to tighten up, as there is not much stretch or strengthening occurring as you remain sedentary in a sitting position for a significant period of time (AAOS. 2013).

In relation to the respiratory therapy job, there are days when clinicians endure a full 8-9 hour shift with not much physical activity. Although both the Acute and Diagnosis/Education job settings have differences in terms of hours and the amount of time you’re sedentary, it’s important to try and increase movement for the body so muscles and joints do not adapt into a sedentary setting.

My recommendations if you work long hours in a sedentary position:

  • Add more activity to your day… starting with your commute. If you take the subway to work, get off a few blocks before your workplace so you can arrive to work with great, positive energy after that short walk. Also, try alternatives routes to your desk, such as taking the stairs instead of the elevator.
  • Being active during your break! Instead of hanging around your desk and indulging on snacks, take these snacks on the go while you take a brisk walk either outdoors or even around the office! Not only will your muscles get activated, but you’ll be feeling a lot more awakened in the mind!
  • Take time-outs every 30 minutes to stand up and have a quick stretch! Sitting for long periods of time can interrupt proper blood flow to all your muscles. Standing up frequently and stretching all the tight muscles on your body will allow blood and oxygen to flow thoroughly around the body.
  • Organize the lay-out of your office space so you have to stand and walk over to machines such as telephones, printers, and medical equipment. Simply moving everything out of reach will allow more activity from your body
  • If your work place allows this; use a medicine ball instead of your usual chair when sitting at the desk. Not only will this fix up your posture, but you will also be working your core muscles trying to balance on the ball.
  • A fun one: When there is available time to use the equipment in your job setting, try testing out your VO2 max! The office can also incorporate a contest among all employees to see who gets can achieve the highest!


Remember, you spend a great chunk of your adult life at work! Therefore, it is important to take care of your well-being and body while doing so.

-Keerthanan Kugathasan (Personal Trainer)

For further questions or advice, please email:


>AAOS. Lower Back Pain.   December 2013

>CDC. Physical Activity and Health . June 04, 2015

[End] [Farzad Refahi RRT. . March 19, 2017]


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